TIBIAL COMPONENT ALIGNMENT IN TOTAL KNEE ARTHROPLASTY: INTRAMEDULLARY OR EXTRAMEDULLARY GUIDE – WHICH IS BEST? A BLINDED RANDOMISED PROSPECTIVE TRIAL

Abstract

We wished to determine the most accurate and reliable technique for insertion of tibial prostheses, with tibial resection guided by either intramedullary (IM) or extramedullary (EM) alignment jigs.

135 consecutive AGC cemented total knee replacements in 126 patients in a single unit were performed by, or directly supervised by, four consultant surgeons. Ethical approval and patient consent was obtained. Intramedullary alignment was used for the femoral cuts and patients were randomised at the time of operation to have either IM or EM guides for resection of the proximal tibia, cut with a zero degree posterior slope in both. The protocol only entered patients into the trial if their knees were suitable for use with both IM and EM tibial alignment although, in the event, no patients were excluded. Long leg radiographs (standing hip to ankle) were taken by a standardised method three months after the surgery. A blinded assessor, unaware of the alignment method used, evaluated acceptable films and measured tibial component alignment. The proportion of tibial prostheses aligned within two degrees of 90 was the endpoint of the study.

Of the 135 knees 100 suitable x-rays were assessed. Correct tibial alignment was more likely in the IM group (85%) than the EM group (65%), p=0. 019. Though mean alignment was similar, variation (standard deviation) was less in the IM group (2. 0 vv 2. 2).

In the AGC knee, intramedullary alignment guides are superior to extramedullary guides for alignment of the tibial prosthesis. We recommend the routine use of intramedullary tibial alignment.