Custom TKA enables adequate realignment with minimal ligament release and grants satisfactory outcomes in knees that had prior osteotomies or extra-articular fracture sequelae

Knee Surg Sports Traumatol Arthrosc. 2023 Apr;31(4):1212-1219. doi: 10.1007/s00167-021-06619-3. Epub 2021 May 27.


Purpose: To report the early clinical and radiographic outcomes of custom total knee arthroplasty (TKA) in knees that had prior osteotomies and/or extra-articular fracture sequelae.

Methods: The authors retrospectively analysed a consecutive series of 444 knees that received custom TKA between 2016 and 2019 and identified 41 knees that had prior extra-articular events (osteotomies or fracture sequelae). Patients responded to pre- and post-operative (> 12 months) questionnaires, including Knee Society Score (KSS), Oxford Knee Score (OKS), Forgotten Joint Score (FJS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Net improvements were calculated by subtracting pre- from post-operative scores. In addition to a preoperative CT scan, pre- and post-operative long-leg weight-bearing radiographs were obtained, on which the hip-knee-ankle (HKA) angle, femoral mechanical angle (FMA, between femoral mechanical axis and joint line) and tibial mechanical angle (TMA, between tibial mechanical axis and joint line) angles were measured, and alignment was planned within a 'target zone' of FMA and TMA within 85°-95° and HKA angle within 175°-183°. Agreements between preoperative, planned and post-operative angles were calculated using intra-class correlation coefficients (ICC).

Results: From the initial 41 knees, 3 had incomplete post-operative data and 1 was revised for painful stiffness due to uncorrected rotational malunion, leaving 37 knees for analysis. Twenty had prior osteotomies (tibia, n = 18, femur, n = 2), 8 had isolated fractures (tibial, n = 3; femoral, n = 5), and 9 had both osteotomies and fractures. Postoperative coronal alignments were 90.4° ± 2.4° for FMA, 89.3° ± 2.6° for TMA and 179.9° ± 3.0° for HKA angle. Agreements between planned and achieved alignments were fair to excellent, and 29 (78%) knees were within the 'target zone'. At a mean follow-up of 15 ± 5 months, all clinical scores had improved significantly (p < 0.001).

Conclusions: Custom TKA granted satisfactory clinical outcomes and a low complication rate in knees that had prior osteotomies and/or extra-articular fracture sequelae. Using custom implants and strategies for coronal alignment, 29 (78%) of the 37 knees were successfully aligned within the 'target zone', and 35 (95%) of the 41 knees did not require ligament release.

Level of evidence: IV.

Keywords: Coronal alignment; Custom; FMA; HKA; Patient-specific; TKA; TMA; Total knee arthroplasty.

MeSH terms

  • Arthroplasty, Replacement, Knee*
  • Femur / surgery
  • Humans
  • Knee Joint / diagnostic imaging
  • Knee Joint / surgery
  • Ligaments / surgery
  • Osteoarthritis, Knee* / complications
  • Osteoarthritis, Knee* / surgery
  • Osteotomy
  • Retrospective Studies
  • Tibia / surgery