Neutral alignment leads to higher knee society scores after total knee arthroplasty in preoperatively non-varus patients: a prospective clinical study using 3D-CT

Knee Surg Sports Traumatol Arthrosc. 2018 Jun;26(6):1602-1609. doi: 10.1007/s00167-017-4744-y. Epub 2017 Oct 12.


Purpose: The optimal coronal alignment is still under debate. However, in most of the studies, alignment was only assessed using radiographs, which are not accurate enough for assessment of tibial and femoral TKA position. The primary purpose of this study was to assess the relationship between coronal TKA alignment using 3D-reconstructed CTs and clinical outcome in patients with preoperative varus in comparison with patients with natural or valgus deformity. It was the hypothesis that neutral limb alignment shows a better outcome after TKA.

Methods: Prospectively collected data of 38 patients were included. The clinical and radiological follow-up was 24 months. The patients were grouped into two groups with regard to their preoperative limb alignment. Group A (varus) consisted of 21 patients with preoperative varus of 3° or more, while group B (non-varus) consisted of 17 patients with neutral (- 3 < 0 > + 3) or valgus alignment (> + 3). For assessment of TKA component position and orientation, 3D-reconstructed CT was used. The measurements of the deviation from the whole limb mechanical axis (HKA angle) and the joint line alignment in the femoral (mLDFA) and the tibial side (MPTA) were assessed in the preoperative leg as well as during follow-up after TKA. For clinical outcome assessment, the Knee Society Score (KSS) was used at 1 and 2 years postoperatively. Correlation between KSS score and each variable was done using a linear and quadratic regression model (p < 0.05).

Results: The mean postoperative HKA angle was - 1.3 (varus) in the varus group and + 1.4 (valgus) in the non-varus group. Overall, significant correlations between the preoperative and postoperative alignments were found. In the preoperatively non-varus group, a highly significant correlation was found between neutral limb alignment (HKA = 0° ± 3°) and higher KSS (r 2 = 0.74, p = 0.00). In the varus group, no correlation was found between the postoperative whole limb alignment and the components' position in the coronal plane to KSS score.

Conclusion: A significant correlation was found between neutral limb alignment and higher KSS only in patients with preoperative non-varus alignment. The concept of constitutional varus alignment is still under debate. Moreover, it appears that one should aim for a more individualized, alignment target based on the individual knee morphotype.

Level of evidence: Diagnostic study, Level II.

Keywords: Alignment; CT; Component position; Individualized alignment; Knee society score; Mechanical alignment; Morphotype; Preoperative alignment, constitutional varus; Total knee arthroplasty; Total knee replacement.

Publication types

  • Clinical Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Arthroplasty, Replacement, Knee / methods*
  • Bone Malalignment / diagnostic imaging*
  • Bone Malalignment / prevention & control
  • Bone Malalignment / surgery
  • Female
  • Femur / surgery
  • Humans
  • Imaging, Three-Dimensional
  • Knee / surgery
  • Knee Joint / surgery*
  • Knee Prosthesis
  • Male
  • Middle Aged
  • Osteoarthritis, Knee / surgery*
  • Retrospective Studies
  • Tibia / surgery
  • Tomography, X-Ray Computed