Rotational positioning of the tibial tray in total knee arthroplasty: A CT evaluation

Introduction: Various surgical techniques have been described to set the rotational alignment of the tibial baseplate during total knee arthroplasty. The self-positioning method ("self-adjustment'') aligns the tibial implant according to the rotational alignment of the femoral component which is used as a reference after performing repeated knee flexion/extension cycles. Postoperative computed tomography scanning produces accurate measurements of the tibial baseplate rotational alignment with respect to the femoral component. Hypothesis: The rotational positioning of the tibial baseplate matches the rotation of the femoral component with parallel alignment to the prosthetic posterior bicondylar axis. Patients and methods: A 3-month follow-up CT scan was carried out after primary total knee arthroplasty implanted in osteoarthritic patients with a mean 7.8 degrees varus deformity of the knee in 50 cases and a mean 8.7 degrees valgus deformity of the knee in 44 cases. The NexGen LPS Flex (Zimmer) fixed-bearing knee prosthesis was used in all cases. An independant examiner (not part of the operating team) measured different variables: the angle between the anatomic transepicondylar axis and the posterior bicondylar axis of the femoral prosthesis (prosthetic posterior condylar angle), the angle between the posterior bicondylar axis and the posterior marginal axis of the tibial prosthesis, the angle between the posterior marginal axis of the tibial prosthesis and the posterior marginal axis of the tibial bone and finally the angle between the anatomic transepicondylar axis and the posterior marginal axis of the tibial prosthesis. Results: For the genu varum and genu valgum subgroups, the mean posterior condylar axis of the femoral prosthesis was 3.1 degrees (SD: 1.91; extremes 0 degrees to 17.5 degrees) and 4.7 degrees (SD: 2.7; extremes 0 degrees to 11 degrees) respectively. The tibial baseplate was placed in external rotation with respect to the femoral component: 0.7 degrees (SD : 4.45; extremes -9.5 degrees to 9.8 degrees) and 0.9 degrees (SD: 4.53; extremes -10.8 degrees to 9.5 degrees), but also to the native tibia: 6.1 degrees (SD: 5.85; extremes -4.6 degrees to 22.5 degrees) and 12.5 degrees (SD: 8.6; extremes -10 degrees to 28.9 degrees). The tibial component was placed in internal rotation relative to the anatomic transepicondylar axis: 1.9 degrees (SD : 4.93; extremes -13.6 degrees to 7 degrees) and 3 degrees (SD : 4.38; extremes -16.2 degrees to 4.8 degrees). Discussion: The tibial component is aligned parallel to the femoral component whatever the initial frontal deformity (P congruent to 0.7). However, a difference was observed between the rotational alignment of the tibial baseplate and the native tibia depending on the initial deformity and could be attributed to the morphological variations of the bony tibial plateau in case of genu valgum. Conclusion: The self-positioning method is a reproducible option when using this type of implant since it allows the tibial component to be positioned parallel to the posterior border of the femur. Level of evidence: Level III. Observational prospective study. (C) 2011 Elsevier Masson SAS. All rights reserved.