Highly variable coronal tibial and femoral alignment in osteoarthritic knees: a systematic review

  • Silvan HessEmail author
  • Lukas B. Moser
  • Felix Amsler
  • Henrik Behrend
  • Michael T. Hirschmann



There is a lack of knowledge about coronal alignment variability in osteoarthritic knees. Therefore, the purpose of this article was to systematically review the literature and collect data about the lower limb alignment including hip–knee–ankle angle (HKA), femoral mechanical angle (FMA), tibial mechanical angle (TMA) and the joint line convergence angle (JLCA) in osteoarthritic knees.


A systematic review was performed using the electronic databases MEDLINE (PubMed), EMBASE and Google Scholar. The following keywords were used: (morphology OR geometr* OR anatomy OR alignment OR phenotypes), (coronal OR neutral OR varus OR valgus), (knee OR lower limb OR femur OR tibia) and (osteoarthritis OR arthritis). Out of 110 full-text articles retrieved, 15 studies were included. Demographic information included author’s names, year of publication, imaging modality, sample size and patient demographics (i.e. sex, age, etc.). Descriptive statistics, such as means, ranges, and measures of variance [e.g. standard deviations, 95% confidence intervals (CI)] for all angles (HKA, FMA, TMA, JLCA) are presented.


Thirteen studies reported mean overall HKA angles ranging from 163.5° ± 2.3° to 179.9° ± 4.8°. The mean HKA angles in females were between 164.1° ± 7.2° and 178.8° ± 4.8°, and in males between 163.4° ± 5.5° and 177.4° ± 3.9°. The lowest and highest reported HKA angles were − 27.7° and + 22.0°, respectively. Seven studies reported mean FMA angles. Mean values ranged from 92.7° ± 2.7° valgus to 88.6° ± 2° varus. The reported mean FMAs for male were 87.9° ± 0.5° to 90.7° ± 3° and for female 89.91° ± 2.8° to 92.9° ± 3.1°. Six studies reported mean TMA values. TMA ranged from 81.7° ± 3.9° varus to 87.7° ± 4.1° varus. Only three studies reported mean JLCA angles, which ranged from − 4.3° to − 6.4° ± 3.8°.


Osteoarthritic knees showed a huge variation in overall coronal limb alignment as well as in femoral and tibial coronal alignment. Current total knee arthroplasty (TKA) alignment philosophies and preoperative planning do not sufficiently consider these variation, which might be one reason for unhappy knees after TKA.

Level of evidence

IV, systematic review.


Knee OA Alignment Anatomy Hip–knee–ankle angle Femoral mechanical angle Tibial mechanical angle TKA 



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

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

Ethical approval was not required as this is a pure review of the literature not involving humans nor animals.


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery and TraumatologyKantonsspital Baselland (Bruderholz, Liestal, Laufen)BruderholzSwitzerland
  2. 2.University of BernBernSwitzerland
  3. 3.University of BaselBaselSwitzerland
  4. 4.Amsler ConsultingBaselSwitzerland
  5. 5.Department of Orthopaedic SurgeryKantonsspital St. GallenSt. GallenSwitzerland

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