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Deviations in femoral joint lines using calipered kinematically aligned TKA from virtually planned joint lines are small and do not affect clinical outcomes

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope



Kinematically aligned total knee arthroplasty (KA TKA) strives to restore the native distal and posterior joint lines of the femur. Because the joint lines of a virtually planned femoral component on the native femur can serve as surrogates of those of the native femur, the present study determined position and orientation deviations of the femoral joint lines following calipered KA TKA from virtually planned joint lines and whether these alignment deviations affect clinical outcomes. Our hypotheses were that the alignment deviations for most knees would be less than 2 mm and/or 2° and that larger alignment deviations would not be associated with lower clinical outcome scores.


A review of lower extremity CT scanograms and CT scans of the knee identified 36 patients treated with calipered KA TKA in one limb and no other skeletal deformities in either limb. 3D models of the operated femur with the implanted femoral component and the native femur were created. The articular surfaces of a 3D model of the implanted femoral component in the TKA knee were shape-matched to the condyles of the native femur to create a virtual plan. The shape-matched femoral component served as a reference from which to determine alignment deviations of the femoral component implanted in the ipsilateral femur. The Forgotten Joint Score (FJS) and Oxford Knee Score (OKS) were obtained at an average of 20 months.


For proximal–distal and anterior–posterior positions and varus–valgus and internal–external orientations of the femoral component, the root mean square deviations from the planned joint lines ranged from 1.4 to 1.5 (mm or degrees). The mean differences ranged from − 0.1 to 0.2 (mm or degrees) indicating an absence of systematic alignment deviations. The proportion of knees with joint lines within ± 2 mm and ± 2° of the joint lines of virtually planned knees ranged from 83 to 92%. For the FJS and OKS, the median values were 79 (out of 100) and 45 (out of 48), respectively, and there were no significant correlations between deviations in the positions and orientations and either the FJS or the OKS.


Alignment deviations were bounded by 2 mm and 2° for most knees, which previous biomechanical studies have shown reduce the risks of stiffness, loss of extension, loss of flexion, and tibial compartment forces higher than those of the native knee. Moreover, because median FJS and OKS were relatively high, and because larger alignment deviations did not correlate with lower outcome scores, deviations did not affect clinical outcomes. These results validate calipered KA TKA as a surgical technique which closely restores the distal and posterior femoral joint lines to those planned and achieves concomitant high patient-reported outcome scores. Thus, surgeons can use the calipered KA TKA technique with confidence that the surgical alignment goal will be satisfied with sufficient accuracy that high patient-reported outcomes are achieved.

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Correspondence to Maury L. Hull.

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Conflict of interest

SMH is a paid consultant for THINK Surgical and Medacta, Inc. MLH receives research support from Zimmer-Biomet and Medacta, Inc.

Ethical approval

An institutional review board approved this retrospective study (IRB 1362165-1) and the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards

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Nedopil, A.J., Howell, S.M. & Hull, M.L. Deviations in femoral joint lines using calipered kinematically aligned TKA from virtually planned joint lines are small and do not affect clinical outcomes. Knee Surg Sports Traumatol Arthrosc 28, 3118–3127 (2020).

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