There is an increasing interest in new devices such as tensiometers for flexion gap balancing during total knee arthroplasty (TKA). The purpose of this study was to determine the influence of patella positioning during flexion gap balancing on femoral component rotation. We prospectively evaluated 32 consecutive knees in 31 patients who underwent primary TKA for degenerative osteoarthritis and where soft tissue balancing was performed using the same tensiometer. Preoperative measurements included valgus/varus deformation, mechanical axis, epicondylar axis, and tibial slope. Intraoperatively, measurement of femoral component rotation in 90 degrees of knee flexion was conducted in three different positions of the patella: (1) patella reduced, (2) patella dislocated but not everted, and (3) patella dislocated and everted. The femoral component had significantly higher rotation when the patella was reduced compared with a dislocated patella (4.9 ± 2.1 degrees vs. 4.2 ± 2.2 degrees; p = 0.006) and compared with a dislocated and everted patella (4.9 ± 2.1 degrees vs. 4.1 ± 2.3 degrees; p = 0.006). Varus knees (n = 22) demonstrated significantly increased femoral component rotation if the patella was reduced (5.3 ± 2.2 degrees) compared with dislocated patella without eversion (4.7 ± 2.3 degrees; p = 0.037) and with eversion (4.4 ± 2.5 degrees; p = 0.019). As such, the measurement of the mediolateral flexion gap stability with a laterally dislocated patella leads to a statistically significant overestimation of the lateral ligament stability and an underestimation of the external rotation positioning of the femoral component of approximately 1 degree, which is aggravated in varus knees. This is a Level II, prospective consecutive series study.
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