Total Limb Rotation after Unilateral Total Knee Arthroplasty: Side-to-Side Discrepancy

Abstract

Total limb rotation, an important anatomical feature of the lower limb, is defined as any rotation of the lower limb on its longitudinal axis. The aim of the present study was to evaluate the discrepancies of rotational profiles of total limb between nonoperated and operated limb following unilateral total knee arthroplasty. We conducted an analysis of the computed tomography (CT) data from 32 patients undergoing primary unilateral total knee arthroplasty. Using these CT scan, rotational profiles of total limb, such as femoral neck anteversion angle expressed as femoral torsion angle (FTA), tibial torsion angle (TTA), knee joint rotation angle (KJRA), and total limb rotation (TLR) were measured. There were significant discrepancies of FTA and KJRA between operated and nonoperated limb following unilateral total knee arthroplasty. The mean difference of operated and nonoperated side for FTA and KJRA were −6.51 ± 11.88 degrees (p = 0.0041) and −6.83 ± 5.04 degrees (p < 0.001), respectively. However, there were no significant discrepancies of TLR, TTA. These results are due to the compensation effect of KJRA. However, excessive external rotation of the femoral component beyond the compensation effect of prosthetic knee joint can lead to a total limb rotational discrepancy in patient undergoing unilateral total knee arthroplasty.

Keywords

rotational profile - femoral torsion angle - tibial torsion angle - total limb rotation - knee joint rotation angle

• References

• 1 Bråten M, Terjesen T, Rossvoll I. Torsional deformity after intramedullary nailing of femoral shaft fractures. Measurement of anteversion angles in 110 patients. J Bone Joint Surg Br 1993; 75 (5) 799-803
• 2 Christie J, Court-Brown C, Kinninmonth AW, Howie CR. Intramedullary locking nails in the management of femoral shaft fractures. J Bone Joint Surg Br 1988; 70 (2) 206-210
• 3 Jaarsma RL, Pakvis DF, Verdonschot N, Biert J, van Kampen A. Rotational malalignment after intramedullary nailing of femoral fractures. J Orthop Trauma 2004; 18 (7) 403-409
• 4 Liodakis E, Aljuneidi W, Krettek C, Ettinger M, Kenawey M. The neck-malleolar angle: an alternative method for measuring total lower limb torsion that considers the knee joint rotation angle. Skeletal Radiol 2011; 40 (5) 617-621
• 5 Søjbjerg JO, Eiskjaer S, Møller-Larsen F. Locked nailing of comminuted and unstable fractures of the femur. J Bone Joint Surg Br 1990; 72 (1) 23-25
• 6 Jaarsma RL, Verdonschot N, van der Venne R, van Kampen A. Avoiding rotational malalignment after fractures of the femur by using the profile of the lesser trochanter: an in vitro study. Arch Orthop Trauma Surg 2005; 125 (3) 184-187
• 7 Netz P, Olsson E, Ringertz H, Stark A. Functional restitution after lower leg fractures. A long-term follow-up. Arch Orthop Trauma Surg 1991; 110 (5) 238-241
• 8 Puloski S, Romano C, Buckley R, Powell J. Rotational malalignment of the tibia following reamed intramedullary nail fixation. J Orthop Trauma 2004; 18 (7) 397-402
• 9 Hauschild O, Muenzberg M, Knothe D , et al. Rotational limb alignment changes following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2013; 21 (10) 2346-2354
• 10 Tazawa M, Sohmiya M, Wada N, Defi IR, Shirakura K. Toe-out angle changes after total knee arthroplasty in patients with varus knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2014; 22 (12) 3168-3173
• 11 Akagi M, Matsusue Y, Mata T , et al. Effect of rotational alignment on patellar tracking in total knee arthroplasty. Clin Orthop Relat Res 1999; (366) 155-163
• 12 Bell SW, Young P, Drury C , et al. Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 2014; 21 (1) 272-277
• 13 Berger RA, Crossett LS, Jacobs JJ, Rubash HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 1998; (356) 144-153
• 14 Berger RA, Rubash HE. Rotational instability and malrotation after total knee arthroplasty. Orthop Clin North Am 2001; 32 (4) 639-647 , ix
• 15 Heesterbeek PJ, Jacobs WC, Wymenga AB. Effects of the balanced gap technique on femoral component rotation in TKA. Clin Orthop Relat Res 2009; 467 (4) 1015-1022
• 16 Heesterbeek PJ, Wymenga AB. Correction of axial and rotational alignment after medial and lateral releases during balanced gap TKA. A clinical study of 54 patients. Acta Orthop 2010; 81 (3) 347-353
• 17 Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Insall Award paper. Why are total knee arthroplasties failing today?. Clin Orthop Relat Res 2002; (404) 7-13
• 18 Eckhoff DG, Metzger RG, Vandewalle MV. Malrotation associated with implant alignment technique in total knee arthroplasty. Clin Orthop Relat Res 1995; (321) 28-31
• 19 Hernandez RJ, Tachdjian MO, Poznanski AK, Dias LS. CT determination of femoral torsion. AJR Am J Roentgenol 1981; 137 (1) 97-101
• 20 Oberst M, Bertsch C, Konrad G, Lahm A, Holz U. CT analysis after navigated versus conventional implantation of TKA. Arch Orthop Trauma Surg 2008; 128 (6) 561-566
• 21 Waidelich HA, Strecker W, Schneider E. [Computed tomographic torsion-angle and length measurement of the lower extremity. The methods, normal values and radiation load]. Rofo 1992; 157 (3) 245-251
• 22 Liodakis E, Doxastaki I, Chu K , et al. Reliability of the assessment of lower limb torsion using computed tomography: analysis of five different techniques. Skeletal Radiol 2012; 41 (3) 305-311
• 23 Nicoll D, Rowley DI. Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Joint Surg Br 2010; 92 (9) 1238-1244
• 24 Citak M, Suero EM, O'Loughlin PF , et al. Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures. Arch Orthop Trauma Surg 2011; 131 (6) 823-827
• 25 Strecker W, Keppler P, Gebhard F, Kinzl L. Length and torsion of the lower limb. J Bone Joint Surg Br 1997; 79 (6) 1019-1023
• 26 Theriault B, Turgeon AF, Pelet S. Functional impact of tibial malrotation following intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 2012; 94 (22) 2033-2039
• 27 Watanabe S, Sato T, Omori G, Koga Y, Endo N. Change in tibiofemoral rotational alignment during total knee arthroplasty. J Orthop Sci 2014; 19 (4) 571-578
• 28 Kenawey M, Liodakis E, Krettek C, Ostermeier S, Horn T, Hankemeier S. Effect of the lower limb rotational alignment on tibiofemoral contact pressure. Knee Surg Sports Traumatol Arthrosc 2011; 19 (11) 1851-1859
• 29 Galaud B, Beaufils P, Michaut M, Abadie P, Fallet L, Boisrenoult P. Distal femoral torsion: comparison of CT scan and intra operative navigation measurements during total knee arthroplasty. A report of 70 cases [in French]. Rev Chir Orthop Repar Appar Mot 2008; 94 (6) 573-579
• 30 van der Linden-van der Zwaag HM, Bos J, van der Heide HJ, Nelissen RG. A computed tomography based study on rotational alignment accuracy of the femoral component in total knee arthroplasty using computer-assisted orthopaedic surgery. Int Orthop 2011; 35 (6) 845-850
• 31 Akagi M, Mori S, Nishimura S, Nishimura A, Asano T, Hamanishi C. Variability of extraarticular tibial rotation references for total knee arthroplasty. Clin Orthop Relat Res 2005; (436) 172-176
• 32 Buck FM, Guggenberger R, Koch PP, Pfirrmann CW. Femoral and tibial torsion measurements with 3D models based on low-dose biplanar radiographs in comparison with standard CT measurements. AJR Am J Roentgenol 2012; 199 (5) W607-W612
• 33 Gandhi S, Singla RK, Kullar JS , et al. Human tibial torsion—morphometric assessment and clinical relevance. Biom J 2014; 37 (1) 10-13
• 34 Eckhoff DG, Johnson KK. Three-dimensional computed tomography reconstruction of tibial torsion. Clin Orthop Relat Res 1994; (302) 42-46