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Which Factors Increase Risk of Malalignment of the Hip-Knee-Ankle Axis in TKA?

  • Symposium: Papers Presented at the Annual Meetings of the Knee Society
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Computer navigation has improved accuracy and reduced the percentage of alignment outliers in TKA. However, the characteristics of outliers and the risk factors for limb malalignment after TKA are still unclear.

Questions/Purposes

We therefore addressed the following questions: (1) What is the incidence and characteristics of outliers for postoperative limb mechanical axis (hip-knee-ankle [HKA] angle outside the conventional 180° ± 3° range) and component alignment in TKA? And (2) what are the preoperative clinical or radiographic risk factors for limb mechanical axis malalignment in TKA?

Methods

We retrospectively reviewed the clinical and radiographic records of 1500 computer-assisted TKAs to identify outliers for postoperative HKA axis and component alignment and determined risk factors for malalignment. Full-length hip-to-ankle and knee radiographs were used to measure preoperative HKA angle, femoral coronal bowing, joint divergence angle, tibial subluxation, and tibial bone loss and postoperative HKA angle and femoral and tibial component angle.

Results

The incidence of outliers for postoperative limb mechanical axis, femoral component alignment, and tibial component alignment was 7% (112 of 1500 TKAs), 7%, and 8%, respectively, with 70% of limbs placed in excessive varus and 30% in excessive valgus. Preoperative varus deformity of more than 20° and femoral bowing of more than 5° were associated with increased risk of placing the limb mechanical axis outside the acceptable ± 3° range after computer-assisted TKA.

Conclusions

The presence of preoperative radiographic risk factors should alert the surgeon to increased chance of malalignment and every measure should be undertaken in such at-risk knees to ensure proper limb and component alignment and soft tissue balance.

Level of Evidence

Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence

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References

  1. Aglietti P, Buzzi R, Scrobe F. Autologous bone grafting for medial tibial defects in total knee arthroplasty. J Arthroplasty. 1991;6:287–294.

    Article  PubMed  CAS  Google Scholar 

  2. Anderson KC, Buehler KC, Markel DC. Computer assisted navigation in total knee arthroplasty: comparison with conventional methods. J Arthroplasty. 2005;20(7 suppl 3):132–138.

    Article  PubMed  Google Scholar 

  3. Bellemans J, D’Hooghe P, Vandenneucker H, Van Damme G, Victor J. Soft tissue balance in total knee arthroplasty: does stress relaxation occur perioperatively? Clin Orthop Relat Res. 2006;452:49–52.

    Article  PubMed  Google Scholar 

  4. Catani F, Biasca N, Ensini A, Leardini A, Bianchi L, Digennaro V, Giannini S. Alignment deviation between bone resection and final implant positioning in computer-navigated total knee arthroplasty. J Bone Joint Surg Am. 2008;90:765–771.

    Article  PubMed  Google Scholar 

  5. Cheng T, Zhao S, Peng X, Zhang X. Does Computer-assisted surgery improve postoperative leg alignment and implant positioning following total knee arthroplasty? A meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc. 2012;20:1307–1322.

    Article  PubMed  Google Scholar 

  6. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty. 2009;24(6 suppl):39–43.

    Article  PubMed  Google Scholar 

  7. Fu Y, Wang M, Liu Y, Fu Q. Alignment outcomes in navigated total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2012;20:1075–1082.

    Article  PubMed  Google Scholar 

  8. 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;433:152–159.

    Article  PubMed  Google Scholar 

  9. Hetaimish BM, Khan MM, Simunovic N, Al-Harbi HH, Bhandari M, Zalzal PK. Meta-analysis of navigation vs conventional total knee arthroplasty. J Arthroplasty. 2012;27:1177–1182.

    Article  PubMed  Google Scholar 

  10. 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 

  11. Kim YH, Kim JS, Choi Y, Kwon OR. Computer-assisted surgical navigation does not improve the alignment and orientation of the components in total knee arthroplasty. J Bone Joint Surg Am. 2009;91:14–19.

    Article  PubMed  Google Scholar 

  12. Lombardi AV Jr, Berend KR, Ng VY. Neutral mechanical alignment: a requirement for successful TKA: affirms. Orthopedics. 2011;34:e504–e506.

    PubMed  Google Scholar 

  13. Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty. 2009;24:570–578.

    Article  PubMed  Google Scholar 

  14. Martin A, Wohlgenannt O, Prenn M, Oelsch C, von Strempel A. Imageless navigation for TKA increases implantation accuracy. Clin Orthop Relat Res. 2007;460:178–184.

    PubMed  Google Scholar 

  15. Matsumoto T, Muratsu H, Tsumura N, Mizuno K, Kurosaka M, Kuroda R. Soft tissue balance measurement in posterior-stabilized total knee arthroplasty with a navigation system. J Arthroplasty. 2009;24:358–364.

    Article  PubMed  Google Scholar 

  16. Molli RG, Anderson KC, Buehler KC, Markel DC. Computer-assisted navigation software advancements improve the accuracy of total knee arthroplasty. J Arthroplasty. 2011;26:432–438.

    Article  PubMed  Google Scholar 

  17. Mullaji A, Kanna R, Marawar S, Kohli A, Sharma A. Comparison of limb and component alignment using computer-assisted navigation versus image intensifier-guided conventional total knee arthroplasty: a prospective, randomized, single-surgeon study of 467 knees. J Arthroplasty. 2007;22:953–959.

    Article  PubMed  Google Scholar 

  18. Mullaji A, Shetty GM. Extra-articular deformity: femur. In: Malhotra R, ed. Mastering Orthopedic Techniques: Total Knee Arthroplasty. New Delhi, India: Jaypee Brothers Medical Publishers; 2010:217–222.

    Google Scholar 

  19. Mullaji AB, Marawar SV, Mittal V. A comparison of coronal plane axial femoral relationships in Asian patients with varus osteoarthritic knees and healthy knees. J Arthroplasty. 2009;24:861–867.

    Article  PubMed  Google Scholar 

  20. Mullaji AB, Padmanabhan V, Jindal G. Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20 degrees. J Arthroplasty. 2005;20:550–561.

    Article  PubMed  Google Scholar 

  21. Mullaji AB, Shetty GM. Lateral epicondylar osteotomy using computer navigation in total knee arthroplasty for rigid valgus deformities. J Arthroplasty. 2010;25:166–169.

    Article  PubMed  Google Scholar 

  22. Parratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am. 2010;92:2143–2149.

    Article  PubMed  Google Scholar 

  23. Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am. 2011;93:1588–1596.

    Article  PubMed  Google Scholar 

  24. Schmitt J, Hauk C, Kienapfel H, Pfeiffer M, Efe T, Fuchs-Winkelmann S, Heyse TJ. Navigation of total knee arthroplasty: rotation of components and clinical results in a prospectively randomized study. BMC Musculoskelet Disord. 2011;12:16–23.

    Article  PubMed  Google Scholar 

  25. Skyttä ET, Haapamäki V, Koivikko M, Huhtala H, Remes V. Reliability of the hip-to-ankle radiograph in determining the knee and implant alignment after total knee arthroplasty. Acta Orthop Belg. 2011;77:329–335.

    PubMed  Google Scholar 

  26. Tingart M, Lüring C, Bäthis 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 

  27. Yau WP, Chiu KY, Tang WM, Ng TP. Coronal bowing of the femur and tibia in Chinese: its incidence and effects on total knee arthroplasty planning. J Orthop Surg (Hong Kong). 2007;15:32–36.

    CAS  Google Scholar 

  28. Yau WP, Chiu KY, Zuo JL, Tang WM, Ng TP. Computer navigation did not improve alignment in a lower-volume total knee practice. Clin Orthop Relat Res. 2008;466:935–945.

    Article  PubMed  CAS  Google Scholar 

  29. Zorman D, Etuin P, Jennart H, Scipioni D, Devos S. Computer-assisted total knee arthroplasty: comparative results in a preliminary series of 72 cases. Acta Orthop Belg. 2005;71:696–702.

    PubMed  Google Scholar 

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Acknowledgments

The authors thank Prof Harshad Thakur, MD, School of Health System Studies, TATA Institute of Social Sciences, Mumbai, India, and Mr Saket Tibrewal, MBBS, FRCS (Tr&Orth), Specialist Registrar, The Percival Pott Rotation, London, UK, for their help in statistical analysis.

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Authors and Affiliations

  1. The Arthritis Clinic, 101, Cornelian, Kemp’s Corner, Cumballa Hill, Mumbai, 400036, India

    Arun B. Mullaji FRCS(Ed), MCh(Orth), MS(Orth)

  2. Department of Orthopaedic Surgery, Breach Candy Hospital, Mumbai, India

    Arun B. Mullaji FRCS(Ed), MCh(Orth), MS(Orth), Gautam M. Shetty MS(Orth), A. P. Lingaraju MS(Orth) & Sagar Bhayde MS(Orth)

Authors
  1. Arun B. Mullaji FRCS(Ed), MCh(Orth), MS(Orth)
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  2. Gautam M. Shetty MS(Orth)
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  3. A. P. Lingaraju MS(Orth)
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  4. Sagar Bhayde MS(Orth)
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Corresponding author

Correspondence to Arun B. Mullaji FRCS(Ed), MCh(Orth), MS(Orth).

Additional information

The institution of one or more of the authors (APL, SB) has received, during the study period, funding from DePuy, India (Mumbai, India) for Joint Replacement Fellowships. One of the authors (ABM) certifies that he is a consultant for DePuy, India. Each of the remaining authors certifies that he or she, or a member of his or her family, 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.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

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

This work was performed at Breach Candy Hospital, Mumbai, India.

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Mullaji, A.B., Shetty, G.M., Lingaraju, A.P. et al. Which Factors Increase Risk of Malalignment of the Hip-Knee-Ankle Axis in TKA?. Clin Orthop Relat Res 471, 134–141 (2013). https://doi.org/10.1007/s11999-012-2520-3

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  • DOI: https://doi.org/10.1007/s11999-012-2520-3

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