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Preoperative Malalignment Increases Risk of Failure After Total Knee Arthroplasty
Merrill A. Ritter, MD1; Kenneth E. Davis, MS1; Peter Davis, BA1; Alex Farris, BA1; Robert A. Malinzak, MD1; Michael E. Berend, MD1; John B. Meding, MD1
1 The Center for Hip and Knee Surgery, St. Francis Hospital, 1199 Hadley Road, Mooresville, IN 46158. E-mail address for M.A. Ritter: marittermd@yahoo.com
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Investigation performed at the Center for Hip and Knee Surgery, St. Francis Hospital, Mooresville, Indiana

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Jan 16;95(2):126-131. doi: 10.2106/JBJS.K.00607
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Implant survival after total knee arthroplasty has historically been dependent on postoperative knee alignment, although failure may occur when alignment is correct. Preoperative knee alignment has not been thoroughly evaluated as a possible risk factor for implant failure after arthroplasty. The purpose of this study was to analyze the effect of preoperative knee alignment on implant survival after total knee arthroplasty.


We performed a retrospective review of 5342 total knee arthroplasties performed with use of cemented Anatomic Graduated Component implants from 1983 to 2006. Each knee was independently measured preoperatively and postoperatively for overall coronal alignment. Neutral ranges for preoperative and postoperative alignment were defined by means of Cox proportional hazards regression.


The overall failure rate was 1.0% (fifty-four of 5342 prostheses); failure was defined as aseptic loosening of the femoral and/or tibial component. The average preoperative anatomical alignment (and standard deviation) was 0.1° ± 7.7° of varus (range, 25° of varus to 35° of valgus), and the average postoperative anatomical alignment (and standard deviation) was 4.7° ± 2.5° of valgus (range, 12° of varus to 20° of valgus). The failure rate in knees in >8° of varus preoperatively (2.2%; p = 0.0005) or >11° of valgus preoperatively (2.4%; p = 0.0081) was elevated when compared with knees in neutral preoperatively (0.71%). Knees with preoperative deformities corrected to postoperative neutral alignment (2.5° through 7.4°) had a lower failure rate (1.9%) than undercorrected or overcorrected knees (3.0%) (p = 0.0103). Knees with postoperative neutral alignment, regardless of preoperative alignment, had a lower failure rate (0.74%) than knees with postoperative alignment of <2.5° or >7.4° of anatomic valgus (1.7%) (p < 0.0001).


Patients with excessive preoperative alignment (>8° of varus or >11° of valgus) have a greater risk of failure (2.3%). Neutral postoperative alignment (2.5° through 7.4° of valgus) improves (1.9% for preoperatively deformed knees) but does not completely eliminate the risk of failure (0.5% for knees that were neutral both preoperatively and postoperatively). Careful attention should be paid to knee alignment during total knee arthroplasty, especially for patients with severe preoperative deformities.

Level of Evidence: 

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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