Skip to main content

Improving tibial component alignment in total knee arthroplasty

Knee Surgery, Sports Traumatology, Arthroscopy volume 23, pages 3563–3570 (2015)Cite this article

Abstract

Purpose

Tibia torsion may influence the accuracy of extramedullary instrumentations in total knee arthroplasty (TKA). This study assessed whether the effect of tibial torsion may be overcome using a surgical technique in which the extramedullary rod is aligned to reference points at the proximal tibia only.

Methods

A consecutive series of 94 knees that underwent TKA were analyzed. In the first 47 knees (group 1), a standard procedure for tibial component alignment was performed while in the second group of 47 knees, a modified surgical technique was used including the alignment of the extramedullary rod to the reference points at the proximal tibia only (group 2). Lower limb, femoral, and tibial component alignment were measured on postoperative long-leg radiographs.

Results

Femorotibial mechanical axes angles were similar in the two groups. Femoral component alignment also did not differ between the groups. A neutral alignment of the tibial component was achieved in 17 and 34 % of the knees in group 1 and group 2, respectively (p = 0.04). A malalignment of the tibial component >3° was found in 34 % of knees in group 1 compared with 4 % of those in group 2 (p = 0.0001).

Conclusions

Coronal alignment of the tibial component may improve by setting the extramedullary rod in line with anatomical references in the proximal tibia only. This technique appears to bypass the influence of tibial torsion on the alignment of the extramedullary guide at the distal tibia. The clinical relevance of the study is that using this technique, the rate of malalignment of the tibial component may be reduced compared to a standard technique in which a fixed reference is used at the ankle joint.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. Aglietti P, Sensi L, Cuomo P, Ciardullo A (2008) Rotational position of femoral and tibial components in TKA using the femoral transepicondylar axis. Clin Orthop Relat Res 466:2751–2755

    PubMed Central  Article  PubMed  Google Scholar 

  2. Akagi M, Oh M, Nonaka T, Tsujimoto H, Asano T, Hamanishi C (2004) An anteroposterior axis of the tibia for total knee arthroplasty. Clin Orthop Relat Res 420:213–219

    Article  PubMed  Google Scholar 

  3. Akagi M, Mori S, Nishimura S, Nishimura A, Asano T, Hamanishi C (2005) Variability of extraarticular tibial rotation references for total knee arthroplasty. Clin Orthop Relat Res 436:172–176

    Article  PubMed  Google Scholar 

  4. Benjamin J (2006) Component alignment in total knee arthroplasty. Am Acad Orthop Surg Instr Course Lect 55:405–412

    Google Scholar 

  5. Chiu KY, Yau WP, Ng TP, Tang WM (2008) The accuracy of extramedullary guides for tibial component placement in total knee arthroplasty. Int Orthop 32:467–471

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  6. Cinotti G, Sessa P, Rocca AD, Ripani FR, Giannicola G (2013) Effects of tibial torsion on distal alignment of extramedullary instrumentation in total knee arthroplasty. Acta Orthop 84:275–279

    PubMed Central  Article  PubMed  Google Scholar 

  7. Cobb JP, Dixon H, Dandachli W, Iranpour F (2008) The anatomical tibial axis: reliable rotational orientation in knee replacement. J Bone Joint Surg (Br) 90:1032–1038

    CAS  Article  Google Scholar 

  8. Dennis DA, Channer M, Susman MH, Stringer EA (1993) Intramedullary versus extramedullary tibial alignment systems in total knee arthroplasty. J Arthroplasty 8:43–47

    CAS  Article  PubMed  Google Scholar 

  9. Dexel J, Kirschner S, Klaus-Günther K-P, Lützner J (2013) Agreement between radiological and computer navigation measurement of lower limb alignment. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2599-4

    Google Scholar 

  10. Eckhoff DG, Johnson KK (1994) Three-dimensional computed tomography reconstruction of tibial torsion. Clin Orthop Relat Res 302:42–46

    PubMed  Google Scholar 

  11. Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12

    PubMed  Google Scholar 

  12. Fang DM, Ritter MA, Davis KE (2009) Coronal alignment in total knee arthroplasty: Just how important is it? J Arthroplasty 24(Suppl 6):39–43

    Article  PubMed  Google Scholar 

  13. Green GV, Berend KR, Berend ME, Glisson RR, Vail TP (2002) The effects of varus tibial alignment on proximal tibial surface strain in total knee arthroplasty: the posteromedial hot spot. J Arthroplasty 17:1033–1039

    Article  PubMed  Google Scholar 

  14. Heyse TJ, Decking R, Davis J, Boettner F, Laskin RS (2009) Varus gonarthrosis predisposes to varus malalignment in TKA. HSSJ 5:143–148

    Article  Google Scholar 

  15. Hovinga KR, Lerner AL (2009) Anatomic variations between Japanese and Caucasian populations in the healthy young adult knee joint. J Orthop Res 27:1191–1196

    Article  PubMed  Google Scholar 

  16. Hsu HP, Garg A, Walker PS, Spector M, Ewald FC (1989) Effect of knee component alignment on tibial load distribution with clinical correlation. Clin Orthop Relat Res 248:135–144

    PubMed  Google Scholar 

  17. Huddleston JL, Scott RD, Wimberley DW (2005) Determination of neutral tibial rotational alignment in rotating platform TKA. Clin Orthop Relat Res 440:101–106

    Article  PubMed  Google Scholar 

  18. Ishii Y, Ohmori G, Bechtold JE, Gustilo RB (1995) Extramedullary versus intramedullary alignment guides in total knee arthroplasty. Clin Orthop Relat Res 318:167–175

    PubMed  Google Scholar 

  19. Jakob RP, Haertel M, Stussi E (1980) Tibial torsion calculated by computerised tomography and compared to other methods of measurement. J Bone Joint Surg 62-B:238–242

    CAS  Google Scholar 

  20. Ko PS, Tio MK, Ban CM, Mak YK, Ip FK, Lam JJ (2001) Radiologic analysis of the tibial intramedullary canal in Chinese varus knees. Implications in total knee arthroplasty. J Arthroplasty 16:212–215

    CAS  Article  PubMed  Google Scholar 

  21. Kim D, Seong SC, Lee MC, Lee S (2012) Comparison of the tibiofemoral rotational alignment after mobile and fixed bearing total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:337–345

    Article  PubMed  Google Scholar 

  22. Lützner J, Krummenauer F, Günther KP, Kirschner S (2010) Rotational alignment of the tibial component in total knee arthroplasty is better at the medial third of tibial tuberosity than at the medial border. BMC Musculoskelet Disord 11:57

    PubMed Central  Article  PubMed  Google Scholar 

  23. Maestro A, Harwin SF, Sandoval MG, Vaguero DH, Murcia A (1998) Influence of intramedullary versus extramedullary alignment guides on final total knee arthroplasty component position: a radiographic analysis. J Arthroplasty 13(5):552–558

    CAS  Article  PubMed  Google Scholar 

  24. Mihalko WM, Krackow KA (2006) Differences between extramedullary, intramedullary and computer-aided surgery tibial alignment techniques for total knee arthroplasty. J Knee Surg 19:33–36

    PubMed  Google Scholar 

  25. Mizu-uchi H, Matsuda S, Miura H, Hikagi H, Okazaki K, Iwamoto Y (2006) The effect of ankle rotation on cutting of the tibia in total knee arthroplasty. J Bone Joint Surg 88-A:2632–2636

    Article  Google Scholar 

  26. Mowlavi A, Whiteman J, Wilhelmi BJ, Neumeister MW, McLafferty R (2002) Dorsalis pedis arterial pulse: palpation using a bony landmark. Postgrad Med J 78:746–747

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  27. Nagamine R, Miura H, Bravo C, Urabe K, Matsuda S, Miyanishi K, Hirata G, Iwamoto Y (2000) Anatomic variation should be considered in total knee arthroplasty. J Orthop Sci 5:232–237

    CAS  Article  PubMed  Google Scholar 

  28. Nagamine R, Miyanishi K, Miura H, Urabe K, Matsuda S, Iwamoto Y (2003) Medial torsion of the tibia in Japanese patients with osteoarthritis of the knee. Clin Orthop Relat Res 408:218–224

    Article  PubMed  Google Scholar 

  29. Nunley RM, Ellison BS, Zhu J, Ruh EL, Howell SM, Barrack RL (2012) Do patient-specific guides improve coronal alignment in total knee arthroplasty? Clin Orthop Relat Res 470:895–902

    PubMed Central  Article  PubMed  Google Scholar 

  30. Parker Vail T, Lang JE (2006) Surgical techniques and instrumentation in total knee arthroplasty. In: Scott WN (ed) Insall and scott surgery of the knee, vol 1. Churchill Livingstone, Elsevier, Philadelphia, pp 1455–1521

  31. Patil S, D’Lima DD, Fait JM, Colwell CW Jr (2007) Improving tibial component coronal alignment during total knee arthroplasty with use of a tibial planing device. J Bone Joint Surg 89-A:381–387

    Article  PubMed  Google Scholar 

  32. Perillo-Mercone A, Taylor M (2007) Effect of varus/valgus malalignment on bone strains in the proximal tibia after an explicit finite element study. J Biomech Eng 129:1–11

    Article  Google Scholar 

  33. Reed MR, Bliss W, Sher JL, Emmerson KP, Jones SM, Partington PF (2002) Extramedullary or intramedullary tibial alignment guides: a randomised, prospective trial of radiological alignment. J Bone Joint Surg 84-B:858–860

    Article  Google Scholar 

  34. Sasanuma H, Hitoshi Sekiya H, Takatoku K, Ajiki T, Hagiwara H (2014) Accuracy of a proximal tibial cutting method using the anterior tibial border in TKA. Eur J Orthop Surg Traumatol. doi:10.1007/s00590-014-1415-2

    PubMed  Google Scholar 

  35. Schneider M, Heisel C, Aldinger PR, Breusch SJ (2007) Use of palpable tendons for extramedullary tibial alignment in total knee arthroplasty. J Arthroplasty 22:219–226

    Article  PubMed  Google Scholar 

  36. Strecker W, Keppler P, Gebhard F, Kinzl L (1997) Length and torsion of the lower limb. J Bone Joint Surg 79-B:1019–1023

    Article  Google Scholar 

  37. Sugimura N, Ikeuchi M, Izumi M, Aso K, Ushida T, Tani T (2013) The dorsal pedis artery as a new distal landmark for extramedullary tibial alignment in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2461-8

    Google Scholar 

  38. Takai S, Sakakida K, Yamashita F, Suzu F, Izuta F (1985) Rotational alignment of the lower limb in osteoarthritis of the knee. Int Orthop 9:209–215

    CAS  Article  PubMed  Google Scholar 

  39. Teter KE, Bregman D, Colwell CW Jr (1995) Accuracy of intramedullary versus extramedullary tibial alignment cutting systems in total knee arthroplasty. Clin Orthop Relat Res 321:106–110

    PubMed  Google Scholar 

Download references

Author information

Affiliations

  1. Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, University “La Sapienza”, Rome, Italy

    G. Cinotti, P. Sessa, A. D’Arino, F. R. Ripani & G. Giannicola

Authors
  1. G. Cinotti
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. P. Sessa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. D’Arino
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. F. R. Ripani
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. G. Giannicola
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. Cinotti.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cinotti, G., Sessa, P., D’Arino, A. et al. Improving tibial component alignment in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23, 3563–3570 (2015). https://doi.org/10.1007/s00167-014-3236-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-014-3236-6

Keywords

  • Total knee arthroplasty
  • Tibial cut
  • Tibial component alignment
  • Total knee alignment
  • Extramedullary instrumentations