Patient Variation Limits Use of Fixed References for Femoral Rotation Component Alignment in Total Knee Arthroplasty

Background: Optimal rotational alignment of the femoral component is a common goal during total knee arthroplasty. The posterior condylar axis (PCA) is thought to be the most reproducible reference in surgery, while the transepicondylar axis (TEA) seems to better approximate the native kinematic flexion axis. This study sought to determine if rules based on patient gender or coronal alignment could allow reliable reproduction of the TEA from the PCA. Methods: Three-dimensional models based on preoperative computed tomography were made representing a patient's arthritic knee joint. The landmarks were defined and angular relationships determined. Results: The population group of 726 patients contained large anatomic variation. When applying the standard reference rule of 3 degrees external rotation from the PCA, 36.9% of patients would have a rotational target greater than +/- 2 degrees from their TEA. When applying the mean external rotation of the TEA from the PCA (1.85 degrees) from this population, this proportion dropped to 26.0% of patients. The use of statistically significant gender and coronal alignment relationships to define the femoral rotation did not reduce the proportion of patients in +/- 2 degrees error. Conclusion: This study shows that gender and coronal alignment relationships to the TEA to PCA angle are not clinically significant as a quarter of patients would still have a target for rotation greater than +/- 2 degrees from the TEA using these relationships. Superior tools for orienting rotational cuts directly to the TEA in surgery or preoperative identification of relevant patient-specific angles might capture the proportion of patients for whom standard reference angles are not appropriate. (C) 2017 Elsevier Inc. All rights reserved.