Kinematically aligned total knee arthroplasty reproduces native patellofemoral biomechanics during deep knee flexion



The implant positioning for kinematically aligned total knee arthroplasty (TKA) differs fundamentally from conventional mechanically aligned TKA. This difference may affect patellofemoral (PF) biomechanics after TKA. This cadaveric study tested the hypothesis that kinematically aligned TKA would restore PF biomechanics to the native condition better than mechanically aligned TKA.


Seven pairs (14 knees) of fresh-frozen cadavers were tested. All specimens were mounted on a customized knee-testing system and digitized using a Microscribe 3DLX instrument (Revware Inc., Raleigh, NC, USA) to measure patellar kinematics in terms of patellar varus/valgus rotation, medial/lateral position, flexion/extension rotation and proximal/distal position at knee flexion angles of 0°, 30°, 60°, 90°, and 120°. The medial and lateral PF joint contact pressure distributions at 120° of knee flexion were measured using a K-scan system (Tekscan Inc., Boston, MA, USA). All patellae remained unresurfaced. For each pair, one knee was randomly assigned to kinematically aligned TKA and the other to mechanically aligned TKA performed using the conventional measured resection technique. During kinematically aligned TKA, the amount of femur and tibia resected was equivalent to implant thickness to maintain the patient-specific joint line. All patellar kinematics were measured and compared between the native condition and after surgery.


The patellae of mechanically aligned TKA rotated more valgus and was positioned more laterally compared with those of kinematically aligned TKA at knee flexion angles ≥ 90°. Neither the patellar flexion/extension rotation nor the proximal/distal position differed between either prosthetic knee design and the native knee at all flexion angles. The contact pressure distribution between the medial and lateral PF joint after kinematically aligned TKA were similar to those of the native knee, while the lateral PF joint contact pressure after mechanically aligned TKA was higher than that of the native knee (p = 0.038).


Kinematically aligned TKA better restores patellar kinematics and PF contact pressure distribution to the native condition than mechanically aligned TKA during deep knee flexion. These findings provide clues to understand why kinematically aligned TKA is associated with less anterior knee pain and better PF functional performance compared to mechanically aligned TKA. Patients undergoing kinematically aligned TKA may experience a more normal feeling during deep knee flexion activities.

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All implants and surgical instruments were donated by Corentec Co. Ltd (Seoul, Republic of Korea). We thank Ji Hyun Ahn MD, PhD of Dongguk University Ilsan Hospital, and Adam Kantor BA, of the Orthopedic Biomechanical Laboratory, for assistance in testing. We also thank the donors and their families.


Partial funding provided by Veterans Affairs Rehabilitation Research and Development Merit Review and the John C. Griswold Foundation.

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Correspondence to In Jun Koh.

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On behalf of all authors, the corresponding authors identify the following possible conflict of interest: Corentec Co. Ltd. donated all prostheses used in this study. The company had no input into the study design, or data collection or interpretation. The company was not involved in manuscript preparation or the decision to submit the article to this journal.

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This article does not contain any studies with human participants performed by any of the authors.

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Koh, I.J., Park, I.J., Lin, C.C. et al. Kinematically aligned total knee arthroplasty reproduces native patellofemoral biomechanics during deep knee flexion. Knee Surg Sports Traumatol Arthrosc 27, 1520–1528 (2019).

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  • Patellofemoral kinematics
  • Total knee arthroplasty
  • Kinematic alignment
  • Mechanical alignment