Patellar medial-lateral position can be used to correct the effect of leg rotation on preoperative planning in total knee arthroplasty for varus knees

Background: Lower limb malrotations can be observed in long leg radiographs, affecting the measurement of the angle between the mechanical and anatomical axes. The purposes were to analyze the effect of limb rotation and to evaluate the accuracy of the corrected angle between the mechanical and anatomical axes based on the patellar ML position. Hypothesis: The hypothesis was that the correction of the angle between the mechanical and anatomical axes according to the patellar ML position can reduce the error from the angle in the true AP view in most of the knees. Patients and methods: A total of 100 consecutive knees with varus deformity undergoing primary total knee arthroplasty were included. Computed tomography images were digitally reconstructed in the neutral position, and internally and externally rotated at 10 degrees and 20 degrees, respectively. The patellar ML position relative to the medial (0%) and lateral (100%) epicondyles and the angle between the mechanical and anatomical axes of the femur were measured. The corrected angle between the mechanical and anatomical axes was calculated using the averaged translational ratio. Results: In the neutral position, the patellar center position was 56.1% (standard deviation [SD] = 4.7%), which was 31.4% (SD = 7.2%) and 80.2% (SD = 5.4%) in the 20 degrees internal and external rotation, respectively. The angle between the mechanical and anatomical axes was 2.6 degrees (SD = 2.0 degrees) and 8.1 degrees (SD = 2.1 degrees) in the 20 degrees internal and external rotation, respectively. On average, if the patellar center shifted 10%, the change of the angle between the mechanical and anatomical axes of the femur was 1.13 degrees. Applying the corrected angle, a discrepancy from the neutral position decreased. Conclusion: The method to correct the angle between the mechanical and anatomical axes according to the patellar ML position can be used to reduce the measurement error for preoperative planning using a long leg radiograph. Level of evidence: III.