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Using the anatomical tibial axis for total knee arthroplasty alignment may lead to an internal rotation error

International Orthopaedics volume 39, pages 2347–2353 (2015)Cite this article

Abstract

Introduction

Despite intensive research, current total knee arthroplasty (TKA) designs do not always provide the correct kinematics for the native joint and thus further optimisation is necessary. Several studies support the importance of malrotation of the tibial components in the failure of TKA. We hypothesise that using the anatomical tibial axis (ATA) to align tibial component rotation on the resected tibial surface may lead to an internal rotation error due to relative anterior shift of the lateral articular surface centre compared to the medial one. The aim of this study was to compare the anatomical tibial axis of the physiological tibial joint surface to the resected one.

Method

Twenty formalin-fixed cadaveric knees were obtained for study. After computed tomography scanning the data of each specimen were entered into a standardised coordinate system and virtual bone cuts were performed with 6, 8 and 10 mm resection depths. The positions of the articular surface centres were determined at each resection depth.

Results

The lateral articular surface centre had moved anteriorly after the resection by a mean 1.475 mm, while the medial one had not changed significantly. Resecting the tibia at a 6-mm cut and using the transverse tibial axis to align the prosthetic tibial plateau will result in a mean 4.0° (95 % confidence interval, 2.5-5.5°) of internal rotation compared to the uncut tibia.

Discussion

The ATA lies in 6 degrees of external rotation compared to the perpendicular to the posterior tibial condylar axis (PTCA). Graw et al. suggest aligning the tibial component in 10 degrees of external rotation to the latter. Thus, if we accept the above suggestion, the ATA is 4 degrees internally rotated compared to the same line on the resected proximal tibia. These prior studies appear to be in accordance with our findings.

Conclusions

We conclude that using the ATA on the resected tibial surface may contribute to an internal rotation error.

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Abbreviations

ATA:

Anatomical tibial axis

FFC:

Flexion facet centre

PTCA:

Posterior tibial condylar axis

TKA:

Total knee arthroplasty

TRP:

Tibial reference points

References

  1. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY (2004) Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am 86-A(5):963–974

    PubMed  Google Scholar 

  2. van Essen GJ, Chipchase LS, O’Connor D, Krishnan J (1998) Primary total knee replacement: short-term outcomes in an Australian population. J Qual Clin Pract 18(2):135–142

    PubMed  Google Scholar 

  3. Jacobs CA, Christensen CP, Karthikeyan T (2014) Patient and intraoperative factors influencing satisfaction two to five years after primary total knee arthroplasty. J Arthroplasty 29(8):1576–1579. doi:10.1016/j.arth.2014.03.022

    Article  PubMed  Google Scholar 

  4. Sesen H, Demirkale I, Karaduman M, Vural CA, Okkaoglu MC, Altay M (2014) Why two-thirds of patients accepted the second session in staged bilateral total knee arthroplasty: a prospective analysis of 111 patients. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-3251-7

    PubMed  Google Scholar 

  5. Bellemans J, Robijns F, Duerinckx J, Banks S, Vandenneucker H (2005) The influence of tibial slope on maximal flexion after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 13(3):193–196. doi:10.1007/s00167-004-0557-x

    CAS  Article  PubMed  Google Scholar 

  6. Briard JL, Witoolkollachit P, Lin G (2007) Soft tissue management in total knee replacement. Analysis of ligament balancing. Orthopade 36(7):635–642. doi:10.1007/s00132-007-1109-0

    Article  PubMed  Google Scholar 

  7. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785. doi:10.2106/JBJS.F.00222

    Article  PubMed  Google Scholar 

  8. Dalury DF, Pomeroy DL, Gorab RS, Adams MJ (2013) Why are total knee arthroplasties being revised? J Arthroplasty 28(8 Suppl):120–121. doi:10.1016/j.arth.2013.04.051

    Article  PubMed  Google Scholar 

  9. Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res 404:7–13

    Article  PubMed  Google Scholar 

  10. Hutter EE, Granger JF, Beal MD, Siston RA (2013) Is there a gold standard for TKA tibial component rotational alignment? Clin Orthop Relat Res 471(5):1646–1653. doi:10.1007/s11999-013-2822-0

    PubMed Central  Article  PubMed  Google Scholar 

  11. Petersen W, Rembitzki IV, Bruggemann GP, Ellermann A, Best R, Koppenburg AG, Liebau C (2014) Anterior knee pain after total knee arthroplasty: a narrative review. Int Orthop 38(2):319–328. doi:10.1007/s00264-013-2081-4

    PubMed Central  Article  PubMed  Google Scholar 

  12. Bedard M, Vince KG, Redfern J, Collen SR (2011) Internal rotation of the tibial component is frequent in stiff total knee arthroplasty. Clin Orthop Relat Res 469(8):2346–2355. doi:10.1007/s11999-011-1889-8

    PubMed Central  Article  PubMed  Google Scholar 

  13. Barrack RL, Schrader T, Bertot AJ, Wolfe MW, Myers L (2001) Component rotation and anterior knee pain after total knee arthroplasty. Clin Orthop Relat Res 392:46–55

    Article  PubMed  Google Scholar 

  14. Lakstein D, Zarrabian M, Kosashvili Y, Safir O, Gross AE, Backstein D (2010) Revision total knee arthroplasty for component malrotation is highly beneficial: a case control study. J Arthroplasty 25(7):1047–1052. doi:10.1016/j.arth.2009.07.004

    Article  PubMed  Google Scholar 

  15. Luyckx T, Peeters T, Vandenneucker H, Victor J, Bellemans J (2012) Is adapted measured resection superior to gap-balancing in determining femoral component rotation in total knee replacement? J Bone Joint Surg (Br) 94(9):1271–1276. doi:10.1302/0301-620X.94B9.28670

    CAS  Article  Google Scholar 

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

    Article  PubMed  Google Scholar 

  17. Kinzel V, Ledger M, Shakespeare D (2005) Can the epicondylar axis be defined accurately in total knee arthroplasty? Knee 12(4):293–296. doi:10.1016/j.knee.2004.09.003

    Article  PubMed  Google Scholar 

  18. Talbot S, Dimitriou P, Radic R, Zordan R, Bartlett J (2014) The sulcus line of the trochlear groove is more accurate than Whiteside’s Line in determining femoral component rotation. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-3137-8

    PubMed Central  PubMed  Google Scholar 

  19. Kobayashi H, Akamatsu Y, Kumagai K, Kusayama Y, Ishigatsubo R, Muramatsu S, Saito T (2014) The surgical epicondylar axis is a consistent reference of the distal femur in the coronal and axial planes. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-2867-y

    Google Scholar 

  20. Incavo SJ, Coughlin KM, Pappas C, Beynnon BD (2003) Anatomic rotational relationships of the proximal tibia, distal femur, and patella: implications for rotational alignment in total knee arthroplasty. J Arthroplasty 18(5):643–648

    Article  PubMed  Google Scholar 

  21. Brooks P (2009) Seven cuts to the perfect total knee. Orthopedics 32 (9). doi:10.3928/01477447-20090728-27

  22. Dalury DF (2001) Observations of the proximal tibia in total knee arthroplasty. Clin Orthop Relat Res 389:150–155

    Article  PubMed  Google Scholar 

  23. Siston RA, Goodman SB, Patel JJ, Delp SL, Giori NJ (2006) The high variability of tibial rotational alignment in total knee arthroplasty. Clin Orthop Relat Res 452:65–69. doi:10.1097/01.blo.0000229335.36900.a0

    Article  PubMed  Google Scholar 

  24. Eckhoff DG, Metzger RG, Vandewalle MV (1995) Malrotation associated with implant alignment technique in total knee arthroplasty. Clin Orthop Relat Res 321:28–31

    PubMed  Google Scholar 

  25. Huddleston JI, Scott RD, Wimberley DW (2005) Determination of neutral tibial rotational alignment in rotating platform TKA. Clin Orthop Relat Res 440:101–106

    Article  PubMed  Google Scholar 

  26. Graw BP, Harris AH, Tripuraneni KR, Giori NJ (2010) Rotational references for total knee arthroplasty tibial components change with level of resection. Clin Orthop Relat Res 468(10):2734–2738. doi:10.1007/s11999-010-1330-8

    PubMed Central  Article  PubMed  Google Scholar 

  27. Ikeuchi M, Yamanaka N, Okanoue Y, Ueta E, Tani T (2007) Determining the rotational alignment of the tibial component at total knee replacement: a comparison of two techniques. J Bone Joint Surg (Br) 89(1):45–49. doi:10.1302/0301-620X.89B1.17728

    CAS  Article  Google Scholar 

  28. Akagi M, Mori S, Nishimura S, Nishimura A, Asano T, Hamanishi C (2005) Variability of extraarticular tibial rotation references for total knee arthroplasty. Clin Orthop Relat Res 436:172–176

    Article  PubMed  Google Scholar 

  29. 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  PubMed  Google Scholar 

  30. Kaech AMN, Müller-Gerbl M (2002) Implementierung eines standardisierten Koordinatensystems für dreidimensionale CT-Darstellungen des Kniegelenks mit VGStudio max. Dissertation, University of Basel, Basel, pp 1–33

  31. Nowakowski AM, Muller-Gerbl M, Valderrabano V (2012) Assessment of knee implant alignment using coordinate measurement on three-dimensional computed tomography reconstructions. Surg Innov 19(4):375–384. doi:10.1177/1553350611429689

    Article  PubMed  Google Scholar 

  32. Grood ES, Suntay WJ (1983) A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng 105(2):136–144

    CAS  Article  PubMed  Google Scholar 

  33. McPherson A, Karrholm J, Pinskerova V, Sosna A, Martelli S (2005) Imaging knee position using MRI, RSA/CT and 3D digitisation. J Biomech 38(2):263–268. doi:10.1016/j.jbiomech.2004.02.007

    CAS  Article  PubMed  Google Scholar 

  34. Cobb JP, Dixon H, Dandachli W, Iranpour F (2008) The anatomical tibial axis: reliable rotational orientation in knee replacement. J Bone Joint Surg (Br) 90(8):1032–1038. doi:10.1302/0301-620X.90B8.19905

    CAS  Article  Google Scholar 

  35. Cheng FB, Ji XF, Lai Y, Feng JC, Zheng WX, Sun YF, Fu YW, Li YQ (2009) Three dimensional morphometry of the knee to design the total knee arthroplasty for Chinese population. Knee 16(5):341–347. doi:10.1016/j.knee.2008.12.019

    Article  PubMed  Google Scholar 

  36. Baier C, Fitz W, Craiovan B, Keshmiri A, Winkler S, Springorum R, Grifka J, Beckmann J (2014) Improved kinematics of total knee replacement following partially navigated modified gap-balancing technique. Int Orthop 38(2):243–249. doi:10.1007/s00264-013-2140-x

    PubMed Central  Article  PubMed  Google Scholar 

  37. Mayr HO, Reinhold M, Hube R, von Roth P, Bernstein A, Suedkamp N, Stoehr A (2014) Rotational laxity and collateral ligament laxity following total knee arthroplasty with rotating platform. Int Orthop 38(7):1379–1386. doi:10.1007/s00264-014-2308-z

    PubMed Central  PubMed  Google Scholar 

  38. Zhao Z, Wang W, Wang S, Jiang L, Zhang S, Zhao Y (2015) Femoral rotation influences dynamic alignment of the lower extremity in total knee arthroplasty. Int Orthop 39(1):55–60. doi:10.1007/s00264-014-2484-x

    Article  PubMed  Google Scholar 

  39. Kim YH, Park JW, Kim JS, Park SD (2014) The relationship between the survival of total knee arthroplasty and postoperative coronal, sagittal and rotational alignment of knee prosthesis. Int Orthop 38(2):379–385. doi:10.1007/s00264-013-2097-9

    PubMed Central  Article  PubMed  Google Scholar 

  40. Iorio R, Mazza D, Drogo P, Bolle G, Conteduca F, Redler A, Valeo L, Conteduca J, Ferretti A (2015) Clinical and radiographic outcomes of an accelerometer-based system for the tibial resection in total knee arthroplasty. Int Orthop 39(3):461–466. doi:10.1007/s00264-014-2541-5

    Article  PubMed  Google Scholar 

  41. Maderbacher G, Schaumburger J, Keshmiri A, Barthel M, Springorum HR, Craiovan B, Grifka J, Baier C (2015) Pinless navigation in total knee arthroplasty: Navigation reduced by the maximum? Int Orthop 39(3):455–460. doi:10.1007/s00264-014-2529-1

    Article  PubMed  Google Scholar 

  42. Crockarell JR Jr, Hicks JM, Schroeder RJ, Guyton JL, Harkess JW, Lavelle DG (2010) Total knee arthroplasty with asymmetric femoral condyles and tibial tray. J Arthroplasty 25(1):108–113. doi:10.1016/j.arth.2008.11.002

    Article  PubMed  Google Scholar 

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Conflict of interest

The authors declare that they have no conflict of interest.

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Author notes

    Affiliations

    1. Orthopaedic Department, University of Basel, Spitalstrasse 21, 4031, Basel, Switzerland

      Csaba Forster-Horvath & Andrej Maria Nowakowski

    2. Institute of Anatomy, University of Basel, Pestalozzistrasse 20, 4056, Basel, Switzerland

      Valerie Kremo, Magdalena Müller-Gerbl & Andrej Maria Nowakowski

    Authors
    1. Csaba Forster-Horvath
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    2. Valerie Kremo
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    3. Magdalena Müller-Gerbl
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    4. Andrej Maria Nowakowski
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    Corresponding author

    Correspondence to Andrej Maria Nowakowski.

    Additional information

    Csaba Forster-Horvath and Valerie Kremo contributed equally to this work

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    Cite this article

    Forster-Horvath, C., Kremo, V., Müller-Gerbl, M. et al. Using the anatomical tibial axis for total knee arthroplasty alignment may lead to an internal rotation error. International Orthopaedics (SICOT) 39, 2347–2353 (2015). https://doi.org/10.1007/s00264-015-2858-8

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    Keywords

    • Total knee replacement
    • Total knee arthroplasty
    • Anatomicalal tibial axis
    • Transverse tibial axis
    • Tibial component alignment
    • Tibial component malrotation