Skip to main content
SpringerLink
Log in

No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty

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

Abstract

Purpose

It was hypothesized that malrotation of femoral component in total knee arthroplasty (TKA) will significantly impact clinical outcome.

Methods

Eighty-eight consecutive patients with primary osteoarthritis of the knee were prospectively evaluated. They received a cemented posterior stabilized TKA (NexGen, Zimmer/Biomet® Inc., Warsaw, IN, USA). The femoral component was placed in 3° of external rotation referenced to the posterior condylar line. Postoperatively, a CT scan was performed to evaluate rotation of femoral component in the transverse plane. SF-36, KSS, and WOMAC, as well as their range of motion was assessed prior to surgery, after 6 and 24 months. Data are presented as mean and standard deviation (SD), as well as range if applicable. Correlation analysis was performed between the placement of the femoral component in the transverse plane and the clinical outcome.

Results

Femoral component placement was on average 0.1° [SD 2.5°, range − 6.5° to + 6.5°] referenced to the surgical transepicondylar line showing a wide range between the two landmarks after surgery. After 6 months, WOMAC category ‘physical function’ correlated significantly with femoral component rotation (r = − 0.28, p = 0.007). After 24 months, WOMAC categories ‘physical function’ and ‘pain’ correlated significantly with femoral rotation (r = − 0.41, p < 0.001; and r = − 0.33, p = 0.001). No significant correlations were found between femoral component rotation and range of motion (r = 0.04), WOMAC category “stiffness”, KSS, as well as SF-36 questionnaires. These reported formally significant correlations were without any clinical relevance.

Discussion

The study showed that there is a significant patients specific femoral component placement in the transverse plane. Internal or external malrotation of the femoral component does not correlate automatically with poor knee function. The lack of correlation between femoral component position and clinical as well as functional outcome underlines complexity and significant individuality of each patient. The surgeon should be aware of the finding and attention should be paid during surgery when significant divergency is seen between the two landmarks. Soft tissue balancing might be very crucial in these specific patients, which needs to be studied in depth in the future.

Level of evidence

II.

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
Fig. 2
Fig. 3

Similar content being viewed by others

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. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840

    CAS  PubMed  Google Scholar 

  4. Bell SW, Young P, Drury C, Smith J, Anthony I, Jones B, Blyth M, McLean A (2014) Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 21:272–277

    Article  PubMed  Google Scholar 

  5. Bhattee G, Moonot P, Govindaswamy R, Pope A, Fiddian N, Harvey A (2014) Does malrotation of components correlate with patient dissatisfaction following secondary patellar resurfacing? Knee 21:247–251

    Article  PubMed  Google Scholar 

  6. Boldt JG, Stiehl JB, Hodler J, Zanetti M, Munzinger U (2006) Femoral component rotation and arthrofibrosis following mobile-bearing total knee arthroplasty. Int Orthop 30:420–425

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Castelli CC, Falvo DA, Iapicca ML, Gotti V (2016) Rotational alignment of the femoral component in total knee arthroplasty. Ann Transl Med 4:4

    PubMed  PubMed Central  Google Scholar 

  8. Chen Z, Wang L, Liu Y, He J, Lian Q, Li D, Jin Z (2015) Effect of component mal-rotation on knee loading in total knee arthroplasty using multi-body dynamics modeling under a simulated walking gait. J Orthop Res 33:1287–1296

    Article  PubMed  Google Scholar 

  9. Dalury DF, Pomeroy DL, Gorab RS, Adams MJ (2013) Why are total knee arthroplasties being revised? J Arthroplast 28:120–121

    Article  Google Scholar 

  10. Davidson D, Yen YM, Jette AM, Olarsch S, Kim YJ (2011) Responsiveness of the SF-36 and WOMAC following periacetabular osteotomy for acetabular dysplasia. J Bone Joint Surg Am 93:2214–2218

    Article  PubMed  Google Scholar 

  11. Dye SF, Vaupel GL, Dye CC (1998) Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med 26:773–777

    Article  CAS  PubMed  Google Scholar 

  12. Eckhoff D, Hogan C, DiMatteo L, Robinson M, Bach J (2007) Difference between the epicondylar and cylindrical axis of the knee. Clin Orthop Relat Res 461:238–244

    PubMed  Google Scholar 

  13. Feczko PZ, Fokkenrood HJP, van Assen T, Deckers P, Emans PJ, Arts JJ (2017) Accuracy of the precision saw versus the sagittal saw during total knee arthroplasty: a randomised clinical trial. Knee 24:1213–1220

    Article  PubMed  Google Scholar 

  14. Fehring TK (2000) Rotational malalignment of the femoral component in total knee arthroplasty. Clin Orthop Relat Res 380:72–79

    Article  Google Scholar 

  15. Franceschini V, Nodzo SR, Gonzalez Della Valle A (2016) Femoral component rotation in total knee arthroplasty: a comparison between transepicondylar axis and posterior condylar line referencing. J Arthroplast 31:2917–2921

    Article  Google Scholar 

  16. Ghosh KM, Merican AM, Iranpour F, Deehan DJ, Amis AA (2010) The effect of femoral component rotation on the extensor retinaculum of the knee. J Orthop Res 28:1136–1141

    Article  PubMed  Google Scholar 

  17. Heesterbeek PJ, Jacobs WC, Wymenga AB (2009) Effects of the balanced gap technique on femoral component rotation in TKA. Clin Orthop Relat Res 467:1015–1022

    Article  PubMed  Google Scholar 

  18. Hernandez-Vaquero D, Noriega-Fernandez A, Fernandez-Carreira JM, Fernandez-Simon JM, De Los Rios JL (2014) Computer-assisted surgery improves rotational positioning of the femoral component but not the tibial component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22:3127–3134

    Article  PubMed  Google Scholar 

  19. Hohmann E, Tetsworth K (2016) Do manual cutting guides for total knee arthroplasty introduce systematic error? Int Orthop 40:277–2784

    Article  PubMed  Google Scholar 

  20. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop 248:13–14

    Google Scholar 

  21. Kessler O, Patil S, Colwell CW, D’Lima DD (2008) The effect of femoral component malrotation on patellar biomechanics. J Biomech 41:3332–3339

    Article  PubMed  Google Scholar 

  22. Lee JK, Lee S, Chun SH, Kim KT, Lee MC (2017) Rotational alignment of femoral component with different methods in total knee arthroplasty: a randomized, controlled trial. BMC Musculoskelet Disord 18:217

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lustig S, Lavoie F, Selmi TA, Servien E, Neyret P (2008) Relationship between the surgical epicondylar axis and the articular surface of the distal femur: an anatomic study. Knee Surg Sports Traumatol Arthrosc 16:674–682

    Article  PubMed  Google Scholar 

  24. Merican AM, Ghosh KM, Iranpour F, Deehan DJ, Amis AA (2011) The effect of femoral component rotation on the kinematics of the tibiofemoral and patellofemoral joints after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 19:1479–1487

    Article  CAS  PubMed  Google Scholar 

  25. Meric G, Gracitelli GC, Aram LJ, Swank ML, Bugbee WD (2015) Variability in distal femoral anatomy in patients undergoing total knee arthroplasty: measurements on 13,546 computed tomography scans. J Arthroplast 30:1835–1838

    Article  Google Scholar 

  26. Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi AV (2012) Improved accuracy of alignment with patient-specific positioning guides compared with manual instrumentation in TKA. Clin Orthop Relat Res 470:99–107

    Article  PubMed  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 Joint Surg Br 92:1238–1244

    Article  CAS  PubMed  Google Scholar 

  28. Okamoto S, Mizu-uchi H, Okazaki K, Hamai S, Tashiro Y, Nakahara H, Iwamoto Y (2016) Two-dimensional planning can result in internal rotation of the femoral component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 24:229–235

    Article  PubMed  Google Scholar 

  29. Pfitzner T, Abdel MP, von Roth P, Perka C, Hommel H (2014) Small improvements in mechanical axis alignment achieved with MRI versus CT-based patient-specific instruments in TKA: a randomized clinical trial. Clin Orthop Relat Res 472:2913–2922

    Article  PubMed  PubMed Central  Google Scholar 

  30. Pietsch M, Hofmann S (2012) Early revision for isolated internal malrotation of the femoral component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:1057–1063

    Article  PubMed  Google Scholar 

  31. Plaskos C, Hodgson AJ, Inkpen K, McGraw RW (2002) Bone cutting errors in total knee arthroplasty. JArthroplast 17:698–705

    Article  Google Scholar 

  32. Rienmüller A, Guggi T, Gruber G, Preiss S, Drobny T (2012) The effect of femoral component rotation on the five-year outcome of cemented mobile bearing total knee arthroplasty. Int Orthop 36:2067–2072

    Article  PubMed  PubMed Central  Google Scholar 

  33. Sanchis-Alfonso V, Roselló-Sastre E (2003) Hypothesis: anterior knee pain in the young patient-what causes the pain?” Neural model”. Acta Orthop Scand 74:697–703

    Article  PubMed  Google Scholar 

  34. Schiapparelli FF, Amsler F, Hirschmann MT (2017) Medial parapatellar approach leads to internal rotation of tibial component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-017-4586-7

    Article  PubMed  Google Scholar 

  35. Silva A, Pinto E, Sampaio R (2016) Rotational alignment in patient-specific instrumentation in TKA: MRI or CT? Knee Surg Sports Traumatol Arthrosc 24:3648–3652

    Article  PubMed  Google Scholar 

  36. Siston RA, Cromie MJ, Gold GE, Goodman SB, Delp SL, Maloney WJ, Giori NJ (2008) Averaging different alignment axes improves femoral rotational alignment in computer-navigated total knee arthroplasty. J Bone Joint Surg Am 90:2098–20104

    Article  PubMed  Google Scholar 

  37. 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 Arthroplast 21:878–882

    Article  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 23:3266–3272

    Article  PubMed  Google Scholar 

  39. Thienpont E, Schwab PE, Paternostre F, Koch P (2014) Rotational alignment of the distal femur: anthropometric measurements with CT-based patient-specific instruments planning show high variability of the posterior condylar angle. Knee Surg Sports Traumatol Arthrosc 22:2995–3002

    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

    Article  CAS  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

    Article  CAS  PubMed  Google Scholar 

  42. Victor J, Van Doninck D, Labey L, Van Glabbeek F, Parizel P, Bellemans J (2009) A common reference frame for describing rotation of the distal femur: a CT-based kinematic study using cadavers. J Bone Joint Surg Br 91:683–690

    Article  CAS  PubMed  Google Scholar 

  43. Walde TA, Bussert J, Sehmisch S, Balcarek P, Stürmer KM, Walde HJ, Frosch KH (2010) Optimized functional femoral rotation in navigated total knee arthroplasty considering ligament tension. Knee 17:381–386

    Article  CAS  PubMed  Google Scholar 

  44. Ware JE, Gandek B (1998) Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. J Clin Epidemiol 51:903–912

    Article  PubMed  Google Scholar 

  45. Witonski D, Wagrowska-Danielewicz M (1999) Distribution of substance-P nerve fibers in the knee joint in patients with anterior knee pain syndrome. Knee Surg Sports Traumatol Arthrosc 7:177–183

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

There was no funding.

Author information

Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Brandenburg Medical Scholl Theodor Fontane, Hochstrasse 26, 14770, Brandenburg, Germany

    Roland Becker & Sebastian Kopf

  2. Department of Traumatolgy, Helios Hospital, August-Bebel-Straße 55A, 39288, Burg bei Magdeburg, Germany

    Katharina Bäker

  3. Department of Orthopaedics, Hospital-MOL GmBH, Sonnenburger Weg 3, 16269, Wriezen, Germany

    Hagen Hommel

  4. Hospital Sanssouci Potsdam, Helene-Lange-Straße 13, 14469, Potsdam, Germany

    Manfred Bernard

Authors
  1. Roland Becker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katharina Bäker
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hagen Hommel
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Manfred Bernard
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sebastian Kopf
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roland Becker.

Ethics declarations

Conflict of interest

I have no potential conflict of interest.

Ethical standard

The study was approved by the ethical committee of the Medical Council of Brandenburg, Germany (AS 67(bB)/2014).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Becker, R., Bäker, K., Hommel, H. et al. No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 27, 1456–1462 (2019). https://doi.org/10.1007/s00167-018-4981-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-018-4981-8

Keywords

Search

Navigation