Maintaining natural knee asymmetry in total knee arthroplasty: short-term outcomes of a novel soft-tissue balancing technique (a retrospective cohort study)
Original Article

Maintaining natural knee asymmetry in total knee arthroplasty: short-term outcomes of a novel soft-tissue balancing technique (a retrospective cohort study)

Jian Wu1, Feng Pan2, Jun Zhang2, Chao Yang2, Yuan Gao2, Desu Luo2, Mao Liu2

1Department of Joint Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China; 2Department of Orthopedics, Guizhou Hospital of Beijing Jishuitan Hospital, Guiyang, China

Contributions: (I) Conception and design: J Wu, J Zhang, F Pan, Y Gao; (II) Administrative support: D Luo, M Liu; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: C Yang; (V) Data analysis and interpretation: C Yang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Yuan Gao, MD. Department of Orthopedics, Guizhou Hospital of Beijing Jishuitan Hospital, 206 Sixian Street, Baiyun District, Guiyang 550000, China. Email: gaoyuan9512@163.com; Jian Wu, PhD. Department of Joint Surgery, Beijing Jishuitan Hospital, Capital Medical University, 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China. Email: wugien@sina.com.

Background: The primary goal of total knee arthroplasty (TKA) is to relieve pain, improve function, and thereby enhance the quality of life. This study compares TKA using conventional mechanical alignment (MA) versus Intelligent Knee Planning and Alignment System (IKPAS) navigation-assisted soft tissue balancing that preserves key factors of knee natural asymmetry, evaluating differences in postoperative functional recovery and overall patient satisfaction.

Methods: A retrospective analysis was conducted on 60 patients with American College of Rheumatology (ACR)-diagnosed, K-L grade III–IV knee osteoarthritis undergoing primary unilateral TKA at Guizhou Hospital of Beijing Jishuitan Hospital, between March 2024 and June 2024. According to the surgical methods, the patients were categorized into the study and control groups. Among them, 30 patients in the study group underwent unilateral TKA using the IKPAS navigation and a new method of soft tissue balancing technique to maintain the key factors of natural knee asymmetry. All surgeries were performed by a single senior surgeon. Simultaneously, the other 30 patients in the control group underwent unilateral TKA using the guided traditional MA and gap-tension equality balancing technique. The first ambulation time, hospital stay duration, and operative time were compared between the two groups. Knee Joint Clinical Score (KJCS), Knee Joint Functional Score (KJFS), knee extension-flexion range of motion (ROM), and Forgotten Joint Score (FJS) were assessed at the 1-, 3-, and 6-month postoperative follow-up visits.

Results: All patients were followed for 1 to 9 months, with a mean follow up duration of 7±1.5 months. No surgical site complications (including infection or wound dehiscence) were reported in either group. Baseline characteristics, including age, sex, body mass index (BMI), preoperative KJCS, KJFS, and ROM, demonstrated no statistically significant differences between the kinematic alignment (KA) and MA groups (P>0.05). The study group demonstrated shorter first ground walking time and hospitalization time than the control group (P<0.05), with statistical significance. No statistically significant difference was noted between the two groups in terms of surgical time (P>0.05). At the 1-, 3-, and 6-month postoperative follow-ups, the study group exhibited higher KJCS, KJFS, knee extension-flexion ROM, and FJS than the control group (P<0.05), with statistical significance.

Conclusions: The new method of soft tissue balancing in TKA by maintaining the natural knee asymmetry shows better clinical outcomes than the traditional gap–tension symmetric balancing TKA in a preliminary short-term follow-up study. The superior clinical outcomes of asymmetry—maintained TKA compared to traditional gap-tension equaled TKA implicated that the real balance of TKA is not simply defined as symmetry.

Keywords: Arthroplasty; knee replacement; medial collateral ligament (MCL); medial pivot motion; I-join Knee Position Assistance System navigation (IKPAS navigation)

Received: 21 June 2025; Accepted: 23 July 2025; Published online: 30 July 2025.

doi: 10.21037/aoj-25-43

Highlight box

Key findings

• This study demonstrates that restricted kinematic alignment (rKA) with medial collateral ligament preservation and asymmetric soft-tissue tensioning successfully replicates natural medial-pivoting kinematics, providing a biomechanically optimized alternative to conventional mechanical alignment in total knee arthroplasty.

What is known and what is new?

• While mechanical alignment-total knee arthroplasty (TKA) is effective for end-stage knee diseases, registry data show 20–25% patient dissatisfaction due to suboptimal biomechanical restoration.

• This study introduces a rKA technique using I-join Knee Position Assistance System navigation to preserve medial collateral ligament (MCL) integrity and replicates natural medial-pivoting kinematics through asymmetric tensioning.

What is the implication, and what should change now?

• The rKA technique with MCL preservation offers a better TKA solution and needs wider clinical adoption.

Introduction

Traditional mechanically aligned total knee arthroplasty (MA-TKA) has been utilized for over five decades. While effective in pain relief, both orthopedic surgeons and patients continue to pursue superior functional outcomes. Nevertheless, the achievement of a forgotten joint remains uncommon following conventional TKA (1-3). Contemporary implant designs—whether posterior cruciate ligament-retaining (CR) or posterior-stabilized (PS) prostheses—fail to replicate normal knee kinematics. The absence of the anterior cruciate ligament (ACL) in TKA precipitates paradoxical anterior femoral translation during flexion, a phenomenon termed paradoxical motion.

Fundamental limitations in both biomechanical understanding and surgical instrumentation have historically constrained TKA from restoring physiological joint kinematics. Suboptimal functional recovery and patient dissatisfaction post-TKA necessitate a comprehensive reevaluation of prosthetic design principles. Consequently, novel instrumentation and personalized alignment techniques represent imperative innovations for advancing knee reconstruction. Weber and Weber (4) proposed that during knee flexion, a combination of rolling and sliding transpires between the femur and tibia, accompanied by gradual posterior axial rotation of the lateral femoral condyle as flexion increases. Some researchers have introduced the principle of kinematic alignment (KA), highlighting natural knee biomechanical balance over mechanical alignment (MA) (5-8). However, KA aim to resurface the knee articular surfaces with Sacrificing ACL or both ACL and posterior cruciate ligament (PCL) and the knee was still balanced by the theory of gap-tension equality, thus make it difficult to replicate natural medial pivot motion. Several systemic reviews and meta-analysis concluded that no superior clinical outcomes of KA-TKA compared to MA-TKA (9-12). Furthermore, achieving true KA in TKA necessitates precise osteotomy and soft tissue balancing, making implementation challenging (13).

This study aimed to enhance the understanding of knee anatomy and biomechanics by preserving the functional integrity of the medial collateral ligament (MCL) as a foundational condition and utilizing the IKPAS navigation system to achieve restricted KA (rKA). With the different anterior-posterior translation movement simulated by different radius condyles and post-cam mechanism, and a certain degree of asymmetric soft tissue tension (higher medially and lower laterally), we replicated the natural pattern of a medial-pivoting knee. We present this article in accordance with the STROBE reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-43/rc).

Methods

This study was a retrospective cohort study involving 60 patients with knee osteoarthritis (KOA) who underwent unilateral TKA. The study was conducted at the Department of Joint Surgery, Beijing Jishuitan Hospital Guizhou Hospital, from March 2024 to June 2024. Patients with valgus knees, severe flexion contracture (>15°), or severe varus deformity (>15°) were excluded. According to the surgical technique, patients were categorized into the study (n=30) and control (n=30) groups. In the study group, unilateral TKA was performed under navigation guidance using a PS prosthesis with the MCL synergized post-cam mechanism to achieve medial pivot motion. The control group received traditional TKA according to standard MA principles. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Beijing Jishuitan Hospital Guizhou Hospital (No. KT2024071527) and informed consent was taken from all the patients.

Preoperative planning

The same chief surgeon performed all surgeries. The IKPAS navigation system was employed for osteotomy positioning of the tibia and femur. The osteotomy thickness and angles for both groups were precalculated on the basis of the kinematic axis technique and MA technology. Routine surgical exposure focused on the navigation-referenced attachment areas of the preoperative bone model, with appropriate removal of surrounding soft tissues in the attachment zones. To prevent compromising positioning accuracy, special care was taken to preserve osteophytes in the attachment areas.

Surgery

(I) Control group: femoral posterior condylar osteotomy was performed with 3° external rotation relative to the posterior condylar line, whereas tibial osteotomy was conducted perpendicular to the mechanical axis, followed by soft tissue release following the common gap-balancing principle. (II) Study group: during femoral 4-in-1 osteotomy, the posterior condylar external rotation angle was set at 0°; the MCL was meticulously protected during tibial osteotomy without routine removal of medial osteophytes or release of deep MCL fibers. Using the IKPAS navigation system, varus osteotomy was initially set at 3° varus and 3° posterior slope. When the knee trial motion without joint surface separation and full range of motion (ROM) from extension to flexion was observed, then this motion pattern was accepted for subsequent procedures. When medial flexion gap tightness caused lateral femoral condyle lift-off, a 2° varus/valgus adjustment jig was applied to add 2° varus osteotomy until optimal kinematic motion was achieved. All prostheses had PS designs (A3GT High-Flex PS Knee Prosthesis, AK Medical, Beijing, China).

Postoperative assessment

Patients were routinely followed up at 1, 3, and 6 months postoperatively and annually thereafter. Data collected for both groups comprised operative time, incision length, time to first ambulation, hospital stay duration, as well as preoperative and postoperative clinical outcomes assessed using the Knee Joint Clinical Score (KJCS), Knee Joint Functional Score (KJFS), ROM in knee extension-flexion, and Forgotten Joint Score (FJS).

Statistical analysis

Statistical analysis was performed using Statistical Package for the Social Sciences (version 26, IBM, Armonk, NY, USA). Normally distributed continuous data were expressed as means ± standard deviations (x¯±s), and intergroup comparisons were conducted using independent samples t-tests or χ2 tests, with P<0.05 considered statistically significant.

Results

All patients were followed up for 1–9 (7±1.5) months.

Comparison of perioperative period

The study group demonstrated shorter time of first ambulation and hospitalization than the control group, and the difference was statistically significant (P<0.05). No significant difference in operation time and incision length was noted between the two groups (P>0.05) (Table 1). No incision-related complications were observed in both groups.

Table 1

Comparison of general condition between internal shaft group and traditional surgery group

Parameter Internal axis group (n=30) Mechanical alignment group (n=30) t P
Time to first ambulation (hours) 24.7±2.1 36.3±2.8 −18.273 <0.001
Hospital stay (days) 6.1±1.5 7.4±1.5 −3.261 0.002
Operative time (min) 78.6±12.5 84.2±13.7 −1.635 0.11
Incision length (cm) 17.5±1.6 17.9±1.7 −1.090 0.28

Data are presented as x¯±s.

Comparative analysis of baseline characteristics and postoperative knee joint scores following kinematic versus mechanical alignment TKA

No statistically significant differences in age, sex, body mass index (BMI), preoperative KJCS, KJFS, and ROM between the two groups (P>0.05). However, at the 1-, 3-, and 6-month postoperative follow-ups, the study group demonstrated significantly superior outcomes in both knee extension-flexion ROM and FJS than the control group (P<0.05; Tables 2,3).

Table 2

Baseline characteristics of patients

Characteristic Internal axis group (n=30) Mechanical alignment group (n=30) Statistic P
Age (years) 68.2±5.3 67.5±6.1 t=0.50 0.62
Sex (F/M) 22/8 20/10 χ²=0.48 0.49
BMI (kg/m²) 26.8±3.2 27.1±2.9 t=0.40 0.50
Preoperative KJCS 44.1±3.4 43.5±3.1 t=0.767 0.18
Preoperative KJFS 51.1±2.4 50.7±2.5 t=0.639 0.53
Preoperative ROM (°) 92.4±11.3 89.7±10.8 t=0.96 0.34

Data are presented as x¯±s for continuous variables and as frequencies (counts) for categorical variables. BMI, body mass index; F, female; KJCS, Knee Joint Clinical Score; KJFS, Knee Joint Functional Score; M, male; ROM, range of motion.

Table 3

Comparison of postoperative KJCS, KJFS, FJS scores, and knee extension-flexion range of motion between the internal axis and traditional surgery groups

Parameter Internal axis group (n=30) Mechanical alignment group (n=30) t P
KJCS
   Postoperative 1 month 74.8±1.6 70.50±2.7 7.484 <0.001
   Postoperative 3 months 84.8±1.6 76.7±1.8 18.431 <0.001
   Postoperative 6 months 85.8±1.4 80.80±2.0 11.288 <0.001
KJFS
   Postoperative 1 month 75.2±1.5 71.3±2.0 8.501 <0.001
   Postoperative 3 months 84.8±1.6 76.7±1.8 18.431 <0.001
   Postoperative 6 months 85.87±1.68 81.37±1.94 9.618 <0.001
FJS
   Postoperative 1 month 73.6±2.0 71.4±2.0 4.276 <0.001
   Postoperative 3 months 80.3±2.3 75.5±1.7 9.005 <0.001
   Postoperative 6 months 82.0±1.6 78.8±1.7 7.532 <0.001
Knee flexion-extension ROM (°)
   Postoperative 1 month 124.5±7.9 91.5±8.3 15.77 <0.001
   Postoperative 3 months 106.7±9.2 94.6±4.7 6.403 <0.001
   Postoperative 6 months 120.7±10.7 104.4±5.8 7.28 <0.001

Data are presented as x¯±s. FJS, Forgotten Joint Score; KJCS, Knee Joint Clinical Score; KJFS, Knee Joint Functional Score; ROM, range of motion.

Typical cases are shown in Figures 1-3.

Figure 1 Preoperative planning for medial pivot total knee arthroplasty. Preoperative weight-bearing full-length radiographs of both lower limbs were used to measure femoral and tibial angles. According to the reference angles, the postoperative lower limb alignment was planned to retain 3° of varus. mLDFA, mechanical lateral distal femoral angle; MPTA, medial proximal tibia angle.
Figure 2 Medial pivot kinematic mechanism. (A) Femoral posterior condylar osteotomy with 0° external rotation. (B) Medial flexion gap tightness compensated by 2° varus correction in tibial osteotomy. (C) Native medial collateral ligament preserved intact. (D) Medial pivot kinematics reproduced intraoperatively.
Figure 3 Postoperative images. (A) At 1-month follow-up, the medial pivot TKA achieved full extension (0°) with no extension lag in the right limb. (B) The prosthesis demonstrated excellent flexion to 130° with maintained stability throughout the arc of motion at 1-month evaluation. (C) Postoperative right limb mechanical alignment maintained at 3° varus. MPTA, medial proximal tibia angle; TKA, total knee arthroplasty.

Discussion

For several decades, TKA has been a highly effective treatment for end-stage osteoarthritis (14-16). The MA technique focuses on reconstructing the hip-knee-ankle center axis, known as the mechanical axis, on a two-dimensional plane for restoring lower limb alignment. Although this method favors long-term prosthesis survival, it overlooks individual variations in knee anatomy, balance, and biomechanics (17-19). It has been reported that the prevalence of residual knee symptoms (pain, instability, and effusion) and patient dissatisfaction following MA-TKA can be as high as 50% and 20%, respectively. Furthermore, neither modern TKA prosthesis designs nor technological aids (computer-assisted surgery, robotic technology, or personalized cutting guides) have resolved these issues (20-24). Studies have demonstrated that lower limb alignment dynamically changes with weight-bearing and knee flexion degree, and the knee joint motion is “loading-dependent” during activities of daily living (25-27). These findings confirm that current TKA techniques cannot reliably preserve intraoperatively established knee kinematics during postoperative function, a limitation that persists across all prosthetic designs and soft tissue management strategies (28,29). Following TKA, the knee may remodel a new pattern of motion according to its individual rehabilitation activities. KA or rKA techniques employ tailored alignment strategies favoring the limb’s natural anatomy and prioritize ligament balance over static two-dimensional planar alignment; however, they pose limitations based on the principle of symmetric gap-tension soft tissue balancing.

The results of this study demonstrate significant advantages in treating end-stage KOA replicating the medial pivot motion generated by a PS prosthesis and natural knee asymmetric mechanism assisted using the IKPAS navigation system. This approach demonstrates promising results of substantial improvement in postoperative rehabilitation outcomes and shortened hospital stays, which hold significant implications for clinical practice. Its unique feature is that, under IKPAS navigation system assistance, distal femoral osteotomy is performed perpendicular to the mechanical axis, and the proximal medial angle for the tibial osteotomy is set at 87°, adjustable by ±2°. The hip-knee-ankle angle was maintained between 175° and 180° (moderate joint line inclination principle). A previous study has indicated that restricting varus tibial osteotomy to within 3° is safe; exceeding 3°, while potentially reducing the need for soft tissue release, requires further confirmation in terms of long-term safety (30).

The difference between this method and previous KA-TKA or rKA techniques lies in its combination of the advantages of MA and functional alignment, ultimately achieving excellent postoperative outcomes. This technique better aligns with the goals of natural anatomical structure and functional alignment. Furthermore, it emphasizes that when evaluating differences between TKA alignment techniques, considering not just coronal plane alignment, but more significantly, the restoration of natural knee asymmetry and the medial pivot motion pattern are crucial. However, the degree of medial pivot is individualized, formed during postoperative rehabilitation and adaptation with the body. This finding deviates from the previous paradigm of attempting to establish an entire kinematic solution through intraoperative measurement.

Despite the excellent performance of the IKPAS navigation system and the medial pivot motion generated by the PS prosthesis coordinated with the MCL in improving surgical accuracy and postoperative rehabilitation efficiency, certain limitations exist. First, the follow-up time is short and we need the data of kinematics at least 1 or 2 years after surgery to demonstrate the customized optimal pattern of movement. Second, precise control of the medial-lateral soft tissue tension difference intraoperatively remains challenging; achieving better soft tissue balance may require future development and use of tension sensors. Third, the sample size in this study was relatively small. Increasing the number of cases in future research and the result of operations performed by other surgeons is necessary to strengthen the evidence of the conclusions.

Conclusions

The new method of soft tissue balancing by maintaining the natural knee asymmetry and medial pivot motion generated by the PS prosthesis coordinated with the MCL demonstrates clear clinical advantages in TKA in the short-term follow up. This concept addresses the shortcomings of only generating static stability, eliminating paradoxical motion within the artificial joint prosthesis. This new method holds promise for substantially improving postoperative rehabilitation outcomes, reducing patient suffering, enhancing overall satisfaction, and providing guidance for shifting the paradigm from standardized procedures to individualized approaches.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-43/rc

Data Sharing Statement: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-43/dss

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-43/prf

Funding: This work was funded by the Science and Technology Fund Project of Guizhou Provincial Health Commission (No. gzwkj2025-360) and the Guizhou Provincial Science and Technology Achievement Transformation and Industrialization Program Project (Clinical Special Project) (Qian Ke He Cheng Guo-LC[2025] General 160).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-43/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Beijing Jishuitan Hospital Guizhou Hospital (No. KT2024071527) and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/aoj-25-43
Cite this article as: Wu J, Pan F, Zhang J, Yang C, Gao Y, Luo D, Liu M. Maintaining natural knee asymmetry in total knee arthroplasty: short-term outcomes of a novel soft-tissue balancing technique (a retrospective cohort study). Ann Joint 2025;10:25.

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