18 March 2026
The why of Motion: A Clinical Perspective on Soft Tissue Balancing with Prof. R. Becker
Soft Tissue Balancing in Total Knee Arthroplasty (TKA) is increasingly recognized not merely as a step in the procedure, but as the primary driver of successful outcomes. As part of our ongoing campaign, “Soft Tissue Balancing – the sense of stability,” today we explore the philosophy that treats TKA as a soft tissue procedure first and a bony procedure second with Prof. R. Becker, Brandenburg/Havel, Germany.
“The soft tissue is the envelope which stabilizes the knee primarily in all three planes,” the expert explains. In this approach, knee kinematics are entirely dependent on the tension of this envelope. “Good knee function can only be expected when the soft tissue is well respected during TKA surgery.”
Achieving a well-balanced knee requires a focus on two major positions: stability in full extension and at 90° of knee flexion. However, the philosophy goes deeper than these two extremes. A critical challenge in traditional surgery is mid-flexion instability, which often occurs at 45° of flexion when the joint line level is not properly respected. “It shows the existence of a harmony between the bony contour and the ligament tension,” Dr. Becker notes. This harmony is the "sweet spot" where the implant and the patient's natural anatomy coexist without conflict.
Why place such a heavy emphasis on the soft tissue over the bone? The answer lies in the source of patient discomfort. “Nociception comes from the soft tissue and not from the bone or cartilage. Therefore, I always refer to TKA as a soft tissue procedure rather than a bony one.”
The clinical stakes are high: stiffness and instability account for approximately 30% of revision surgeries. By prioritizing balancing, surgeons can directly address these primary causes of failure. Proper tensioning allows patients to regain a good range of motion early after surgery, leading to less pain and more rapid mobilization.
The main clinical advantage, less postoperative pain and rapid functional improvement, is clear, yet the execution remains a sophisticated challenge. Much like the individuality found in joint line orientation and tibial slope, ligaments also exhibit unique tension patterns.
“Similar to the bone, we need to understand that the ligaments around the knee show individual tension patterns and thus individual function. This is the major challenge in TKA,” he emphasizes. Recognizing this individuality is what moves a surgeon from a "one-size-fits-all" alignment toward a truly patient-centric result.
Looking toward the future, the integration of robotics, AR, and VR offers two distinct advantages. First is the immediate increase in precision regarding bone cuts and component placement. Second, and perhaps more importantly, is the collection of data.
“We are collecting data which will enable us in the future to operate in a manner respecting both the bony and the soft tissue as much as possible. It will happen due to Artificial Intelligence, and I am sure we are not far away from that.”
* Please note: Enovis, as a manufacturer of prosthetic implants, does not practice the medical profession. The choice of the most suitable surgical procedure and technique is the responsibility of the healthcare professional. Each Surgeon must evaluate the appropriateness of the implant technique they intend to perform in light of their own preparation, experience and clinical evaluation of each individual Patient.
Please note that Prof. S . Eggli receive compensation from Enovis under contract for advisory services in relation to Limacorporate, Mathys and Enovis’ medical products. Such services do not include the promotion of any Enovis product.
