Research Article

‘Rotational alignment on patients’ clinical outcome of total knee arthroplasty: Distal femur axillary X-ray view to qualify rotation of the femoral component

S Magersky*

Published: 04 May, 2020 | Volume 5 - Issue 2 | Pages: 008-011

Background: Rotation of the femoral component in total knee replacement (TKR) is very important for good long-term results. Malrotation of the femoral component usually requires subsequent reimplantation. We performed X-ray projections of the knee at 90° to determine proper rotation of the femoral component without use of computed tomography.

Methods: The axial projection of the distal femur was measured in post-TKR cases. During the TKR operation, Whiteside’s method had been used to provide symmetrical flexion space. The exact outer rotation of the femoral component was measured by x-ray determination of the middle condylar twist angle, from the central epicondylar axis and posterior condylar axis.

Results: The middle condylar twist angle was in outer rotation, with an average of 3.36° (range: 1-7.6), similar to the literature. Six of the patients underwent bilateral TKR. In total, the case series included 18 women and 15 men, with average age of 71.34 years-old (range: 56-85). As a clinical evaluation we used Knee Society Score (2011). From results 2 patients were not very satisfied with the instability TKR. Axially X-ray seemed to be only which could distribute these patients.

Summary: X-ray values have the same evaluation as computed tomography. The results were 2 patients in pattern of 48, which were sufficient to extrapolate to whole population according to the statistical methods. This corresponds to 4% which we can add to evaluate satisfaction of all patients after TKR and eventually lower the total of unsatisfactory patients which is total of ¼ of total. It is also forensic reason for all patients. Our recommendation to have good results and patient satisfaction in TKR is to do x-rays before and after operation. Important are x-rays antero-posterior, lateral, and Kanekasu projection to know the rotation after TKR. Other cases without stability in flexion are nor very rarely planed for revision surgery, which is much more expensive, and burdens overall health system. 

Read Full Article HTML DOI: 10.29328/journal.jsmt.1001050 Cite this Article Read Full Article PDF


Arthroplasty; Malrotation; Total knee replacement


  1. Rodrics DJ, Patil P, Cowell Jr CW. Press-fit condaylar design total knee artroplasty. Fourteen to seventeen-year follow up. J Bone Joint Surg Am. 2007; 89: 89-95. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/17200315
  2. Hernandez-Vaquero D, Noriega-Fernandez A, Fernandez-Carreira JM, Fernandez-Simon JM, Llorens de los Rios J. Computer-assisted surgery improves rotational positioning of the femoral component but not the tibial component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014; 22: 3127–3134. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25155048
  3. Scott CE, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br. 2010; 92: 1253–1258. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/20798443
  4. Lombardi Jr AV, Berend KR, Adams JB. Why knee replacements fail in 2013: patient, surgeon, or implant? Bone Joint J. 2014; 96-B(11 Supple A): 101–104. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25381419
  5. Sharkey PF, Lichstein PM, Shen C, Tokarski AT, Parvizi J. Why are total knee arthroplasties failing today—has anything changed after 10 years? J Arthroplasty. 2014; 29: 1774–1778. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25007726
  6. Franceschini V, Nodzo SR, Gonzalez Della Valle A. Femoral component rotation in total knee arthroplasty: a comparison between Transepicondylar Axis and posterior condylar line referencing. J Arthroplasty. 2016; 31: 2917–2921. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27374639
  7. McDougall CJ, Gallie P, Whitehouse SL. Preoperative assessment of femoral rotation and its relationship with coronal alignment: a magnetic resonance imaging study. J Orthop. 2016; 13: 290–293. Y. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/27408506
  8. Victor J. Rotational alignment of the distal femur: a literature review. Orthop Traumatol Surg Res. 2009; 95: 365–372. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19592323
  9. Howell SM, Papadopoulos S, Kuznik KT, Hull ML. Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc. 2013; 21: 2271–2280. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/23948721
  10. Nam D, Lin KM, Howell SM, Hull ML. Femoral bone and cartilage wear is predictable at 0 degrees and 90 degrees in the osteoarthritic knee treated with total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014; 22: 2975–2981. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24839078
  11. Kobayashi H, Akamatsu Y, Kumagai K, Kusayama Y, Aratake M, et al. Is the surgical epicondylar axis the center of rotation in the osteoarthritic knee? J Arthroplasty. 2015; 30: 479–483. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/25466167
  12. Aunan E, Østergaard D, Meland A, Dalheim K, Sandvik L. A simple method for accurate rotational positioning of the femoral component in total knee arthroplasty. Acta Orthop. 2017; 11: 1–7. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28799446
  13. Akagi M, Yamashita E, Nakagawa T, Asano T, Nakamura T. Relationship between frontal knee alignment and reference axes in the distal femur. Clin Orthop Relat Res. 2001; 388: 147–156. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/11451114
  14. Kanekasu K, Kondo M, Kadoya Y. Axial radiography of the distal femur to asses rotational alignment in total knee artroplasty. Clin Orthop Relat Res. 2004; 434: 193-197. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/15864052
  15. Noble PC, Scuderi GR, Brekke AC, Sikorskii A, Benjamin JB, et al. Development of a new Knee Society scoring system. Clin Orthop Relat Res. 2012; 470: 20-32. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22065240
  16. Scuderi GR1, Bourne RB, Noble PC, Benjamin JB, Lonner JH, et al. The new Knee Society knee scoring system. Clin Orthop Relat Res. 2012; 470: 003-019. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22045067


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