Skip to main content

Advertisement

SpringerLink
Log in

Wide variation in tibial slopes and trochlear angles in the arthritic knee: a CT evaluation of 4116 pre-operative knees

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

As surgeons continue to grapple with persistent issues of patient dissatisfaction post-TKA, the literature has focused on the coronal plane when considering alignment strategies but has largely ignored the sagittal and axial planes. The purpose of this retrospective observational cohort study is to evaluate variability in knee anatomy and alignment beyond the coronal plane and rationalise how this relates to existing arthroplasty alignment philosophies.

Methods

4116 knee CTs from 360 Knee Systems© database of arthritic pre-operative TKA patients were evaluated. Standardised bony landmarks were used in each CT to determine the hip–knee angle, medial proximal tibial angle, lateral distal femoral angle, medial plateau posterior tibial slope, lateral plateau posterior tibial slope, trochlea angle (TA) to distal femoral angle (TA–DFA) and TA to posterior condylar angle (TA–PCA). Analysis was performed to determine the distributions of each measure across the cohort population.

Results

Both the medial and lateral PTS ranged from 5° anterior to 25° posterior. 22.6% of patients had differential PTS greater than 5°. 14.5% have greater lateral PTS (mean difference to medial PTS of 4.8° ± 5.0°), whilst 31.0% have greater medial PTS (mean difference to lateral PTS of 5.7° ± 3.2°). 14% of TA–DFAs and 5.2% of TA–PCAs vary greater than 10°.

Conclusion

This study demonstrates a wide variation in tibial slope, differential slope between the medial and lateral tibial plateau as well as variation in the trochlear geometry. There has been an overemphasis in the literature on coronal alignment, ignoring the considerable variability present in tibial and patellofemoral morphology. Existing arthroplasty techniques are based on assumptions that may not adequately address the anatomy of morphologic outliers and could lead to dissatisfaction.

Level of evidence

III—retrospective cohort study.

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

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9

Similar content being viewed by others

References

  1. Almaawi AM, Hutt JRB, Masse V, Lavigne M, Vendittoli P-A (2017) The impact of mechanical and restricted kinematic alignment on knee anatomy in total knee arthroplasty. J Arthroplasty 32:2133–2140

    Article  PubMed  Google Scholar 

  2. Bellemans J, Colyn W, Vandenneucker H, Victor J (2012) The Chitranjan Ranawat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 470:45–53

    Article  PubMed  Google Scholar 

  3. Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M (2017) PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 25:1743–1748

    Article  PubMed  Google Scholar 

  4. Diduch DR, Insall JN, Scott WN, Scuderi GR, Font-Rodriguez D (1997) Total knee replacement in young, active patients. Long-term follow-up and functional outcome. J Bone Jt Surg 79:575–582

    Article  CAS  Google Scholar 

  5. Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG (2014) A randomised controlled trial of kinematically and mechanically aligned total knee replacements. Bone Jt J 96-B:907–913

    Article  CAS  Google Scholar 

  6. Dossett HG, Swartz GJ, Estrada NA, Lefevre GW, Kwasman BG (2012) Kinematically versus mechanically aligned total knee arthroplasty. Orthopedics 35:160–169

    Article  Google Scholar 

  7. Du Z, Chen S, Yan M, Yue B, Wang Y (2017) Differences between native and prosthetic knees in terms of cross-sectional morphology of the femoral trochlea: a study based on three-dimensional models and virtual total knee arthroplasty. BMC Musculoskelet Disord 18:166

    Article  PubMed  PubMed Central  Google Scholar 

  8. Grelsamer RP, Dubey A, Weinstein CH (2005) Men and women have similar Q angles. J Bone Jt Surg Br 87-B:1498–1501

    Article  Google Scholar 

  9. Hashemi J, Chandrashekar N, Gill B, Beynnon BD, Slauterbeck JR, Schutt RC, Mansouri H, Dabezies E (2008) The Geometry of the tibial plateau and its influence on the biomechanics of the tibiofemoral joint. J Bone Jt Surg Am 90:2724–2734

    Article  Google Scholar 

  10. Hess S, Moser LB, Amsler F, Behrend H, Hirschmann MT (2019) Highly variable coronal tibial and femoral alignment in osteoarthritic knees: a systematic review. Knee Surg Sports Traumatol Arthrosc 27:1368–1377

    Article  PubMed  Google Scholar 

  11. Hirschmann MT, Hess S, Behrend H, Amsler F, Leclercq V, Moser LB (2019) Phenotyping of hip–knee–ankle angle in young non-osteoarthritic knees provides better understanding of native alignment variability. Knee Surg Sports Traumatol Arthrosc 27:1378–1384

    Article  PubMed  Google Scholar 

  12. Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclercq V, Hess S (2019) Phenotyping the knee in young non-osteoarthritic knees shows a wide distribution of femoral and tibial coronal alignment. Knee Surg Sports Traumatol Arthrosc 27:1385–1393

    Article  PubMed  Google Scholar 

  13. Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclerq V, Hess S (2019) Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non-osteoarthritic patients. Knee Surg Sports Traumatol Arthrosc 27:1394–1402

    Article  PubMed  Google Scholar 

  14. Hochreiter B, Moser LB, Hess S, Hirschmann MT, Amsler F, Behrend H (2021) Osteoarthritic knees have a highly variable patellofemoral alignment: a systematic review. Knee Surg Sports Traumatol Arthrosc 29:483–490

    Article  PubMed  Google Scholar 

  15. Howell SM, Papadopoulos S, Kuznik K, Ghaly LR, Hull ML (2015) Does varus alignment adversely affect implant survival and function six years after kinematically aligned total knee arthroplasty? Int Orthop 39:2117–2124

    Article  PubMed  Google Scholar 

  16. Howell SM, Shelton TJ, Hull ML (2018) Implant survival and function ten years after kinematically aligned total knee arthroplasty. J Arthroplasty 33:3678–3684

    Article  PubMed  Google Scholar 

  17. Hutt J, Massé V, Lavigne M, Vendittoli P-A (2016) Functional joint line obliquity after kinematic total knee arthroplasty. Int Orthop 40:29–34

    Article  PubMed  Google Scholar 

  18. Hutt JRB, LeBlanc M-A, Massé V, Lavigne M, Vendittoli P-A (2016) Kinematic TKA using navigation: surgical technique and initial results. Orthop Traumatol Surg Res 102:99–104

    Article  CAS  PubMed  Google Scholar 

  19. Keshmiri A, Springorum HR, Baier C, Zeman F, Grifka J, Maderbacher G (2016) Changes in sagittal component alignment alters patellar kinematics in TKA: an in vitro study. Knee Surg Sports Traumatol Arthrosc 24:823–829

    Article  PubMed  Google Scholar 

  20. Koh IJ, Park IJ, Lin CC, Patel NA, Chalmers CE, Maniglio M, McGarry MH, Lee TQ (2019) Kinematically aligned total knee arthroplasty reproduces native patellofemoral biomechanics during deep knee flexion. Knee Surg Sports Traumatol Arthrosc 27:1520–1528

    Article  PubMed  Google Scholar 

  21. Laende EK, Richardson CG, Dunbar MJ (2019) A randomized controlled trial of tibial component migration with kinematic alignment using patient-specific instrumentation versus mechanical alignment using computer-assisted surgery in total knee arthroplasty. Bone Jt J 101 B:929–940

    Article  Google Scholar 

  22. Lee HJ, Lim JW, Lee DH, Kim DH, Park YB (2020) Slight under-correction using individualized intentional varus femoral cutting leads to favorable outcomes in patients with lateral femoral bowing and varus knee. Knee Surg Sports Traumatol Arthrosc 28:1579–1586

    Article  PubMed  Google Scholar 

  23. Lee JK, Lee S, Chun SH, Kim KT, Lee MC (2017) Rotational alignment of femoral component with different methods in total knee arthroplasty: a randomized, controlled trial. BMC Musculoskelet Disord 18:1–7

    Article  CAS  Google Scholar 

  24. Lozano R, Campanelli V, Howell S, Hull M (2019) Kinematic alignment more closely restores the groove location and the sulcus angle of the native trochlea than mechanical alignment: implications for prosthetic design. Knee Surg Sports Traumatol Arthrosc 27:1504–1513

    Article  PubMed  Google Scholar 

  25. MacDessi SJ, Griffiths-Jones W, Harris IA, Bellemans J, Chen DB (2021) Coronal plane alignment of the knee (CPAK) classification. Bone Jt J 103-B:329–337

    Article  Google Scholar 

  26. Maillot C, Leong A, Harman C, Morelli A, Mospan R, Cobb J, Rivière C (2019) Poor relationship between frontal tibiofemoral and trochlear anatomic parameters: implications for designing a trochlea for kinematic alignment. Knee 26:106–114

    Article  PubMed  Google Scholar 

  27. Matsumoto T, Takayama K, Ishida K, Hayashi S, Hashimoto S, Kuroda R (2017) Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty. Bone Jt J 99B:640–646

    Article  Google Scholar 

  28. McEwen PJ, Dlaska CE, Jovanovic IA, Doma K, Brandon BJ (2020) Computer-assisted kinematic and mechanical axis total knee arthroplasty: a prospective randomized controlled trial of bilateral simultaneous surgery. J Arthroplasty 35:443–450

    Article  PubMed  Google Scholar 

  29. Meric G, Gracitelli GC, Aram L, Swank M, Bugbee WD (2015) Tibial slope is highly variable in patients undergoing primary total knee arthroplasty: analysis of 13,546 computed tomography scans. J Arthroplasty 30:1228–1232

    Article  PubMed  Google Scholar 

  30. Nakamura S, Tian Y, Tanaka Y, Kuriyama S, Ito H, Furu M, Matsuda S (2017) The effects of kinematically aligned total knee arthroplasty on stress at the medial tibia: a case study for varus knee. Bone Jt Res 6:43–51

    Article  CAS  Google Scholar 

  31. Nam D, Nunley RM, Barrack RL (2014) Patient dissatisfaction following total knee replacement: a growing concern? Bone Jt J 96B:96–100

    Article  Google Scholar 

  32. Nicolet-Petersen S, Saiz A, Shelton T, Howell S, Hull ML (2020) Kinematically aligned TKA restores physiological patellofemoral biomechanics in the sagittal plane during a deep knee bend. Knee Surg Sports Traumatol Arthrosc 28:1497–1507

    Article  PubMed  Google Scholar 

  33. Nunley RM, Nam D, Johnson SR, Barnes CL (2014) Extreme variability in posterior slope of the proximal tibia: measurements on 2395 CT scans of patients undergoing UKA? J Arthroplasty 29:1677–1680

    Article  PubMed  PubMed Central  Google Scholar 

  34. Okazaki K, Tashiro Y, Mizu-uchi H, Hamai S, Doi T, Iwamoto Y (2014) Influence of the posterior tibial slope on the flexion gap in total knee arthroplasty. Knee 21:806–809

    Article  PubMed  Google Scholar 

  35. Rivière C, Dhaif F, Shah H, Ali A, Auvinet E, Aframian A, Cobb J, Howell S, Harris S (2018) Kinematic alignment of current TKA implants does not restore the native trochlear anatomy. Orthop Traumatol Surg Res 104:983–995

    Article  PubMed  Google Scholar 

  36. Rivière C, Iranpour F, Auvinet E, Aframian A, Asare K, Harris S, Cobb J, Parratte S (2017) Mechanical alignment technique for TKA: are there intrinsic technical limitations? Orthop Traumatol Surg Res 103:1057–1067

    Article  PubMed  Google Scholar 

  37. Rivière C, Iranpour F, Harris S, Auvinet E, Aframian A, Parratte S, Cobb J (2018) Differences in trochlear parameters between native and prosthetic kinematically or mechanically aligned knees. Orthop Traumatol Surg Res 104:165–170

    Article  PubMed  Google Scholar 

  38. Seo SS, Kim CW, Kim JH, Min YK (2013) Clinical results associated with changes of posterior tibial slope in total knee arthroplasty. Knee Surg Relat Res 25:25–29

    Article  PubMed  PubMed Central  Google Scholar 

  39. Theodore W, Twiggs J, Kolos E, Roe J, Fritsch B, Dickison D, Liu D, Salmon L, Miles B, Howell S (2017) Variability in static alignment and kinematics for kinematically aligned TKA. Knee 24:733–744

    Article  PubMed  Google Scholar 

  40. Victor J, Van Doninck D, Labey L, Innocenti B, Parizel PM, Bellemans J (2009) How precise can bony landmarks be determined on a CT scan of the knee? Knee 16:358–365

    Article  CAS  PubMed  Google Scholar 

  41. Wakelin EA, Tran L, Twiggs JG, Theodore W, Roe JP, Solomon MI, Fritsch BA, Miles BP (2018) Accurate determination of post-operative 3D component positioning in total knee arthroplasty: the AURORA protocol. J Orthop Surg Res 13:275

    Article  PubMed  PubMed Central  Google Scholar 

  42. Waterson HB, Clement ND, Eyres KS, Mandalia VI, Toms AD (2016) The early outcome of kinematic versus mechanical alignment in total knee arthroplasty: a PROSPECTIVE RANDOMISED CONTROL TRIAL. Bone Jt J 98-B:1360–1368

    Article  CAS  Google Scholar 

  43. Young SW, Walker M, Bayan A, Briant-Evans T, Pavlou P, Farrington B (2017) No difference in 2-year functional outcomes using kinematic versus mechanical alignment in TKA: a randomized controlled clinical trial. Arthrosc J Arthrosc Relat Surg 33:e115

    Article  Google Scholar 

Download references

Acknowledgements

The authors acknowledge Andrea Grant-Administration and Clinical Research Governance support. 360 Knee Group—Andrew Shimmin, Bede O'Connor, Brad Miles, Brett Fritsch, David Dickison, David Liu, David Parker, Jonathan Baré, Joshua Twiggs, Justin Roe, Michael Solomon, Richard Boyle, and Stephen McMahon.

Author information

Authors and Affiliations

  1. The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, QLD, 4812, Australia

    Kaushik Hazratwala, William B. O’Callaghan & Matthew P. R. Wilkinson

  2. 360 Knee Systems, Pymble, NSW, Australia

    Shilpa Dhariwal

Authors
  1. Kaushik Hazratwala
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. William B. O’Callaghan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shilpa Dhariwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Matthew P. R. Wilkinson
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

360 Knee Group

Contributions

A/Prof KH, WBO and MPRW collaborated to synthesise and write the article based on the data collated, analysed and presented by Ms SD. The 360 Knee Group contributed to collection of data, formation and development of population measurements derived from the data.

Corresponding author

Correspondence to Kaushik Hazratwala.

Ethics declarations

Conflict of interest

ORIQL members of the research team have no financial association with 360 Knee Systems Pty Ltd. Shilpa Dhariwal is an employee of 360 Knee Systems Pty Ltd and has provided the study data and statistical analysis pro-bono for interpretation.

Funding

No institutional or commercial funding was obtained for this study.

Ethical approval

Bellberry Human Research Ethics Committee, approval number 2012-03-710.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix 1

Appendix 1

360 Knee Systems© Knee CT Protocol:

Slice increment—1.25 mm.

Slice thickness—1.25 mm.

The estimated effective dose for the protocol was determined to be a Category IIb (2 mSv to 20Msv) risk.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hazratwala, K., O’Callaghan, W.B., Dhariwal, S. et al. Wide variation in tibial slopes and trochlear angles in the arthritic knee: a CT evaluation of 4116 pre-operative knees. Knee Surg Sports Traumatol Arthrosc 30, 3049–3060 (2022). https://doi.org/10.1007/s00167-021-06725-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-021-06725-2

Keywords

Search

Navigation