The Journal of Bone and Joint Surgery (American). 2005;87:2276-2280.
doi:10.2106/JBJS.D.02945
© 2005 The Journal of Bone and Joint Surgery, Inc.
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The Variability of Femoral Rotational Alignment in Total Knee Arthroplasty

Robert A. Siston, MS1, Jay J. Patel, MS2, Stuart B. Goodman, MD, PhD3, Scott L. Delp, PhD1 and Nicholas J. Giori, MD, PhD4

1 S-322 (R.A.S.) and S-321 (S.L.D.), James H. Clark Center, Stanford University, 318 Campus Drive, Stanford, CA 94305-5450
2 1058 Nez Perce Court, Fremont, CA 94539
3 300 Pasteur Drive, R144, Stanford, CA 94305
4 Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Surgical Services-MC 112, Palo Alto, CA 94304. E-mail address: ngiori{at}stanford.edu

Investigation performed at the Division of Biomechanical Engineering and the Department of Orthopedic Surgery, Stanford University, Stanford, California, and the VA Palo Alto Health Care System, Palo Alto, California

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Whitaker Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Several reference axes are used to establish femoral rotational alignment during total knee arthroplasty, but debate continues with regard to which axis is most accurately and easily identified during surgery. Computer-assisted navigation systems have been developed in an attempt to more accurately and consistently align implants during total knee arthroplasty, but it is unknown if navigation systems can improve the accuracy of femoral rotational alignment as compared with that achieved with more traditional techniques involving mechanical guides. The purposes of the present study were to characterize the variability associated with femoral rotational alignment techniques and to determine whether the use of a computer-assisted surgical navigation system reduced this variability.

Methods: Eleven orthopaedic surgeons used five alignment techniques (including one computer-assisted technique and four traditional techniques) to establish femoral rotational alignment axes on ten cadaveric specimens, and the orientation of these axes was recorded with use of a navigation system. These derived axes were compared against a reference transepicondylar axis on each femur that was established after complete dissection of all soft tissues.

Results: There was no difference between the mean errors of all five techniques (p > 0.11). Only 17% of the knees were rotated <5° from the reference transepicondylar axis, with alignment errors ranging from 13° of internal rotation to 16° of external rotation. There were significant differences among the surgeons with regard to their ability to accurately establish femoral rotational alignment axes (p < 0.001).

Conclusions: All techniques resulted in highly variable rotational alignment, with no technique being superior. This variability was primarily due to the particular surgeon who was performing the alignment procedure. A navigation system that relies on directly digitizing the femoral epicondyles to establish an alignment axis did not provide a more reliable means of establishing femoral rotational alignment than traditional techniques did.


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