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Varus alignment of the tibial component up to seven degrees is not associated with poor long-term outcomes in a neutrally aligned total knee arthroplasty



The purpose of this retrospective study was to evaluate the effect of varus alignment of the tibial component on the outcomes with a minimum follow-up of 10 years. The hypothesis was that varus alignment of the tibial component might not affect the outcomes and survival of a neutrally aligned primary TKA.


A matched case–control study was designed between 66 patients with varus alignment of the tibial component and 66 with neutral alignment with a minimum follow-up of 10 years. Functional outcome was assessed with the knee surgery scores (KSS) and reduced Western Ontario and MacMaster Universities questionnaire (WOMAC). Patient satisfaction was evaluated by a 0–10 visual analog scale. Radiological evaluation was performed at early postoperative and at final follow-up.


The mean follow-up was 11.9 (SD 2.6) years for both groups. The mean postoperative proximal tibial angle in the varus group was 85.0° (SD 0.9) and 88.8° (SD 0.9) in control group. At the final follow-up, there were no significant differences in KSS, WOMAC, range of motion or patient satisfaction. There were no differences in the coronal anatomical alignment of the TKA between groups. Revision of TKA was performed in four knees in the varus group, and one in control group, due to aseptic loosening of the tibial component in all cases. TKA survival at 10 years was not significantly different between groups.


The alignment of the tibial component up to 7° varus did not negatively affect implant survival, patient satisfaction, and function of a well-aligned TKA, with a minimum postoperative follow-up of 10 years.

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Availability of data and material

Authors ensure that all data and materials, as well as software application or custom code, support their published claims, meeting field standards. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.


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The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support was received.

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Authors and Affiliations



All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by FAM-M, MR-M and LB-T. Substantial contributions to the design of the work was performed by SG-P and interpretation of data for the work was performed by CA-M. The first draft of the manuscript was written by FAM-M and AL-U and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Francisco Antonio Miralles-Muñoz.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of the Elda University Hospital, Elda, Spain (number PI.2020-024).

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Miralles-Muñoz, F.A., Rubio-Morales, M., Bello-Tejada, L. et al. Varus alignment of the tibial component up to seven degrees is not associated with poor long-term outcomes in a neutrally aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 30, 2768–2775 (2022).

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  • Total knee arthroplasty
  • Varus alignment
  • Tibial component
  • Outcome
  • Survival
  • Total knee replacement