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Preoperative tibial mechanical axis orientation and articular surface design influence on the coronal joint line orientation relative to the ground during gait after total knee arthroplasties

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



Neutral lower limb alignment does not necessarily produce a horizontal joint line after total knee arthroplasty (TKA). The orientation of the pre- and postoperative tibial mechanical axes (TMAs-G), tibial component, and joint line relative to the ground were evaluated.


The study group included 46 knees, 23 posterior-stabilized (PS) and 23 bicruciate-stabilized (BCS) TKAs. Using whole-leg standing radiographs, the static orientation of the pre- and postoperative TMAs-G and the tibial component as well as the postoperative alignment were measured. Applying image-matching techniques, the dynamic coronal orientation of the tibial component and joint line over the stance phase of gait were analysed. The correlation between static and dynamic orientation of the tibial component and differences in the joint line between the PS and BCS TKAs were evaluated.


In standing, the postoperative TMA-G (0.8° ± 2.8°) and tibial component (1.5° ± 2.4°) were laterally tilted with a strong correlation. The preoperative lateral tilt of the TMA-G (7.9° ± 5.1°) was a significant predictor of the postoperative TMA-G. The lateral tilt of the tibial component increased to 5.1° ± 2.4° on dynamic analysis, and was moderately correlated to static orientation. The dynamic orientation of the joint line was smaller for the BCS (1.8° ± 2.4°) compared to the PS (5.5° ± 2.7°) TKA.


Even with a mechanically well-aligned TKA, a lateral tilt of the tibial component was identified due to the lateral tilt of the postoperative TMA-G and the stance phase of gait. The BCS can better accommodate the residual lateral tilt of the joint line due to the 3° medial inclination of the joint surfaces of the implant. This study increases the awareness of surgeons regarding the possibility of the coronal joint line orientation to influence preoperative TMA-G and be accommodated by articular surface design, even in mechanically aligned TKA.

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This work was supported by a Grant of Kaibara Morikazu Medical Science Promotion Foundation. We thank Junji Kishimoto, a statistician from the Digital Medicine Initiative at Kyushu University, for his valuable comments and suggestions in regard to statistical analyses.


There was no funding for this study.

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Correspondence to Satoshi Hamai.

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The study protocol was approved by the Institutional Review Board of Kyushu University (IRB number 24-166). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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

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Murakami, K., Hamai, S., Okazaki, K. et al. Preoperative tibial mechanical axis orientation and articular surface design influence on the coronal joint line orientation relative to the ground during gait after total knee arthroplasties. Knee Surg Sports Traumatol Arthrosc 26, 3368–3376 (2018).

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