Linked TKA technique

Redefining Total Knee Replacement Through Precision and Personalization

Total knee arthroplasty (TKA) has long relied on mechanical alignment principles, aiming to create standardized cuts perpendicular to the mechanical axis of the femur and tibia. While effective in many cases, traditional mechanical alignment can often overlook the unique anatomical and soft tissue variations that define each patient’s native knee kinematics. As a result, some patients report persistent discomfort, unnatural joint movement, or dissatisfaction following standard knee replacement procedures.

In recent years, kinematic alignment has emerged as a transformative approach to TKA—one that restores the pre-arthritic anatomy and joint line of the knee, offering patients a more natural feel and function. At the forefront of this advancement is the Linked Soft Tissue Guided Technique, developed by Dr. Yaron Bar-Ziv, a senior orthopedic surgeon and innovator in personalized joint replacement.

What Is the Linked Technique?

The Linked Soft Tissue Guided Technique is a novel, reproducible, and soft tissue-respecting method for performing kinematic knee arthroplasty. Unlike conventional techniques that rely on computer navigation, robotic assistance, or patient-specific instrumentation (PSI), the Linked Technique simplifies tibial alignment by “linking” the tibial cut to the kinematically aligned femur, guided by natural ligament tension.

This technique blends the best aspects of:

• Femoral kinematic alignment (restoring native joint surfaces).
• Gap balancing in extension
• Soft tissue envelope preservation.
• Achieving balance by compensating for selective cartilage loss while avoiding overcorrection of intact joint surfaces
• It enables the surgeon to recreate native joint line obliquity, limb alignment, and tissue tension without compromising stability—offering both high precision and broad accessibility for orthopedic teams.

Why Kinematic Alignment Matters

Traditional mechanical alignment assumes a one-size-fits-all approach—often resulting in joint lines and component placements that do not match the patient’s natural anatomy. In contrast, kinematic alignment aims to mimic the knee’s original biomechanics by preserving the orientation of the joint line, the relationship between femur and tibia, and the natural soft tissue laxity.

This results in:

• Improved range of motion
• Better functional outcomes
• Enhanced patient satisfaction

Clinical Evidence and Patient Outcomes

A study led by Dr. Bar-Ziv and colleagues, involving 146 consecutive kinematic TKA patients, revealed that the Linked Technique delivers superior outcomes in key patient-reported areas. Among 26 patients who had undergone bilateral knee replacements—one with mechanical alignment and one with the linked kinematic approach—73% preferred the kinematic knee. They reported:

• Less post-operative pain
• Quicker return to activity
• A more “natural” joint sensation

In fact, many patients described the kinematic knee as requiring less effort in daily walking, especially over short distances. The study also indicated that after a learning curve of just 20 patients, the technique became reliably reproducible—making it accessible even to surgeons new to kinematic TKA.

How the Linked Technique Works

The procedure begins with the kinematic alignment of the femoral component, followed by gap balancing using anatomically shaped shims that creating feeler gauge effect within the joint space compensating for the volumetric tibial wear to restore the limb’s natural tension and alignment. The surgeon then links the tibial cutting guide to the femoral alignment using a dedicated instrument that references the femur’s position at 90° flexion. This ensures the tibial cut is perfectly aligned with the kinematically positioned femur, resulting in accurate restoration of the joint line and optimal soft tissue balance.

Critically, this method:

• Avoids unnecessary ligament releases
• Preserves the native soft tissue envelope
• Ensures proper tibial slope and rotation
• Supports decision-making based on anatomically relevant joint surface landmarks, rather than relying solely on traditional mechanical axes, allowing for a more personalized and precise orientation of the resection planes
• Enables accurate, first-pass tibial cutting without the need for repeated resections
• Does not require additional technologies or costly PSI