Download PDF
J Knee Surg 2021; 34(13): 1436-1440
DOI: 10.1055/s-0040-1709676
Original Article

The Relationships between the Rotational Axes of the Distal Femur in the Arthritic Caucasian Knee: A Magnetic Resonance Imaging Analysis

Mansur Halai 
1   Department of Orthopaedic Surgery, University Hospital Crosshouse, Kilmarnock, Scotland, United Kingdom
,
Sahil Kooner
2   Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
,
Bilal Jamal
1   Department of Orthopaedic Surgery, University Hospital Crosshouse, Kilmarnock, Scotland, United Kingdom
,
Jacquelyn McMillan
1   Department of Orthopaedic Surgery, University Hospital Crosshouse, Kilmarnock, Scotland, United Kingdom
,
Brian Syme
1   Department of Orthopaedic Surgery, University Hospital Crosshouse, Kilmarnock, Scotland, United Kingdom
,
Graeme Holt
1   Department of Orthopaedic Surgery, University Hospital Crosshouse, Kilmarnock, Scotland, United Kingdom
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Four distal femoral axes have been described to aid in the accuracy of transverse plane component alignment in total knee arthroplasty (TKA). These include the surgical epicondylar axis (SEA), the posterior condylar axis (PCA), and the anteroposterior (AP) axis. Therefore, the primary purpose of this study is to identify the axial femoral relationship with the least variation in a Caucasian population awaiting TKA for osteoarthritis. Secondarily, we further plan to determine if these femoral axis relationships differ with respect to sex or preoperative coronal alignment. These anatomic relationships were measured using preoperative magnetic resonance imaging, which was performed within 2 months of the planned operation date for patient specific instrumentation templating. In terms of our primary outcome, the mean SEA/AP angle was 92.8 degrees (standard deviation [SD]: 2.5 degrees), the mean PCA/AP angle was 95.7 degrees (SD: 2.8 degrees), and the mean PCA/SEA angle was 3.4 degrees (SD: 1.8 degrees). Overall, the PCA/SEA relationship had the smallest variance, while the PCA/AP had the most variance for all comparisons. In terms of our secondary outcome, there was no statistical difference between femoral axis relationships based on preoperative coronal plane alignment. In terms of sex differences, the PCA/SEA was significantly higher in female knees compared with males. Females had a PCA/SEA relationship of 4.7 degrees (SD: 1.3 degrees) compared with 2.6 degrees (SD: 1.2 degrees) for males (p < 0.05). By using the PCA/AP axes, the AP axis was externally rotated by 96.7 degrees (SD: 2.3 degrees) in females, compared with 93.2 degrees (SD: 2.1 degrees) in males, from the PCA. In conclusion, our results demonstrate that the PCA/SEA relationship should be used to determine axial rotation in TKA as it shows the least variation. When using the PCA, approximately 5 degrees of external rotation for Caucasian women and 3 degrees of external rotation for the Caucasian men should be dialed into the femoral cutting block to restore anatomic axial rotation. Further evaluation is needed to determine to role of preoperative coronal alignment on distal femoral axial alignment.

Keywords

total knee arthroplasty - axis - distal femur - caucasian - arthritis - axial - transverse


Publication History

Received: 02 January 2020

Accepted: 01 March 2020

Article published online:
30 April 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Buly RL, Sculco TP. Recent advances in total knee replacement surgery. Curr Opin Rheumatol 1995; 7 (02) 107-113
    CrossrefPubMedGoogle Scholar
  • 2 Kim J-H, Gwak H-C, Lee C-R, Choo H-J, Kim J-G, Kim D-Y. A comparison of screw fixation and suture-button fixation in a syndesmosis injury in an ankle fracture. J Foot Ankle Surg 2016; 55 (05) 985-990
    CrossrefPubMedGoogle Scholar
  • 3 Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. National Joint Registry for England and Wales; Data from the National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007; 89 (07) 893-900
    CrossrefPubMedGoogle Scholar
  • 4 Hofmann S, Romero J, Roth-Schiffl E, Albrecht T. [Rotational malalignment of the components may cause chronic pain or early failure in total knee arthroplasty]. Orthopade 2003; 32 (06) 469-476
    CrossrefPubMedGoogle Scholar
  • 5 Verlinden C, Uvin P, Labey L, Luyckx JP, Bellemans J, Vandenneucker H. The influence of malrotation of the femoral component in total knee replacement on the mechanics of patellofemoral contact during gait: an in vitro biomechanical study. J Bone Joint Surg Br 2010; 92 (05) 737-742
    CrossrefPubMedGoogle Scholar
  • 6 Kessler O, Patil S, Colwell Jr CW, D'Lima DD. The effect of femoral component malrotation on patellar biomechanics. J Biomech 2008; 41 (16) 3332-3339
    CrossrefPubMedGoogle Scholar
  • 7 Blaha JD, Mancinelli CA, Simons WH. Using the transepicondylar axis to define the sagittal morphology of the distal part of the femur. J Bone Joint Surg Am 2002; 84-A (Suppl. 02) 48-55
    CrossrefPubMedGoogle Scholar
  • 8 Yan CH, Yau WP, Ng TP, Lie WH, Chiu KY, Tang WM. Inter- and intraobserver errors in identifying the transepicondylar axis and Whiteside's line. J Orthop Surg (Hong Kong) 2008; 16 (03) 316-320
    CrossrefPubMedGoogle Scholar
  • 9 Griffin FM, Math K, Scuderi GR, Insall JN, Poilvache PL. Anatomy of the epicondyles of the distal femur: MRI analysis of normal knees. J Arthroplasty 2000; 15 (03) 354-359
    CrossrefPubMedGoogle Scholar
  • 10 Churchill DL, Incavo SJ, Johnson CC, Beynnon BD. The transepicondylar axis approximates the optimal flexion axis of the knee. Clin Orthop Relat Res 1998; (356) 111-118
    CrossrefPubMedGoogle Scholar
  • 11 Arima J, Whiteside LA, McCarthy DS, White SE. Femoral rotational alignment, based on the anteroposterior axis, in total knee arthroplasty in a valgus knee. A technical note. J Bone Joint Surg Am 1995; 77 (09) 1331-1334
    CrossrefPubMedGoogle Scholar
  • 12 Laskin RS. Flexion space configuration in total knee arthroplasty. J Arthroplasty 1995; 10 (05) 657-660
    CrossrefPubMedGoogle Scholar
  • 13 Middleton FR, Palmer SH. How accurate is Whiteside's line as a reference axis in total knee arthroplasty?. Knee 2007; 14 (03) 204-207
    CrossrefPubMedGoogle Scholar
  • 14 Luyckx T, Zambianchi F, Catani F, Bellemans J, Victor J. Coronal alignment is a predictor of the rotational geometry of the distal femur in the osteo-arthritic knee. Knee Surg Sports Traumatol Arthrosc 2013; 21 (10) 2331-2337
    CrossrefPubMedGoogle Scholar
  • 15 Victor J. Rotational alignment of the distal femur: a literature review. Orthop Traumatol Surg Res 2009; 95 (05) 365-372
    CrossrefPubMedGoogle Scholar
  • 16 Luksanapruksa P, Rojvanit V, Sanpakit S. Axial radiography of the normal distal femur for assessment of rotational alignment in Thai. J Med Assoc Thai 2012; 95 (04) 526-531
    PubMedGoogle Scholar
  • 17 Sun T, Lv H, Hong N. [Rotational landmarks and total knee arthroplasty in osteoarthritic knees]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2007; 21 (03) 226-230
    PubMedGoogle Scholar
  • 18 Urabe K, Mahoney OM, Mabuchi K, Itoman M. Morphologic differences of the distal femur between Caucasian and Japanese women. J Orthop Surg (Hong Kong) 2008; 16 (03) 312-315
    CrossrefPubMedGoogle Scholar
  • 19 Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 1987; 69 (05) 745-749
    CrossrefPubMedGoogle Scholar
  • 20 Paternostre F, Schwab P-E, Thienpont E. The combined Whiteside's and posterior condylar line as a reliable reference to describe axial distal femoral anatomy in patient-specific instrument planning. Knee Surg Sports Traumatol Arthrosc 2014; 22 (12) 3054-3059
    CrossrefPubMedGoogle Scholar
  • 21 Akagi M, Yamashita E, Nakagawa T, Asano T, Nakamura T. Relationship between frontal knee alignment and reference axis in the distal femur. Clin Orthop Relat Res 2001; (388) 147-156
    CrossrefPubMedGoogle Scholar
  • 22 Matsuda S, Matsuda H, Miyagi T, Sasaki K, Iwamoto Y, Miura H. Femoral condyle geometry in the normal and varus knee. Clin Orthop Relat Res 1998; (349) 183-188
    CrossrefPubMedGoogle Scholar
  • 23 Mullaji AB, Sharma AK, Marawar SV, Kohli AF, Singh DP. Distal femoral rotational axis in Indian knees. J Orthop Surg (Hong Kong) 2009; 17 (02) 166-169
    CrossrefPubMedGoogle Scholar
  • 24 Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 1993; (286) 40-47
    PubMedGoogle Scholar
  • 25 Yip DKH, Zhu YH, Chiu KY, Ng TP. Distal rotational alignment of the Chinese femur and its relevance in total knee arthroplasty. J Arthroplasty 2004; 19 (05) 613-619
    CrossrefPubMedGoogle Scholar
  • 26 Jenny J-Y, Boeri C. Low reproducibility of the intraoperative measurement of the transepicondylar axis during total knee replacement. Acta Orthop Scand 2004; 75 (01) 74-77
    CrossrefPubMedGoogle Scholar
  • 27 Tashiro Y, Uemura M, Matsuda S. et al. Articular cartilage of the posterior condyle can affect rotational alignment in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012; 20 (08) 1463-1469
    CrossrefPubMedGoogle Scholar
  • 28 Victor J, Dujardin J, Vandenneucker H, Arnout N, Bellemans J. Patient-specific guides do not improve accuracy in total knee arthroplasty: a prospective randomized controlled trial. Clin Orthop Relat Res 2014; 472 (01) 263-271
    CrossrefPubMedGoogle Scholar
  • 29 Nagamine R, Miura H, Inoue Y. et al. Reliability of the anteroposterior axis and the posterior condylar axis for determining rotational alignment of the femoral component in total knee arthroplasty. J Orthop Sci 1998; 3 (04) 194-198
    CrossrefPubMedGoogle Scholar