The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 12

Scientific Articles | December 01, 2006

The Effect of Ankle Rotation on Cutting of the Tibia in Total Knee Arthroplasty

Hideki Mizu-uchi, MD¹; Shuichi Matsuda, MD, PhD¹; Hiromasa Miura, MD, PhD¹; Hidehiko Higaki, PhD²; Ken Okazaki, MD, PhD¹; Yukihide Iwamoto, MD, PhD¹

¹ Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka City, 812-8582, Japan. E-mail address for H. Mizu-uchi: himizu@ortho.med.kyushu-u.ac.jp. E-mail address for S. Matsuda: mazda@ortho.med.kyushu-u.ac.jp. E-mail address for H. Miura: miura@ortho.med.kyushu-u.ac.jp. E-mail address for K. Okazaki: okazaki@ortho.med.kyushu-u.ac.jp. E-mail address for Y. Iwamoto: yiwamoto@ortho.med.kyushu-u.ac.jp
² Department of Mechanical Engineering, Kyushu Sangyo University, 2-3-1, Matsukadai, Higashi-ku, Fukuoka City, 813-8503, Japan. E-mail address: higaki@ip.kyusan-u.ac.jp

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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive 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.

Investigation performed at the Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Japan

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2006 Dec 01;88(12):2632-2636. doi: 10.2106/JBJS.E.01288

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Abstract

Background: Extramedullary alignment guides are commonly used to prepare the tibia during total knee arthroplasty. One disadvantage is that the guide is easily affected by the position of the ankle joint. The tibia may have a rotational mismatch between its proximal and distal ends. We hypothesized that a rotational mismatch might cause incorrect positioning of an extramedullary alignment guide and evaluated such a mismatch on the predicted postoperative coronal alignment of the tibia.

Methods: Fifty-three osteoarthritic knees with varus deformity in fifty-one patients were evaluated with use of computerized tomography scans before total knee arthroplasty. We defined one anteroposterior axis of the ankle joint and five different anteroposterior axes of the proximal aspect of the tibia using three-dimensional bone models from the computerized tomography data. We measured the rotational angle between the anteroposterior axis of the ankle joint and the proximal part of the tibia. The distal end of the extramedullary guide was placed in front of the center of the ankle joint (on the line of the extended anteroposterior axis of the ankle joint), and the proximal end was placed on the line of the extended anteroposterior axis of the proximal part of the tibia. We established spatial coordinates to evaluate the effect of the rotational angle on the predicted postoperative coronal alignment of the tibia and calculated the presumed tibial coronal alignment.

Results: The rotational angle was positive (3.6° to 19.7°) for all of the anteroposterior axes of the proximal aspect of the tibia, indicating that the ankle joint was externally rotated relative to the proximal part of the tibia. The predicted tibial coronal alignment was varus (0.5° to 5.1°) for all of the anteroposterior axes of the proximal part of the tibia.

Conclusions: When an extramedullary alignment guide is used to prepare the tibia in total knee arthroplasty, varus alignment of the tibial component can occur because of a rotational mismatch between the proximal part of the tibia and the ankle joint.

Clinical Relevance: To avoid tibial component malalignment, it is important to consider a rotational mismatch between the proximal part of the tibia and the ankle joint when an extramedullary alignment guide is used in total knee arthroplasty.

Figures in this Article

Proper alignment of the lower extremity is an important factor for the long-term success of total knee arthroplasty^1-14. Lower extremity malalignment may lead to various modes of failure, such as aseptic loosening, instability, polyethylene wear, and patellar dislocation^1-14. It has been reported that varus malalignment is associated with higher failure rates, and the femoral and tibial components should be positioned within 3° of the neutral mechanical axis^4,13.

Surgeons use alignment guides to ascertain the correct alignment. Intramedullary alignment guides are generally used for the femoral side; however, for the tibial side, both extramedullary and intramedullary alignment guides are commonly used. Extramedullary alignment guides avoid the risk of fat embolization and are useful in cases of bowing or severe deformity of the tibia^1-3,5,12,14. Some authors have reported a greater frequency of varus malalignment when the tibia is cut with use of an extramedullary alignment guide^12,14. This probably occurs because the extramedullary alignment guide is easily affected by the position of the ankle joint^{2,3,5,6,12,14}. Reed et al.¹² reported that the correct alignment was found in 65% of forty-six knees with use of an extramedullary alignment guide when the distal end of the guide was placed 3 mm medial to the midpoint of the ankle. Teter et al.¹⁴ reported that the use of an extramedullary guide in 140 knees resulted in 61% varus cuts, 20% perfect cuts, and 19% valgus cuts despite aligning the distal end of the guide at 3 to 5 mm medial to the midpoint of the ankle.

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Fig. 1: The anteroposterior (AP) axis of the ankle joint was defined as the line perpendicular to the anterior cortical bone of the talus.

Many studies have described a rotational mismatch between the proximal part of the tibia and the distal end of the tibia (the ankle joint)^15-19. We hypothesized that this rotational mismatch might cause incorrect positioning of the extramedullary alignment guide. Even if the distal end of the guide is placed correctly at the front of the center of the ankle joint, the position of the guide can be lateralized relative to the center of the proximal part of the tibia when the distal end of the tibia is externally rotated. In addition, lateral placement of the distal end of the guide can result in cutting the proximal end of the tibia from the anterolateral side, which would result in a varus cut when the tibia is cut with a posterior slope^20,21. We performed this study to evaluate the effects of rotational mismatch between the proximal end of the tibia and the ankle joint on the predicted postoperative coronal alignment of the tibia using preoperative computerized tomography data.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Fifty-three osteoarthritic knees with a varus deformity in fifty-one patients were evaluated with use of full-length weight-bearing anteroposterior radiographs and computerized tomography scans before total knee arthroplasty. This study was approved by the institutional review board. Patients were informed of the risk of exposure to radiation required by this study. Informed consent was obtained for participation in the study by all patients. The study group consisted of eleven men and forty women who had a total of fifty-three osteoarthritic knees indicated for arthroplasty. The mean patient age (and standard deviation) was 75.9 ± 5.8 years (range, sixty-one to eighty-six years) at the time of the proposed surgery. The mean patient height was 151.1 ± 8.0 cm (range, 137 to 176 cm), and the mean patient weight was 58.0 ± 9.1 kg (range, 39 to 81 kg). The mean preoperative maximum flexion angle was 117.6° ± 14.9° (range, 90° to 140°). The mean flexion deformity was —6.2° ± 4.3° (range, —10° to 0°). None of the patients had had surgery on the ipsilateral knee prior to the total knee arthroplasty. Patients with a flexion deformity of >10° were excluded from this study to avoid measurement errors due to incorrect positioning of the knee^15,19.

Radiographic assessments were performed on full-length weight-bearing anteroposterior radiographs by measuring the femorotibial angle and the weight-bearing ratio. The weight-bearing ratio was calculated by measuring the distance from the medial edge of the proximal part of the tibia to the point where the mechanical axis intersects the proximal part of the tibia, and then dividing by the entire width of the proximal end of the tibia⁷. The percentage was calculated by multiplying this ratio by 100%.

For computed tomography scans, the patient was placed in the supine position on a table and the knee was extended while the ankle was maintained at 0° of flexion with a leg holder. The scanning direction in the sagittal plane was aligned to be perpendicular to the tibial anatomical axis. Computerized tomography scans were made of the knee (from the proximal area of the femoral epicondyle to the tibial tuberosity) and of the ankle (from the proximal area of the malleoli to the calcaneus) with 2-mm-thick slices. We analyzed the computed tomography scan data by reconstructing three-dimensional bone models using computer software (version 2.0, Real INTAGE; KGT, Tokyo, Japan).

Definition of the Anteroposterior Axis of the Ankle Joint

We selected the ankle slice level at which the anterior cortical bone of the talus was approximately a straight line. The anteroposterior axis of the ankle joint was defined as the line perpendicular to the anterior cortical line (Fig. 1).

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Fig. 2: Anatomical landmarks for the anteroposterior axes of the proximal part of the tibia. Axis 1 connected the posterior notch and the medial border of the patellar tendon. Axis 2 connected the posterior notch and the medial one-third of the patellar tendon. Axis 3 was perpendicular to and passed through the midpoint of line P-CEA (the line parallel to the clinical epicondylar axis). Axis 4 connected the midpoint of line P-CEA and the medial border of the patellar tendon. Axis 5 connected the midpoint of line P-CEA and the medial one-third of the patellar tendon.

Definition of the Anteroposterior Axis of the Proximal Part of the Tibia

We selected a slice level of the proximal part of the tibia 8 mm distal from the lateral tibial plateau. Five different anteroposterior axes of the proximal part of the tibia were evaluated (Fig. 2). Axis 1 and axis 2 were anteroposterior axes that connected the posterior notch and the medial border (axis 1) or the medial one-third (axis 2) of the patellar tendon²². The clinical epicondylar axis (CEA) was defined as a line connecting the most prominent points of the medial and lateral epicondyles of the femur, and a line was drawn parallel to the clinical epicondylar axis and traversing the longest distance on the proximal part of the tibia (line P-CEA). Axis 3 was perpendicular to and passed through the midpoint of line P-CEA. Axis 4 and axis 5 were anteroposterior axes that connected the midpoint of line P-CEA and the medial border (axis 4) or the medial one-third (axis 5) of the patellar tendon. For the five axes of the proximal part of the tibia, we measured the difference in the rotational angle (?) between the anteroposterior axis of the ankle joint and the anteroposterior axis of the proximal part of the tibia (we considered a positive value of the angle [+] as an external rotation of the anteroposterior axis of the distal end of the tibia).

To evaluate the predicted tibial coronal alignments from a rotational mismatch, we established spatial coordinates to evaluate the effect of angle ? on the predicted postoperative coronal alignment of the tibia (see Appendix). The spatial coordinates were established as X (anterior-posterior), Y (mediallateral), and Z (proximal-distal). The presumed tibial alignment was calculated when an extramedullary guide was used with one of the anteroposterior axes (the five axes of the proximal part of the tibia and the one axis of the ankle joint). The distal end of the extramedullary guide was placed in front of the center of the ankle joint (on the line of the extended anteroposterior axis of the ankle joint), and the proximal end was placed on the line of the extended anteroposterior axis of the proximal part of the tibia. From the rotational angle ?, the predicted tibial coronal alignment (Y-Z plane) (we considered a positive value of the angle [+] as varus) was calculated with and without 7° of posterior tibial slope²³. In addition, we compared differences in the rotational angle between males and females. Significance was evaluated with use of the Student t test. We considered a p value of <0.05 as significant.

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Fig. 3: The plane perpendicular to the mechanical axis of the tibia (axial plane). The yellow point indicates the center of the proximal part of the tibia and the ankle joint. The red point indicates the distal end of the guide, which is an extension of the anteroposterior axis of the proximal part of the tibia and is the ideal position. The blue point indicates the distal end of the guide and is an extension of the anteroposterior axis of the ankle joint (coronal plane). On the average, the ankle joint is externally rotated compared with the proximal part of the tibia. The postoperative coronal alignment tends to be varus when the distal end of the guide is an extension of the anteroposterior axis of the ankle joint.

Results

Materials and Methods | Results | Discussion | Appendix | References

The average femorotibial angle (and standard deviation) was 183.9° ± 7.1° (range, 170° to 196°), and the average weight-bearing ratio was 5.4% ± 24.6% (range, —47.1% to 49%). The rotational angle ? and the predicted tibial coronal alignment ? are shown in Tables I and II. We did not find significant differences in the rotational angle ? between men and women, on the basis of the numbers available. The rotational angle ? was positive in all axes, indicating that the ankle joint was externally rotated relative to the proximal part of the tibia. The average predicted tibial coronal alignment ? was a varus alignment for all of the anteroposterior axes of the proximal part of the tibia. The rotational angle and predicted tibial coronal alignment were smallest with anteroposterior axis 3, which was perpendicular to the longest line parallel to the clinical epicondylar axis and passing through its midpoint. These values were largest with anteroposterior axis 4, which connected the midpoint of the longest line parallel to the clinical epicondylar axis and the medial border of the patellar tendon. The rotational angles and predicted tibial coronal alignments with use of the medial border of the patellar tendon (anteroposterior axes 1 and 4) were larger than those with use of the medial one-third of the patellar tendon (anteroposterior axes 2 and 5). The predicted tibial varus alignments with 7° of posterior tibial slope were approximately twice those without posterior tibial slope.

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TABLE I Data on Rotational Angle ?

	Angle ?*
Tibial Anteroposterior Axis	All Knees (N = 53)	Male Patients (N = 11)	Female Patients (N = 42)
1	16.5 ± 7.4 (1.0 to 32.0)	16.0 ± 7.3 (6.1 to 26.0)	16.7 ± 7.5 (1.0 to 32.0)
2	8.0 ± 7.6 (-10.0 to 24.0)	7.4 ± 7.6 (-4.5 to 18.0)	8.2 ± 7.6 (-10.0 to 24.0)
3	3.6 ± 6.8 (-16.0 to 16.0)	3.3 ± 7.3 (-8.0 to 14.0)	3.7 ± 6.7 (-16.0 to 16.0)
4	19.7 ± 6.4 (7.0 to 33.0)	20.5 ± 5.8 (12.0 to 30.5)	19.5 ± 6.6 (7.0 to 33.0)
5	5.9 ± 6.6 (-7.0 to 20.0)	5.8 ± 5.2 (-2.0 to 16.0)	6.0 ± 6.9 (-7.0 to 20.0)

The values are given as the mean and the standard deviation, with the range in parentheses. A positive value of the angle indicates external rotation of the anteroposterior axis of the distal end of the tibia.

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TABLE I Data on Rotational Angle ?

	Angle ?*
Tibial Anteroposterior Axis	All Knees (N = 53)	Male Patients (N = 11)	Female Patients (N = 42)
1	16.5 ± 7.4 (1.0 to 32.0)	16.0 ± 7.3 (6.1 to 26.0)	16.7 ± 7.5 (1.0 to 32.0)
2	8.0 ± 7.6 (-10.0 to 24.0)	7.4 ± 7.6 (-4.5 to 18.0)	8.2 ± 7.6 (-10.0 to 24.0)
3	3.6 ± 6.8 (-16.0 to 16.0)	3.3 ± 7.3 (-8.0 to 14.0)	3.7 ± 6.7 (-16.0 to 16.0)
4	19.7 ± 6.4 (7.0 to 33.0)	20.5 ± 5.8 (12.0 to 30.5)	19.5 ± 6.6 (7.0 to 33.0)
5	5.9 ± 6.6 (-7.0 to 20.0)	5.8 ± 5.2 (-2.0 to 16.0)	6.0 ± 6.9 (-7.0 to 20.0)

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TABLE II Predicted Postoperative Tibial Coronal Alignment

	Angle ? for All Knees* (N = 53)
Tibial Anteroposterior Axis	7° Slope	0° Slope
1	4.3 ± 1.9 (0.2 to 8.2)	2.3 ± 1.0 (0.1 to 4.6)
2	2.1 ± 2.0 (-2.6 to 6.3)	1.1 ± 1.1 (-1.4 to 3.5)
3	1.0 ± 1.8 (-4.1 to 4.3)	0.5 ± 1.0 (-2.2 to 2.4)
4	5.1 ± 1.6 (1.7 to 8.2)	2.8 ± 0.9 (0.9 to 4.7)
5	1.6 ± 1.7 (-1.7 to 5.2)	0.9 ± 0.9 (-0.9 to 2.8)

The values are given as the mean and the standard deviation, with the range in parentheses. A positive value indicates varus alignment.

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TABLE II Predicted Postoperative Tibial Coronal Alignment

	Angle ? for All Knees* (N = 53)
Tibial Anteroposterior Axis	7° Slope	0° Slope
1	4.3 ± 1.9 (0.2 to 8.2)	2.3 ± 1.0 (0.1 to 4.6)
2	2.1 ± 2.0 (-2.6 to 6.3)	1.1 ± 1.1 (-1.4 to 3.5)
3	1.0 ± 1.8 (-4.1 to 4.3)	0.5 ± 1.0 (-2.2 to 2.4)
4	5.1 ± 1.6 (1.7 to 8.2)	2.8 ± 0.9 (0.9 to 4.7)
5	1.6 ± 1.7 (-1.7 to 5.2)	0.9 ± 0.9 (-0.9 to 2.8)

The values are given as the mean and the standard deviation, with the range in parentheses. A positive value indicates varus alignment.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

Our results show that the ankle joint was externally rotated compared with the anteroposterior axes of the proximal part of the tibia as has been shown previously^15-19. Five axes were chosen for analysis on the basis of the rotational landmarks recommended for cutting the proximal part of the tibia^22,24-26. A line perpendicular to the transepicondylar axis (anteroposterior axis 3) is frequently used for obtaining computed tomography studies^22,24, and the medial border or medial one-third of the tibial tubercle and the posterior notch of the tibia or attachment point of the posterior cruciate ligament (anteroposterior axes 1 and 2) are often used as rotational landmarks in total knee arthroplasty^22,24,25. Because the tibial tubercle is not visible on the slice we chose (8 mm distal from the lateral tibial plateau; anteroposterior axes 1, 2, 4, and 5), we used the patellar tendon. The average rotational angles ranged from 3.6° (anteroposterior axis 3) to 19.7° (anteroposterior axis 4) in this study.

In all of the proximal tibial references in this study, the postoperative coronal alignment was predicted to be varus. Thus, varus alignment may occur because of rotational mismatch between the proximal part of the tibia and the ankle joint. When external torsion is applied to the tibia, the distal end of the extramedullary guide is shifted laterally if it is placed in front of the center of the ankle joint; this may result in varus cutting of the proximal part of the tibia. Our results also show that when the distal end of the guide is lateralized, cutting the proximal part of the tibia with a posterior tibial slope can result in varus cutting.

The minimum value of varus alignment was 0.5° without posterior tibial slope when the proximal anteroposterior axis was chosen as a line perpendicular to the clinical epicondylar axis and passing through the midpoint of the longest line parallel to the clinical epicondylar axis. Although controversy exists regarding the rotational alignment of the tibial component, it seems unlikely that the tibia would be cut in varus when the rotational alignment of the tibia is set perpendicular to the clinical epicondylar axis because there would be less rotational mismatch between the proximal part of the tibia and the ankle joint.

Our three-dimensional simulation suggests that varus alignment would occur if we ignore the rotational mismatch between the proximal part of the tibia and the ankle joint (Fig. 3). To avoid tibial malalignment, it is important to first place the extramedullary alignment guide at right angles to the proximal tibial anteroposterior axis and then the distal end of the extramedullary guide should be placed at the center of the ankle joint. The center of the ankle joint should be aligned with the proximal tibial anteroposterior axis, rather than the anteroposterior axis of the ankle joint. However, it is difficult to determine the center of the ankle joint intraoperatively. The use of preoperative anteroposterior radiographic controls²⁷ and navigation systems^28-30 may be helpful in avoiding cutting errors due to rotational mismatch. The use of an intramedullary alignment guide may also eliminate these problems due to the rotational mismatch. To achieve proper tibial alignment, it is important to take into account the rotational mismatch between the proximal part of the tibia and the ankle joint.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

Details regarding the establishment of the spatial coordinates are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

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Topics

ankle ; ankle joint ; tibia ; knee replacement arthroplasty ; self-mutilation by cutting

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Hideki Mizu-uchi, Shuichi Matsuda, Hiromasa Miura, Hidehiko Higaki, Ken Okazaki, Yukihide Iwamoto; The Effect of Ankle Rotation on Cutting of the Tibia in Total Knee Arthroplasty. The Journal of Bone & Joint Surgery. 2006 Dec;88(12):2632-2636.

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