{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T16:06:54Z","timestamp":1790698014457,"version":"4.1.0"},"reference-count":26,"publisher":"Wiley","issue":"10","license":[{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T00:00:00Z","timestamp":1768780800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["esskajournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Knee surg. sports traumatol. arthrosc."],"published-print":{"date-parts":[[2026,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Achieving balanced soft tissue tension is crucial for successful total knee arthroplasty (TKA), yet remains challenging. This study investigated the effect of standardised distraction forces on medial and lateral femorotibial gap sizing during robotic\u2010assisted TKA, with particular attention to specific patient characteristics like gender and age.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this prospective single\u2010center cohort study, 238 patients (83 males, 155 females; mean age 70\u2009\u00b1\u20099.6 years) undergoing primary robotic\u2010assisted TKA were enroled. A force\u2010controlled ligament tensioner applied distraction forces of 100, 150, 200 and 250\u2009N at 5\u00b0 and 90\u00b0 of flexion. Medial and lateral joint gaps were recorded intraoperatively via the MAKO\u00ae Robotic\u2010Arm Assisted Surgery System. Subgroup analyses were performed for gender and age categories, and stiffness was calculated as the slope of force\u2013displacement curves.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Gap widening increased non\u2010linearly with higher distraction forces, with greater expansion in the lateral compartment, particularly in flexion. Female patients demonstrated significantly larger medial gap increases at forces \u2265 150\u2009N compared to males (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.01; small effect sizes). Age had a comparatively minor influence, with statistically significant differences limited to older subgroups (80\u201390 years). Gender\u2010based differences were found in gap behaviour. Female patients showed greater gap increases and lower medial stiffness, particularly at higher distraction force between 150\u2013250\u2009N than males.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The results underline the need for individualised, force\u2010adaptive balancing, where robotic real\u2010time gap analysis may help to optimise stability and reduce the risk of postoperative instability (caused by under\u2010tensioning), stiffness (caused by over\u2010tensioning), or pain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>Level II.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ksa.70269","type":"journal-article","created":{"date-parts":[[2026,1,19]],"date-time":"2026-01-19T12:22:27Z","timestamp":1768825347000},"page":"3617-3626","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Non\u2010linear, compartment\u2010specific gap widening with rising distraction forces highlights the need for individualised, force\u2010guided soft\u2010tissue balancing in total knee arthroplasty"],"prefix":"10.1002","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-9969-6189","authenticated-orcid":false,"given":"Jonathan","family":"Lettner","sequence":"first","affiliation":[{"name":"Center of Orthopaedics, Traumatology and Plastic Surgery, Brandenburg Medical School University Hospital Brandenburg an der Havel Brandenburg an der Havel Germany"},{"name":"Faculty of Health Science, University of Brandenburg University of Potsdam Potsdam 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and Plastic Surgery, Brandenburg Medical School University Hospital Brandenburg an der Havel Brandenburg an der Havel Germany"},{"name":"Faculty of Health Science, University of Brandenburg University of Potsdam Potsdam Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1833-7608","authenticated-orcid":false,"given":"Roland","family":"Becker","sequence":"additional","affiliation":[{"name":"Center of Orthopaedics, Traumatology and Plastic Surgery, Brandenburg Medical School University Hospital Brandenburg an der Havel Brandenburg an der Havel Germany"},{"name":"Faculty of Health Science, University of Brandenburg University of Potsdam Potsdam Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,1,19]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00590-023-03798-2"},{"issue":"9","key":"e_1_2_11_3_1","article-title":"Stiffness after 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