Relationship between the surgical epicondylar axis and the articular surface of the distal femur: an anatomic study

  • Sébastien Lustig
  • Frédéric Lavoie
  • Tarik Ait Si Selmi
  • Elvire Servien
  • Philippe Neyret
Knee

Abstract

Many authors presented the epicondylar axis as the fixed axis of rotation of the femoral condyles during flexion of the knee. Positioning of the femoral component of a total knee arthroplasty (TKA) based on the epicondyles has been proposed. This work is a critical analysis of this concept. Metallic bodies were inserted at the level of collateral ligament insertions on 16 dried femurs, allowing us to locate the surgical epicondylar axis. The dried femurs were studied using standard radiographs and CT-scan. CT cuts were made perpendicular to the epicondylar axis. The medial mechanical femoral angle and the epicondylar angle were measured on the radiographs. The posterior and distal epiphyseal rotations relative to the epicondylar axis (Posterior Condylar Angle, PCA, and Distal Condylar Angle, DCA, respectively) were measured on the CT-scans. PCA and DCA values were compared. The centre of the posterior femoral condyles was located on sagittal reconstructions using the tangent method and was confirmed with circular templates, and then compared to the location of the epicondyles. Circle-fitting of the entire femoral condylar contours centred on the epicondyles was also tried. The mechanical femoral axis was nearly perpendicular to the epicondylar axis but with important variations. The average PCA and DCA were 1.9° ± 1.8° and 3.1° ± 2.1°, respectively. No relationship could be established between the mechanical femoral angle and the PCA. The individual differences between the PCA and the DCA averaged 2.2°. A significant distance was found between the centre of the condylar contours and the epicondyles: 6.5 mm in average on the lateral side (range 2.3–11.3 mm) and 8.4 mm on the medial side (range 4.0–11.6 mm). Circle-fitting of the entire medial or lateral femoral condylar contours centred on the epicondyles was not possible. The centre of the posterior femoral condyles is significantly different from the epicondylar axis, thus refuting the conclusions of previous authors. Furthermore, considering the differences between the distal and posterior condylar angles shown here, as well as the difficulty of repeatably locating the epicondyles during surgery, using the epicondylar axis as the only landmark to position the femoral component during a first intention TKA is not recommended. The surgical epicondylar axis does not appear to be an adequate basis for the understanding of the shape of the distal femur.

Keywords

Total knee arthroplasty Surgical epicondylar axis Femoral anatomy 

References

  1. 1.
    Akagi M, Yamashita E, Nakagawa T, Asano T, Nakamura T (2001) Relationship between frontal knee alignment and reference axes in the distal femur. Clin Orthop Relat Res 147–156Google Scholar
  2. 2.
    Arima J, Whiteside LA, McCarthy DS, White SE (1995) Femoral rotational alignment, based on the anteroposterior axis, in total knee arthroplasty in a valgus knee. A technical note. J Bone Joint Surg Am 77:1331–1334PubMedGoogle Scholar
  3. 3.
    Asano T, Akagi M, Nakamura T (2005) The functional flexion-extension axis of the knee corresponds to the surgical epicondylar axis: in vivo analysis using a biplanar image-matching technique. J Arthroplasty 20:1060–1067PubMedCrossRefGoogle Scholar
  4. 4.
    Asano T, Akagi M, Tanaka K, Tamura J, Nakamura T (2001) In vivo three-dimensional knee kinematics using a biplanar image-matching technique. Clin Orthop 388:157–166PubMedCrossRefGoogle Scholar
  5. 5.
    Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS (1993) Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop 40-47Google Scholar
  6. 6.
    Blaha JD, Mancinelli CA, Simons WH (2002) Using the transepicondylar axis to define the sagittal morphology of the distal part of the femur. J Bone Joint Surg Am 84-A Suppl 2:48–55Google Scholar
  7. 7.
    Blaha JD, Mancinelli CA, Simons WH, Kish VL, Thyagarajan G (2003) Kinematics of the human knee using an open chain cadaver model. Clin Orthop Relat Res 25–34Google Scholar
  8. 8.
    Blankevoort L, Huiskes R, de Lange A (1990) Helical axes of passive knee joint motions. J Biomech 23:1219–1229PubMedCrossRefGoogle Scholar
  9. 9.
    Boisgard S, Moreau PE, Descamps S, Courtalhiac C, Silbert H, Moreel P, Michel JL, Levai JP (2003) Computed tomographic study of the posterior condylar angle in arthritic knees: its use in the rotational positioning of the femoral implant of total knee prostheses. Surg Radiol Anat 25:330–334PubMedCrossRefGoogle Scholar
  10. 10.
    Churchill DL, Incavo SJ, Johnson CC, Beynnon BD (1998) The transepicondylar axis approximates the optimal flexion axis of the knee. Clin Orthop 111–118Google Scholar
  11. 11.
    Desme D, Galand-Desme S, Besse JL, Henner J, Moyen B, Lerat JL (2006) Axial lower limb alignment and knee geometry in patients with osteoarthritis of the knee. Rev Chir Orthop Reparatrice Appar Mot 92:673–679PubMedGoogle Scholar
  12. 12.
    Eckhoff DG, Bach JM, Spitzer VM, Reinig KD, Bagur MM, Baldini TH, Rubinstein D, Humphries S (2003) Three-dimensional morphology and kinematics of the distal part of the femur viewed in virtual reality. Part II. J Bone Joint Surg Am 85-A Suppl 4:97–104Google Scholar
  13. 13.
    Elias SG, Freeman MA, Gokcay EI (1990) A correlative study of the geometry and anatomy of the distal femur. Clin Orthop 98–103Google Scholar
  14. 14.
    Freeman MA, Pinskerova V (2003) The movement of the knee studied by magnetic resonance imaging. Clin Orthop 35–43Google Scholar
  15. 15.
    Griffin FM, Insall JN, Scuderi GR (1998) The posterior condylar angle in osteoarthritic knees. J Arthroplasty 13:812–815PubMedCrossRefGoogle Scholar
  16. 16.
    Griffin FM, Math K, Scuderi GR, Insall JN, Poilvache PL (2000) Anatomy of the epicondyles of the distal femur: MRI analysis of normal knees. J Arthroplasty 15:354–359PubMedCrossRefGoogle Scholar
  17. 17.
    Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG (1993) The axes of rotation of the knee. Clin Orthop 259–268Google Scholar
  18. 18.
    Iwaki H, Pinskerova V, Freeman MA (2000) Tibiofemoral movement 1: the shapes and relative movements of the femur and tibia in the unloaded cadaver knee. J Bone Joint Surg Br 82:1189–1195PubMedCrossRefGoogle Scholar
  19. 19.
    Jiang CC, Insall JN (1989) Effect of rotation on the axial alignment of the femur. Pitfalls in the use of femoral intramedullary guides in total knee arthroplasty. Clin Orthop Relat Res 50–56Google Scholar
  20. 20.
    Jonsson H, Karrholm J (1994) Three-dimensional knee joint movements during a step-up: evaluation after anterior cruciate ligament rupture. J Orthop Res 12:769–779PubMedCrossRefGoogle Scholar
  21. 21.
    Katz MA, Beck TD, Silber JS, Seldes RM, Lotke PA (2001) Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques. J Arthroplasty 16:301–305PubMedCrossRefGoogle Scholar
  22. 22.
    Kinzel V, Ledger M, Shakespeare D (2005) Can the epicondylar axis be defined accurately in total knee arthroplasty? Knee 12:293–296PubMedCrossRefGoogle Scholar
  23. 23.
    Kurosawa H, Walker PS, Abe S, Garg A, Hunter T (1985) Geometry and motion of the knee for implant and orthotic design. J Biomech 18:487–499PubMedCrossRefGoogle Scholar
  24. 24.
    Laskin RS (1995) Flexion space configuration in total knee arthroplasty. J Arthroplasty 10:657–660PubMedCrossRefGoogle Scholar
  25. 25.
    Mantas JP, Bloebaum RD, Skedros JG, Hofmann AA (1992) Implications of reference axes used for rotational alignment of the femoral component in primary and revision knee arthroplasty. J Arthroplasty 7:531–535PubMedCrossRefGoogle Scholar
  26. 26.
    Matsuda S, Miura H, Nagamine R, Urabe K, Mawatari T, Iwamoto Y (2003) A comparison of rotational landmarks in the distal femur and the tibial shaft. Clin Orthop Relat Res 183–188Google Scholar
  27. 27.
    Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE (2001) Optimizing femoral component rotation in total knee arthroplasty. Clin Orthop Relat Res 38–45Google Scholar
  28. 28.
    Nagamine R, Miura H, Inoue Y, Urabe K, Matsuda S, Okamoto Y, Nishizawa M, Iwamoto Y (1998) Reliability of the anteroposterior axis and the posterior condylar axis for determining rotational alignment of the femoral component in total knee arthroplasty. J Orthop Sci 3:194–198PubMedCrossRefGoogle Scholar
  29. 29.
    Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE (1996) Rotational landmarks and sizing of the distal femur in total knee arthroplasty. Clin Orthop Relat Res 35–46Google Scholar
  30. 30.
    Scott WN (2006) Insall & Scott Surgery of the Knee, 4th edn. Churchill Livingstone, PhiladelphiaGoogle Scholar
  31. 31.
    Shiavi R, Limbird T, Frazer M, Stivers K, Strauss A, Abramovitz J (1987) Helical motion analysis of the knee-II. Kinematics of uninjured and injured knees during walking and pivoting. J Biomech 20:653–665PubMedCrossRefGoogle Scholar
  32. 32.
    Stiehl JB, Abbott BD (1995) Morphology of the transepicondylar axis and its application in primary and revision total knee arthroplasty. J Arthroplasty 10:785–789PubMedCrossRefGoogle Scholar
  33. 33.
    Stoeckl B, Nogler M, Krismer M, Beimel C, de la Barrera JL, Kessler O (2006) Reliability of the transepicondylar axis as an anatomical landmark in total knee arthroplasty. J Arthroplasty 21:878–882PubMedCrossRefGoogle Scholar
  34. 34.
    Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P (2005) Tibiofemoral instability in primary total knee replacement: A review Part 2: diagnosis, patient evaluation, and treatment. Knee 12:336–340PubMedCrossRefGoogle Scholar
  35. 35.
    Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P (2005) Tibiofemoral instability in primary total knee replacement: a review, Part 1: Basic principles and classification. Knee 12:257–266PubMedCrossRefGoogle Scholar
  36. 36.
    Yoshino N, Takai S, Ohtsuki Y, Hirasawa Y (2001) Computed tomography measurement of the surgical and clinical transepicondylar axis of the distal femur in osteoarthritic knees. J Arthroplasty 16:493–497PubMedCrossRefGoogle Scholar
  37. 37.
    Yoshioka Y, Siu D, Cooke TD (1987) The anatomy and functional axes of the femur. J Bone Joint Surg Am 69:873–880PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Sébastien Lustig
    • 1
  • Frédéric Lavoie
    • 2
  • Tarik Ait Si Selmi
    • 1
  • Elvire Servien
    • 1
  • Philippe Neyret
    • 1
  1. 1.Service de Chirurgie Orthopédique, Centre LivetHôpital de la Croix-RousseCaluire, LyonFrance
  2. 2.Service de Chirurgie OrthopédiqueHôpital Notre-Dame, Centre Hospitalier de l’Université de MontréalMontrealCanada

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