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The contralateral limb is no reliable reference to restore coronal alignment in TKA

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Implementation of morphometric reference data from the contralateral, unaffected lower limb is suggested when reconstructing the coronal plane alignment in TKA. Limited information, however, is available which confirms this left-to-right symmetry in coronal alignment based upon radiographs. The purpose of the study was, therefore, (1) to verify if a left-to-right symmetry is present and (2) to assess whether the contralateral lower limb would be a reliable reference for reconstructing the frontal plane alignment.

Methods

Full-leg standing radiographs of 250 volunteers (male, 125; female,125) were reviewed for three alignment parameters (Hip–Knee–Ankle angle (HKA), Femoral Mechanical Angle (FMA) and Tibial Mechanical Angle (TMA)). Evaluation of assumed left-to-right symmetry was performed according to two coronal alignment classifications (HKA subdivisions (HKA) and limb, femoral and tibial phenotypes (HKA, FMA and TMA)). Inter- and within-subject variability was calculated, along with correlations coefficients (r) and coefficients of determination (r2). Reliability of the contralateral limb as a personalized reference to reconstruct the constitutional alignment was investigated by intervals, expanding by 1° increments (0.5° increment both to varus and valgus) around the right knee alignment parameters. Subsequently, it was verified whether or not the left knee parameters fell within this interval.

Results

Symmetrical distribution in coronal alignment was found in 79% (HKA subdivision) and 59% (limb phenotype) of the cohort. Gender differences were present for the most common symmetric limb phenotypes (VARHKA3° (23.2%) in males and NEUHKA0° (38.4%) in females). Inter-subject variability was more prominent than the within-subject side differences for all parameters. Correlations analyses revealed mostly moderate correlations between the alignment measurements. Coefficients of determination showed overall weak left-to-right relationship, except for a moderate predictability for HKA (r2 = 0.538, p < 0.001) and FMA (r2 = 0.618, p < 0.001) in females. FMA and TMA marked weak predictive values for contralateral HKA. Only 60% of left knees were referenced within a 3° interval around the right knee.

Conclusion

No strict left-to-right symmetry was observed in coronal alignment measurements. There is insufficient left-to-right agreement to consider the concept of the contralateral unaffected limb as an idealized reference for frontal plane alignment reconstruction based upon full-leg standing radiographs.

Level of evidence

I.

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Abbreviations

CT scan:

Computed tomography scan

FMA:

Femoral mechanical angle

HKA:

Hip–knee–ankle angle

ICC:

Intra-class correlation coefficient

mLDFA:

Mechanical lateral distal femoral angle

MRI:

Magnetic resonance imaging

OA:

Osteoarthritis

TKA:

Total knee arthroplasty

TMA:

Tibial mechanical angle

SD:

Standard deviation

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, Sint-Jan Hospital, Ruddershove 10, 8000, Bruges, Belgium

    Lucas Beckers & Pieter-Jan Vandekerckhove

  2. Department of Orthopaedic Surgery and Traumatology, Sint-Lucas Hospital, Sint-Lucaslaan 29, 8310, Bruges, Belgium

    Lucas Beckers, Jan Victor & Pieter-Jan Vandekerckhove

  3. Orthoclinic Orthopaedic Centre Bruges, Gistelsesteenweg 446, 8200, Sint-Andries, Belgium

    Lucas Beckers, Jan Victor & Pieter-Jan Vandekerckhove

  4. Department of Orthopaedic Surgery and Traumatology, General Hospital Turnhout, Steenweg op Merksplas 44, 2300, Turnhout, Belgium

    William Colyn

  5. Department of Orthopaedic Surgery and Traumatology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium

    Johan Bellemans

  6. Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan D, 3500, Diepenbeek, Belgium

    Johan Bellemans

  7. GRIT Belgian Sports Clinic, Engels Plein 35, 3000, Leuven, Belgium

    Johan Bellemans

  8. Department of Orthopaedic Surgery, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium

    Jan Victor

Authors
  1. Lucas Beckers
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  2. William Colyn
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  3. Johan Bellemans
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  4. Jan Victor
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Contributions

LB: Designed the study, analyzed and interpreted the data, performed the statistical analysis, prepared the manuscript. WC: Performed the radiographic measurements, reviewed the manuscript. JB: Provided the database, analyzed and interpreted the data, reviewed the manuscript. JV: Analyzed and interpreted the data, reviewed the manuscript. PJV: Designed the study, analyzed and interpreted the data, reviewed the manuscript. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Pieter-Jan Vandekerckhove.

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Conflict of interest

Lucas Beckers or any member of his or her immediate family has no funding or commercial associations that might pose a conflict of interest in connection with the submitted article. William Colyn or any member of his or her immediate family has no funding or commercial associations that might pose a conflict of interest in connection with the submitted article. Johan Bellemans or any member of his or her immediate family has no funding or commercial associations that might pose a conflict of interest in connection with the submitted article. Jan Victor or any member of his or her immediate family has no funding or commercial associations that might pose a conflict of interest in connection with the submitted article. Pieter-Jan Vandekerckhove or any member of his or her immediate family has no funding or commercial associations that might pose a conflict of interest in connection with the submitted article.

Ethical approval

All investigations were conducted in conformity with ethical principles of research and that institutional approval of the human protocol for this investigation was obtained from the Ethics Committee from the University of Leuven (B32220097076).

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Informed consent for participation in the study was obtained.

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Beckers, L., Colyn, W., Bellemans, J. et al. The contralateral limb is no reliable reference to restore coronal alignment in TKA. Knee Surg Sports Traumatol Arthrosc 30, 477–487 (2022). https://doi.org/10.1007/s00167-020-06152-9

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  • DOI: https://doi.org/10.1007/s00167-020-06152-9

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