Skip to main content

Advertisement

Log in

Differences between Sagittal Femoral Mechanical and Distal Reference Axes Should Be Considered in Navigated TKA

  • Original Article
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

In computer-assisted TKA, surgeons determine positioning of the femoral component in the sagittal plane based on the sagittal mechanical axis identified by the navigation system. We hypothesized mechanical and distal femoral axes may differ on lateral views and these variations are influenced by anteroposterior bowing and length of the femur. We measured angles between the mechanical axis and distal femoral axis on 200 true lateral radiographs of the whole femur from 100 adults. We used multivariate linear regression to identify predictors of differences between the axes. Depending on the method used to define the two axes, the mean angular difference between the axes was as much as 3.8° and as little as 0.0°, with standard differences ranging from 1.7° to 1.9°. Variation between the two axes increased with increased femoral bowing and increased femoral length. Surgeons should consider differences between the mechanical axes and distal femoral axes when they set the sagittal plane position of a femoral component in navigated cases. Our findings also may be relevant when measuring rotation of the femoral component in the sagittal plane from postoperative radiographs or when interpreting femoral component sagittal rotation results reported in other studies.

Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2A–C
Fig. 3A–B
Fig. 4A–D
Fig. 5A–B
Fig. 6A–D
Fig. 7A–D

Similar content being viewed by others

References

  1. Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty: comparison with conventional methods. J Arthroplasty. 2005;20:132–138.

    Article  PubMed  Google Scholar 

  2. Bathis H, Perlick L, Tingart M, Luring C, Zurakowski D, Grifka J. Alignment in total knee arthroplasty: a comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br. 2004;86:682–687.

    Article  PubMed  CAS  Google Scholar 

  3. Bolognesi M, Hofmann A. Computer navigation versus standard instrumentation for TKA: a single-surgeon experience. Clin Orthop Relat Res. 2005;440:162–169.

    Article  PubMed  Google Scholar 

  4. Brattstrom H. Patella alta in non-dislocating knee joints. Acta Orthop Scand. 1970;41:578–588.

    Article  PubMed  CAS  Google Scholar 

  5. Chauhan SK, Scott RG, Breidahl W, Beaver RJ. Computer-assisted knee arthroplasty versus a conventional jig-based technique: a randomised, prospective trial. J Bone Joint Surg Br. 2004;86:372–377.

    Article  PubMed  CAS  Google Scholar 

  6. Chin PL, Foo LS, Yang KY, Yeo SJ, Lo NN. Randomized controlled trial comparing the radiologic outcomes of conventional and minimally invasive techniques for total knee arthroplasty. J Arthroplasty. 2007;22:800–806.

    Article  PubMed  Google Scholar 

  7. Chin PL, Yang KY, Yeo SJ, Lo NN. Randomized control trial comparing radiographic total knee arthroplasty implant placement using computer navigation versus conventional technique. J Arthroplasty. 2005;20:618–626.

    Article  PubMed  Google Scholar 

  8. Dutton AQ, Yeo SJ, Yang KY, Lo NN, Chia KU, Chong HC. Computer-assisted minimally invasive total knee arthroplasty compared with standard total knee arthroplasty: a prospective, randomized study. J Bone Joint Surg Am. 2008;90:2–9.

    Article  PubMed  Google Scholar 

  9. Ensini A, Catani F, Leardini A, Romagnoli M, Giannini S. Alignments and clinical results in conventional and navigated total knee arthroplasty. Clin Orthop Relat Res. 2007;457:156–162.

    PubMed  CAS  Google Scholar 

  10. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989;248:9–12.

    PubMed  Google Scholar 

  11. Gilbert BM. Anterior femoral curvature: its probable basis and utility as a criterion of racial assessment. Am J Phys Anthropol. 1976;45:601–604.

    Article  PubMed  CAS  Google Scholar 

  12. Haaker RG, Stockheim M, Kamp M, Proff G, Breitenfelder J, Ottersbach A. Computer-assisted navigation increases precision of component placement in total knee arthroplasty. Clin Orthop Relat Res. 2005;454:152–159.

    Article  Google Scholar 

  13. Harper MC, Carson WL. Curvature of the femur and the proximal entry point for an intramedullary rod. Clin Orthop Relat Res. 1987;220:155–161.

    PubMed  Google Scholar 

  14. Jenny JY, Clemens U, Kohler S, Kiefer H, Konermann W, Miehlke RK. Consistency of implantation of a total knee arthroplasty with a non-image-based navigation system: a case-control study of 235 cases compared with 235 conventionally implanted prostheses. J Arthroplasty. 2005;20:832–839.

    Article  PubMed  Google Scholar 

  15. Kim TH, Lee DH, Bin SI. The NexGen LPS-flex to the knee prosthesis at a minimum of three years. J Bone Joint Surg Br. 2008;90:1304–1310.

    Article  PubMed  Google Scholar 

  16. Kim TK, Chung BJ, Kang YG, Chang CB, Seong SC. Clinical implications of anthropometric patellar dimensions for TKA in Asians. Clin Orthop Relat Res. 2008 Oct 15. [Epub ahead of print].

  17. Kim YH, Kim JS, Hong KS, Kim YJ, Kim JH. Prevalence of fat embolism after total knee arthroplasty performed with or without computer navigation. J Bone Joint Surg Am. 2008;90:123–128.

    Article  PubMed  Google Scholar 

  18. Kim YH, Kim JS, Yoon SH. Alignment and orientation of the components in total knee replacement with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br. 2007;89:471–476.

    Article  PubMed  Google Scholar 

  19. Lesh ML, Schneider DJ, Deol G, Davis B, Jacobs CR, Pellegrini VD Jr. The consequences of anterior femoral notching in total knee arthroplasty: a biomechanical study. J Bone Joint Surg Am. 2000;82:1096–1101.

    PubMed  Google Scholar 

  20. Lonner JH, Laird MT, Stuchin SA. Effect of rotation and knee flexion on radiographic alignment in total knee arthroplasties. Clin Orthop Relat Res. 1996;331:102–106.

    Article  PubMed  Google Scholar 

  21. Matziolis G, Krocker D, Weiss U, Tohtz S, Perka C. A prospective, randomized study of computer-assisted and conventional total knee arthroplasty: three-dimensional evaluation of implant alignment and rotation. J Bone Joint Surg Am. 2007;89:236–243.

    Article  PubMed  Google Scholar 

  22. Mihalko WM, Boyle J, Clark LD, Krackow KA. The variability of intramedullary alignment of the femoral component during total knee arthroplasty. J Arthroplasty. 2005;20:25–28.

    Article  PubMed  Google Scholar 

  23. O’Rourke MR, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC. Osteolysis associated with a cemented modular posterior-cruciate-substituting total knee design: five to eight-year follow-up. J Bone Joint Surg Am. 2002;84:1362–1371.

    PubMed  Google Scholar 

  24. Phillips BB. (2003) Recurrent dislocations. In Canale ST, ed. Campbell’s Operative Orthopaedics. Vol 3. Philadelphia, PA: Mosby; 2377-2448.

    Google Scholar 

  25. Piazza SJ, Delp SL, Stulberg SD, Stern SH. Posterior tilting of the tibial component decreases femoral rollback in posterior-substituting knee replacement: a computer simulation study. J Orthop Res. 1998;16:264–270.

    Article  PubMed  CAS  Google Scholar 

  26. Picard F. (2007) Computer Assisted Orthopaedics: The Image Free Concept. Berlin, Germany: Pro BUSINESS GmbH; 375.

  27. Pitto RP, Graydon AJ, Bradley L, Malak SF, Walker CG, Anderson IA. Accuracy of a computer-assisted navigation system for total knee replacement. J Bone Joint Surg Br. 2006;88:601–605.

    Article  PubMed  CAS  Google Scholar 

  28. Puloski SK, McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB. Tibial post wear in posterior stabilized total knee arthroplasty: an unrecognized source of polyethylene debris. J Bone Joint Surg Am. 2001;83:390–397.

    PubMed  Google Scholar 

  29. Ritter MA, Thong AE, Keating EM, Faris PM, Meding JB, Berend ME, Pierson JL, Davis KE. The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoral fractures and on clinical outcome. J Bone Joint Surg Am. 2005;87:2411–2414.

    Article  PubMed  Google Scholar 

  30. Rosenberger RE, Hoser C, Quirbach S, Attal R, Hennerbichler A, Fink C. Improved accuracy of component alignment with the implementation of image-free navigation in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2008;16:249–257.

    Article  PubMed  Google Scholar 

  31. Shawen SB, Belmont PJ Jr, Klemme WR, Topoleski LD, Xenos JS, Orchowski JR. Osteoporosis and anterior femoral notching in periprosthetic supracondylar femoral fractures: a biomechanical analysis. J Bone Joint Surg Am. 2003;85:115–121.

    Article  PubMed  Google Scholar 

  32. Sparmann M, Wolke B, Czupalla H, Banzer D, Zink A. Positioning of total knee arthroplasty with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br. 2003;85:830–835.

    PubMed  CAS  Google Scholar 

  33. Stulberg SD. How accurate is current TKR instrumentation? Clin Orthop Relat Res. 2003;416:177–184.

    Article  PubMed  Google Scholar 

  34. Swanson KE, Stocks GW, Warren PD, Hazel MR, Janssen HF. Does axial limb rotation affect the alignment measurements in deformed limbs? Clin Orthop Relat Res. 2000;371:246–252.

    Article  PubMed  Google Scholar 

  35. Tang WM, Chiu KY, Kwan MF, Ng TP, Yau WP. Sagittal bowing of the distal femur in Chinese patients who require total knee arthroplasty. J Orthop Res. 2005;23:41–45.

    Article  PubMed  CAS  Google Scholar 

  36. Tingart M, Luring C, Bathis H, Beckmann J, Grifka J, Perlick L. Computer-assisted total knee arthroplasty versus the conventional technique: how precise is navigation in clinical routine? Knee Surg Sports Traumatol Arthrosc. 2008;16:44–50.

    Article  PubMed  Google Scholar 

  37. Victor J, Hoste D. Image-based computer-assisted total knee arthroplasty leads to lower variability in coronal alignment. Clin Orthop Relat Res. 2004;428:131–139.

    Article  PubMed  Google Scholar 

  38. Yehyawi TM, Callaghan JJ, Pedersen DR, O’Rourke MR, Liu SS. Variances in sagittal femoral shaft bowing in patients undergoing TKA. Clin Orthop Relat Res. 2007;464:99–104.

    PubMed  Google Scholar 

Download references

Acknowledgments

We thank Dr Sae Kwang Kwon (Yeonsei Sarang Hospital, Seoul, Korea) and Professor Jae Ho Yoo (Sunchonhyang University Hospital, Bucheon, Korea) for participation in scientific discussion to design and perform this study.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Tae Kyun Kim MD, PhD.

Additional information

One or more of the authors (TKK) have received funding from the clinical research fund (B-0704/044-013) of Seoul National University Bundang Hospital.

Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.

This work was performed at Seoul National University Bundang Hospital.

About this article

Cite this article

Chung, B.J., Kang, Y.G., Chang, C.B. et al. Differences between Sagittal Femoral Mechanical and Distal Reference Axes Should Be Considered in Navigated TKA. Clin Orthop Relat Res 467, 2403–2413 (2009). https://doi.org/10.1007/s11999-009-0762-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-009-0762-5

Keywords

Navigation