Skip to main content
Log in

Persistent Hindfoot Valgus Causes Lateral Deviation of Weightbearing Axis after Total Knee Arthroplasty

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



The weightbearing axis of the limb goes from the pelvis to the ground and includes the hindfoot. However, the influence of hindfoot alignment on mechanical axis and overall limb alignment after TKA is unclear.


We therefore addressed the following questions: (1) Does hindfoot alignment change after TKA for knee osteoarthritis? (2) What factors influence hindfoot alignment after TKA? (3) Does deviation of the mechanical axis from the center of the knee vary when the hindfoot is considered (ground mechanical axis) as compared with when it is not (conventional mechanical axis) after TKA?

Patients and Methods

We prospectively reviewed the radiographs of 125 patients who underwent 165 TKAs. We evaluated the preoperative and postoperative hip-knee-ankle (HKA) angle, conventional mechanical axis deviation, ground mechanical axis (mechanical axis which included the hindfoot) deviation, and tibiocalcaneal angle.


The preoperative hindfoot valgus alignment decreased after TKA. Preoperative hindfoot alignment was the only factor that influenced hindfoot alignment after TKA. The conventional mechanical axis showed less deviation from the center of the knee when compared with ground mechanical axis which showed lateral deviation after TKA. Despite limb alignment being restored to within 3° of neutral of the conventional mechanical axis after TKA, 29% of limbs had a postoperative ground mechanical axis deviation of 10 mm or greater.


Accurate restoration of limb alignment after TKA may be associated with persistent hindfoot valgus alignment with the ground mechanical axis passing lateral to the center of the knee. This could have implications on long-term survival of the implant owing to possible excessive loading laterally and needs further investigation.

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

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

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

Instant access to the full article PDF.

Fig. 1A–D
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others


  1. Bouysset M, Hugueny P. The rheumatoid foot: pathomechanics, clinical and radiological features. Therapeutic conditions. In: Bouysset M, Tourne Y, Tillmann K, eds. Foot and Ankle in Rheumatoid Arthritis. Paris, France: Springer Verlag; 2006:9–48.

    Chapter  Google Scholar 

  2. Chandler JT, Moskal JT. Evaluation of knee and hindfoot alignment before and after total knee arthroplasty: a prospective analysis. J Arthroplasty. 2004;19:211–216.

    Article  PubMed  Google Scholar 

  3. Cobey JC, Sella E. Standardizing methods of measurement of foot shape by including the effects of subtalar rotation. Foot Ankle. 1981;2:30–36.

    PubMed  CAS  Google Scholar 

  4. Desai SS, Shetty GM, Song HR, Lee SH, Kim TY, Hur CY. Effect of foot deformity on conventional mechanical axis deviation and ground mechanical axis deviation during single leg stance and two leg stance in genu varum. Knee. 2007;14:452–457.

    Article  PubMed  Google Scholar 

  5. Guichet JM, Javed A, Russell J, Saleh M. Effect of the foot on the mechanical alignment of the lower limbs. Clin Orthop Relat Res. 2003;415:193–201.

    Article  PubMed  Google Scholar 

  6. Lee ST, Song HR, Mahajan R, Makwana V, Suh SW, Lee SH. Development of genu varum in achondroplasia: relation to fibular overgrowth. J Bone Joint Surg Br. 2007;89:57–61.

    Article  PubMed  CAS  Google Scholar 

  7. Meding JB, Keating EM, Ritter MA, Faris PM, Berend ME, Malinzak RA. The planovalgus foot: a harbinger of failure of posterior cruciate-retaining total knee replacement. J Bone Joint Surg Am. 2005;87(suppl 2):59–62.

    Article  PubMed  Google Scholar 

  8. Souter WA. Surgical strategy in surgery of the lower limb in rheumatoid arthritis. In: Bouysset M, Tourne Y, Tillmann K, eds. Foot and Ankle in Rheumatoid Arthritis. Paris, France: Springer Verlag; 2006:229–236.

    Chapter  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Arun Mullaji FRCS Ed, MCh Orth, MS Orth.

Additional information

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

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

This work was performed at Breach Candy Hospital.

About this article

Cite this article

Mullaji, A., Shetty, G.M. Persistent Hindfoot Valgus Causes Lateral Deviation of Weightbearing Axis after Total Knee Arthroplasty. Clin Orthop Relat Res 469, 1154–1160 (2011).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: