Skip to main content
SpringerLink
Log in

Medial parapatellar approach leads to internal rotation of tibial component in total knee arthroplasty

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The purpose of this study was to investigate if the type of approach [medial parapatellar approach (MPA) versus lateral parapatellar approach with tibial tubercle osteotomy (LPA)] influences rotation of femoral and/or tibial component and leg axis in total knee arthroplasty (TKA). It was the hypothesis that MPA leads to an internally rotated tibial TKA component.

Methods

This study included 200 consecutive patients in whom TKA was performed using either a parapatellar medial (n = 162, MPA) or parapatellar lateral approach with tibial tubercle osteotomy (n = 38, LPA). All patients underwent clinical follow-up, standardized radiographs and computed radiography (CT). TKA components’ position and the whole leg axis were assessed on 3D reconstructed CT scans (sagittal, coronal and rotational). Mean values of TKA component position and the whole leg alignment of both groups were compared using a t test. The tibial component was graded as internally rotated (<3° of external rotation (ER)), neutral rotation (equal or between 3° and 6° of ER) and externally rotated (>6° ER). The femoral component was graded as internally rotated [>3° of internal rotation (IR)], neutral rotation (equal or between −3° IR and 3° of ER) and externally rotated (>3° ER).

Results

There was no significant difference in terms of whole leg axis after TKA between both groups (MPA: 0.2° valgus ± 3.4; LPA: 0.0° valgus ± 3.5). Means of tibial component rotation were 2.7° ER ± 6.1 (MPA) and 7.6° ER ± 5.4 (LPA). Patients of group LPA presented a significantly less internally rotated (LPA: 18.4%; MPA: 48.8%) and more externally rotated (LPA: 52.6%; MPA: 22.8%) tibial component (p < 0.001). No significant differences were seen for the femoral component position, tibial valgus/varus and tibial slope.

Conclusion

The type of approach (medial versus lateral) significantly influenced tibial TKA component rotation. It appears that a MPA tends to internally rotate the tibial TKA component and a LPA tends to externally rotate the tibial TKA. The anterior cortex should not be used as landmark for tibial TKA component placement when using the lateral approach with tibial tubercle osteotomy.

Level of Evidence

Retrospective comparative study, Level III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

TKA:

Total knee arthroplasty

LPA:

Lateral parapatellar subvastus approach with tibial tubercle osteotomy

MPA:

Medial parapatellar approach

CT:

Computed tomography

ER:

External rotation

IR:

Internal rotation

EKNZ:

Ethikkommission Nordwest- und Zentralschweiz

VAS:

Visual analogue scale

KSS:

Knee society score

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. 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 

  3. Apostolopoulos AP, Nikolopoulos DD, Polyzois I, Nakos A, Liarokapis S, Stefanakis G, Michos IV (2010) Total knee arthroplasty in severe valgus deformity: interest of combining a lateral approach with a tibial tubercle osteotomy. Orthop Traumatol Surg Res 96(7):777–784

    Article  CAS  PubMed  Google Scholar 

  4. Barrack RL, Schrader T, Bertot AJ, Wolfe MW, Myers L (2001) Component rotation and anterior knee pain after total knee arthroplasty. Clin Orthop Relat Res 392:46–55

    Article  Google Scholar 

  5. Bédard M, Vince KG, Redfern J, Collen SR (2011) Internal rotation of the tibial component is frequent in stiff total knee arthroplasty. Clin Orthop Relat Res 469(8):2346–2355

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bell SW, Young P, Drury C, Smith J, Anthony I, Jones B, Blyth M, McLean A (2012) Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 21(1):272–277

    Article  PubMed  Google Scholar 

  7. Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM, Redelman R, Faris GW, Davis KE (2004) Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res 428:26–34

    Article  Google Scholar 

  8. 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 

  9. Boonen B, Schotanus MG, Kerens B, van der Weegen W, van Drumpt RA, Kort NP (2013) Intra-operative results and radiological outcome of conventional and patient-specific surgery in total knee arthroplasty: a multicentre, randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 21(10):2206–2212

    Article  CAS  PubMed  Google Scholar 

  10. Buechel FF (1990) A sequential three-step lateral release for correcting fixed valgus knee deformities during total knee arthroplasty. Clin Orthop Relat Res 260:170–175

    Google Scholar 

  11. Choong PF, Dowsey MM, Stoney JD (2009) Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplast 24(4):560–569

    Article  Google Scholar 

  12. Cila E, Güzel V, Ozalay M, Tan J, Simşek SA, Kanatli U, Oztürk A (2002) Subvastus versus medial parapatellar approach in total knee arthroplasty. Arch Orthop Trauma Surg 122(2):65–68

    Article  PubMed  Google Scholar 

  13. Dennis DA, Komistek RD, Walker SA, Cheal EJ, Stiehl JB (2001) Femoral condylar lift-off in vivo in total knee arthroplasty. J Bone Jt Surg Br 83(1):33–39

    Article  CAS  Google Scholar 

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

    Article  Google Scholar 

  15. Figueroa J, Guarachi JP, Matas J, Arnander M, Orrego M (2016) Is computed tomography an accurate and reliable method for measuring total knee arthroplasty component rotation? Int Orthop 40(4):709–714

    Article  PubMed  Google Scholar 

  16. Hirschmann MT, Hoffmann M, Krause R, Jenabzadeh RA, Arnold MP, Friederich NF (2010) Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter? BMC Musculoskelet Disord 11:167

    Article  PubMed  PubMed Central  Google Scholar 

  17. Hirschmann MT, Iranpour F, Konala P, Kerner A, Rasch H, Cobb JP, Friederich NF (2010) A novel standardized algorithm for evaluating patients with painful total knee arthroplasty using combined single photon emission tomography and conventional computerized tomography. Knee Surg Sports Traumatol Arthrosc 18(7):939–944

    Article  PubMed  Google Scholar 

  18. Hirschmann MT, Konala P, Amsler F, Iranpour F, Friederich NF, Cobb JP (2011) The position and orientation of total knee replacement components: a comparison of conventional radiographs, transverse 2D-CT slices and 3D-CT reconstruction. J Bone Jt Surg Br 93(5):629–633

    Article  CAS  Google Scholar 

  19. Kayler DE, Lyttle D (1988) Surgical interruption of patellar blood supply by total knee arthroplasty. Clin Orthop Relat Res 229:221–227

    Google Scholar 

  20. Keblish PA (1991) The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over 2-year follow-up evaluation. Clin Orthop Relat Res 271:52–62

    Google Scholar 

  21. Khan H, Grob K, Milne LP, Kuster MS (2016) Tibial tubercle osteotomy to improve exposure in complex knee fractures: a cadaveric study and case series. Injury 47(10):2331–2338

    Article  PubMed  Google Scholar 

  22. Langen S, Gaber S, Zdravkovic V, Giesinger K, Jost B, Behrend H (2016) Lateral subvastus approach with tibial tubercle osteotomy for primary total knee arthroplasty: clinical outcome and complications compared to medial parapatellar approach. Eur J Orthop Surg Traumatol 26(2):215–222

    Article  PubMed  Google Scholar 

  23. Maderbacher G, Baier C, Springorum HR, Maderbacher H, Birkenbach AM, Benditz A, Grifka J, Keshmiri A (2016) Impact of axial component alignment in total knee arthroplasty on lower limb rotational alignment: an in vitro study. J Knee Surg. doi:10.1055/s-0036-1592148

    PubMed  Google Scholar 

  24. Matsueda M, Gustilo RB (2000) Subvastus and medial parapatellar approaches in total knee arthroplasty. Clin Orthop Relat Res 371:161–168

    Article  Google Scholar 

  25. Meccia B, Komistek RD, Mahfouz M, Dennis D (2014) Abnormal axial rotations in TKA contribute to reduced weightbearing flexion. Clin Orthop Relat Res 471(1):248–253

    Article  Google Scholar 

  26. 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 

  27. Nicoll D, Rowley DI (2010) Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Jt Surg Br 92(9):1238–1244

    Article  CAS  Google Scholar 

  28. Passeron D, Gaudota F, Boisrenoulta P, Falletb L, Beaufilsa P (2009) Does lateral versus medial exposure influence total knee tibial component final external rotation? A CT based study. Orthop Traumatol Surg Res 95(6):420–424

    Article  CAS  PubMed  Google Scholar 

  29. Punwar SA, Fick DP, Khan RJ (2016) Tibial tubercle osteotomy in revision knee arthroplasty. J Arthroplast. doi:10.1016/j.arth.2016.08.029

    Google Scholar 

  30. Radulescu R, Badila A, Nutiu O, Japie I, Terinte S, Radulescu D, Manolescub R (2013) Extended exposure in difficult total knee arthroplasty using tibial tubercle osteotomy. Maedica (Buchar) 8(4):380–383

    Google Scholar 

  31. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S (2005) Total knee arthroplasty for severe valgus deformity. J Bone Jt Surg Am 87(Suppl 1(Pt 2)):271–284

    Article  Google Scholar 

  32. Rasch H, Falkowski AL, Forrer F, Henckel J, Hirschmann MT (2013) 4D-SPECT/CT in orthopaedics: a new method of combined quantitative volumetric 3D analysis of SPECT/CT tracer uptake and component position measurements in patients after total knee arthroplasty. Skelet Radiol 42(9):1215–1223

    Article  Google Scholar 

  33. Sanna M, Sanna C, Caputo F, Piu G, Salvi M (2013) Surgical approaches in total knee arthroplasty. Joints 1(2):34–44

    PubMed  PubMed Central  Google Scholar 

  34. Segur JM, Vilchez-Cavazos F, Martinez-Pastor JC, Macule F, Suso S, Acosta-Olivo C (2014) Tibial tubercle osteotomy in septic revision total knee arthroplasty. Arch Orthop Trauma Surg 134(9):1311–1315

    Article  PubMed  Google Scholar 

  35. Sekiya H, Takatoku K, Takada H, Sugimoto N, Hoshino Y (2014) Lateral approach is advantageous in total knee arthroplasty for valgus deformed knee. Eur J Orthop Surg Traumatol 24(1):111–115

    Article  PubMed  Google Scholar 

  36. Su EP, Su SL, Della Valle AG (2010) Stiffness after TKR: how to avoid repeat surgery. Orthopedics 33(9):658

    PubMed  Google Scholar 

  37. Teng Y, Du W, Jiang J, Gao X, Pan S, Wang J, An L, Ma J, Xia Y (2012) Subvastus versus medial parapatellar approach in total knee arthroplasty: meta-analysis. Orthopedics 35(12):e1722–e1731

    Article  PubMed  Google Scholar 

  38. Terashima T, Onodera T, Sawaguchi N, Kasahara Y, Majima T (2015) External rotation of the femoral component decreases patellofemoral contact stress in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23(11):3266–3272

    Article  PubMed  Google Scholar 

  39. Valkering KP, Breugem SJ, van den Bekerom MP, Tuinebreijer WE, van Geenen RC (2015) Effect of rotational alignment on outcome of total knee arthroplasty. Acta Orthop 86(4):432–439

    Article  PubMed  PubMed Central  Google Scholar 

  40. 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 

  41. Zonnenberg CB, Lisowski LA, van den Bekerom MP, Nolte PA (2010) Tuberositas osteotomy for total knee arthroplasty: a review of the literature. J Knee Surg 23(3):121–129

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland

    Filippo-Franco Schiapparelli & Michael T. Hirschmann

  2. University of Basel, Basel, Switzerland

    Filippo-Franco Schiapparelli & Michael T. Hirschmann

  3. Amsler Consulting, 4059, Basel, Switzerland

    Felix Amsler

Authors
  1. Filippo-Franco Schiapparelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Felix Amsler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael T. Hirschmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Author contributions

FFS collected and analysed the data and prepared the manuscript. FA carried out the statistical analysis and helped drafting the manuscript. MTH designed the study, helped with the analysis of data and prepared and revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Michael T. Hirschmann.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Funding

There was no financial conflict of interest with regards to this study.

Ethical approval

Ethical approval was obtained from the Ethikkommission Nordwest- und Zentralschweiz (EKNZ, Basel). All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schiapparelli, FF., Amsler, F. & Hirschmann, M.T. Medial parapatellar approach leads to internal rotation of tibial component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 26, 1564–1570 (2018). https://doi.org/10.1007/s00167-017-4586-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-017-4586-7

Keywords

Search

Navigation