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The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA)

Knee Surgery, Sports Traumatology, Arthroscopy volume 25, pages 1736–1742 (2017)Cite this article

Abstract

Purpose

The objective of this study was to quantify the amount of ensuing internal rotation of the tibial component when positioned along the medial border of the tibial tubercle, thus establishing a reproducible intraoperative reference for tibial component rotational alignment during total knee arthroplasty (TKA).

Methods

The angle formed from the tibial geometric centre to the intersection of both lines from the middle of the tibial tuberosity and its medial border was measured in 50 patients. The geometric centre was determined on an axial CT slice at 10 mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were taken in 25 patients after TKA, in order to simulate the intraoperative appearance of the tibia after making its proximal resection.

Results

This angle was found to be similar (n.s.) in normal and post-TKA tibiae [median 20.4° (range 15°–24°) vs. 20.7° (range 16°–25°), respectively]. In 89.3 % of the patients, the angle ranged from 17° to 24°. No statistical difference (p n.s.) was found between women and men in both normal [median −20.7° (range 16°–25°) vs. 19.9° (range 15°–24°)] and post-TKA tibiae [median 21.4° (range 19°–24°) vs. 20° (range 16°–25°)].

Conclusion

This study found that in 90 % of the patients, the medial border of the tibial tuberosity is internally rotated 17°–24° in relation to the line connecting the middle of the tuberosity to the tibial geometric centre. Since this anatomical landmark may be more easily identifiable intraoperatively than the commonly used “medial 1/3”, it can provide a better quantitative reference point and help surgeons achieve a more accurate tibial implant rotational position.

Level of evidence

Cohort and case control studies, Level III.

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References

  1. Akagi M, Matsusue Y, Mata T, Asada Y, Horiguchi M, Iida H, Nakamura T (1999) Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res 366:155–163

    Article  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  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  Google Scholar 

  4. Anouchi YS, Whiteside LA, Kaiser AD, Milliano MT (1993) The effects of axial rotational alignment of the femoral component on knee stability and patellar tracking in total knee arthroplasty demonstrated on autopsy specimens. Clin Orthop Relat Res 287:170–177

    Google Scholar 

  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 Relat Res 286:40–47

    Google Scholar 

  6. Berger RA, Crossett LS, Jacobs JJ, Rubash HE (1998) Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 356:144–153

    Article  Google Scholar 

  7. 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(3):275–279

    Article  PubMed  PubMed Central  Google Scholar 

  8. Colwell CW Jr, Chen PC, D’Lima D (2011) Extensor malalignment arising from femoral component malrotation in knee arthroplasty: effect of rotating-bearing. Clin Biomech (Bristol, Avon) 26:52–57

    Article  Google Scholar 

  9. Dalury DF (2001) Observations of the proximal tibia in total knee arthroplasty. Clin Orthop Relat Res 389:150–155

    Article  Google Scholar 

  10. Drexler M, Dwyer T, Chakravertty R, Farno A, Backstein D (2013) Assuring the happy total knee replacement patient. Bone Joint J 95-B:120–123

    CAS  Article  PubMed  Google Scholar 

  11. Eckhoff DG, Johnston RJ, Stamm ER, Kilcoyne RF, Wiedel JD (1994) Version of the osteoarthritic knee. J Arthroplasty 9:73–79

    CAS  Article  PubMed  Google Scholar 

  12. Eckhoff DG, Metzger RG, Vandewalle MV (1995) Malrotation associated with implant alignment technique in total knee arthroplasty. Clin Orthop Relat Res 321:28–31

    Google Scholar 

  13. Graves S, Davidson D, de Steiger R (2011) Australian Orthopaedic Association National Joint Replacement Registry Annual Report for 2011

  14. Hartel MJ, Loosli Y, Gralla J, Kohl S, Hoppe S, Roder C, Eggli S (2009) The mean anatomical shape of the tibial plateau at the knee arthroplasty resection level: an investigation using MRI. Knee 16:452–457

    Article  PubMed  Google Scholar 

  15. Hofmann S, Romero J, Roth-Schiffl E, Albrecht T (2003) Rotational malalignment of the components may cause chronic pain or early failure in total knee arthroplasty. Orthopade 32:469–476

    CAS  Article  PubMed  Google Scholar 

  16. Howell SM, Chen J, Hull ML (2013) Variability of the location of the tibial tubercle affects the rotational alignment of the tibial component in kinematically aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2288–2295

    Article  PubMed  Google Scholar 

  17. Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD (2007) Early revision for component malrotation in total knee arthroplasty. Clin Orthop Relat Res 458:131–136

    PubMed  Google Scholar 

  18. Insall JN (1993) Surgical techniques and instrumentation in total knee arthroplasty. In: Insall JN, Windsor RE, Scott WN, Kelly M, Aglietti P (eds) Surgery of the knee, 2nd edn. Churchill livingstone, New York, pp 739–804

    Google Scholar 

  19. Jazrawi LM, Birdzell L, Kummer FJ, Di Cesare PE (2000) The accuracy of computed tomography for determining femoral and tibial total knee arthroplasty component rotation. J Arthroplasty 15:761–766

    CAS  Article  PubMed  Google Scholar 

  20. Kawahara S, Matsuda S, Okazaki K, Tashiro Y, Mitsuyasu H, Nakahara H, Iwamoto Y (2012) Relationship between the tibial anteroposterior axis and the surgical epicondylar axis in varus and valgus knees. Knee Surg Sports Traumatol Arthrosc 20:2077–2081

    Article  PubMed  Google Scholar 

  21. Kawahara S, Okazaki K, Matsuda S, Mitsuyasu H, Nakahara H, Okamoto S, Iwamoto Y (2014) Medial sixth of the patellar tendon at the tibial attachment is useful for the anterior reference in rotational alignment of the tibial component. Knee Surg Sports Traumatol Arthrosc 22:1070–1075

    Article  PubMed  Google Scholar 

  22. Lakstein D, Zarrabian M, Kosashvili Y, Safir O, Gross AE, Backstein D (2010) Revision total knee arthroplasty for component malrotation is highly beneficial: a case control study. J Arthroplasty 25:1047–1052

    Article  PubMed  Google Scholar 

  23. Lewis P, Rorabeck CH, Bourne RB, Devane P (1994) Posteromedial tibial polyethylene failure in total knee replacements. Clin Orthop Relat Res 299:11–17

    Google Scholar 

  24. Li P, Tsai TY, Li JS, Zhang Y, Kwon YM, Rubash HE, Li G (2014) Morphological measurement of the knee: race and sex effects. Acta Orthop Belg 80:260–268

    PubMed  Google Scholar 

  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 7:531–535

    CAS  Article  PubMed  Google Scholar 

  26. Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE (2001) Optimizing femoral component rotation in total knee arthroplasty. Clin Orthop Relat Res 392:38–45

    Article  Google Scholar 

  27. Moreland JR (1988) Mechanisms of failure in total knee arthroplasty. Clin Orthop Relat Res 226:49–64

    Google Scholar 

  28. Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 69:745–749

    CAS  Article  PubMed  Google Scholar 

  29. Mortazavi SM, Molligan J, Austin MS, Purtill JJ, Hozack WJ, Parvizi J (2011) Failure following revision total knee arthroplasty: infection is the major cause. Int Orthop 35:1157–1164

    Article  PubMed  Google Scholar 

  30. Nagamine R, Whiteside LA, White SE, McCarthy DS (1994) Patellar tracking after total knee arthroplasty. The effect of tibial tray malrotation and articular surface configuration. Clin Orthop Relat Res 304:262–271

    Google Scholar 

  31. Ollivier M, Tribot-Laspiere Q, Amzallag J, Boisrenoult P, Pujol N, Beaufils P (2015) Abnormal rate of intraoperative and postoperative implant positioning outliers using “MRI-based patient-specific” compared to “computer assisted” instrumentation in total knee replacement. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3645-1

    PubMed  Google Scholar 

  32. Roberts TD, Clatworthy MG, Frampton CM, Young SW (2015) Does computer assisted navigation improve functional outcomes and implant survivability after total knee arthroplasty? J Arthroplasty 30:59–63

    Article  PubMed  Google Scholar 

  33. Sahin N, Atici T, Kurtoglu U, Turgut A, Ozkaya G, Ozkan Y (2013) Centre of the posterior cruciate ligament and the sulcus between tubercle spines are reliable landmarks for tibial component placement. Knee Surg Sports Traumatol Arthrosc 21:2384–2391

    Article  PubMed  Google Scholar 

  34. Streiner DL, Norman GR (1995) Health measurement scales: a practical guide to their development and use. Oxford University Press, New York

    Google Scholar 

  35. Su EP, Su SL, Della Valle AG (2010) Stiffness after TKR: how to avoid repeat surgery. Orthopedics 33:658-20100722-48

    Google Scholar 

  36. Thompson JA, Hast MW, Granger JF, Piazza SJ, Siston RA (2011) Biomechanical effects of total knee arthroplasty component malrotation: a computational simulation. J Orthop Res 29:969–975

    Article  PubMed  Google Scholar 

  37. Uehara K, Kadoya Y, Kobayashi A, Ohashi H, Yamano Y (2002) Bone anatomy and rotational alignment in total knee arthroplasty. Clin Orthop Relat Res 402:196–201

    Article  Google Scholar 

  38. van der Linden-van der Zwaag HM, Bos J, van der Heide HJ, Nelissen RG (2011) A computed tomography based study on rotational alignment accuracy of the femoral component in total knee arthroplasty using computer-assisted orthopaedic surgery. Int Orthop 35:845–850

    Article  PubMed  Google Scholar 

  39. van Gennip S, Schimmel JJ, van Hellemondt GG, Defoort KC, Wymenga AB (2014) Medial patellofemoral ligament reconstruction for patellar maltracking following total knee arthroplasty is effective. Knee Surg Sports Traumatol Arthrosc 22(10):2569–2573

    Article  PubMed  Google Scholar 

  40. Vanbiervliet J, Bellemans J, Verlinden C, Luyckx JP, Labey L, Innocenti B, Vandenneucker H (2011) The influence of malrotation and femoral component material on patellofemoral wear during gait. J Bone Joint Surg Br 93:1348–1354

    CAS  Article  PubMed  Google Scholar 

  41. Verlinden C, Uvin P, Labey L, Luyckx JP, Bellemans J, Vandenneucker H (2010) The influence of malrotation of the femoral component in total knee replacement on the mechanics of patellofemoral contact during gait: an in vitro biomechanical study. J Bone Joint Surg Br 92:737–742

    CAS  Article  PubMed  Google Scholar 

  42. Wasielewski RC, Galante JO, Leighty RM, Natarajan RN, Rosenberg AG (1994) Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty. Clin Orthop Relat Res 299:31–43

    Google Scholar 

  43. Yang B, Song CH, Yu JK, Yang YQ, Gong X, Chen LX, Wang YJ, Wang J (2014) Intraoperative anthropometric measurements of tibial morphology: comparisons with the dimensions of current tibial implants. Knee Surg Sports Traumatol Arthrosc 22:2924–2930

    Article  PubMed  Google Scholar 

  44. Yoshioka Y, Siu D, Cooke TD (1987) The anatomy and functional axes of the femur. J Bone Joint Surg Am 69:873–880

    CAS  Article  PubMed  Google Scholar 

  45. Yoshioka Y, Siu DW, Scudamore RA, Cooke TD (1989) Tibial anatomy and functional axes. J Orthop Res 7:132–137

    CAS  Article  PubMed  Google Scholar 

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Author information

Affiliations

  1. Tel-Aviv Sourasky Medical Center, Tel Aviv University, Waitzman 6 St, 6423906, Tel Aviv, Israel

    Michael Drexler, Tal Frenkel Rutenberg, Yaniv Warschawski & Ehud Rath

  2. Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada

    David Backstein, Ueli Studler, Dror Lakstein & Yona Kosashvili

  3. Hasharon Campus, Rabin Medical Center Hospital, Derech Ze’ev Jabotinsky 39, 4941492, Petah Tikva, Israel

    Barak Haviv

  4. Department of Orthopaedics, NYU Langone Medical Center Hospital for Joint Diseases, New York, NY, 10003, USA

    Ran Schwarzkopf

Authors
  1. Michael Drexler
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  2. David Backstein
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  3. Ueli Studler
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  4. Dror Lakstein
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  7. Tal Frenkel Rutenberg
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  8. Yaniv Warschawski
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  9. Ehud Rath
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  10. Yona Kosashvili
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Correspondence to Michael Drexler.

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Drexler, M., Backstein, D., Studler, U. et al. The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA). Knee Surg Sports Traumatol Arthrosc 25, 1736–1742 (2017). https://doi.org/10.1007/s00167-016-4072-7

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  • DOI: https://doi.org/10.1007/s00167-016-4072-7

Keywords

  • Tibial component
  • Internal rotation angle
  • Reference point
  • Total knee arthroplasty