We compared lower limb coronal alignment measurements obtained pre- and post-operatively with long-leg radiographs and computer navigation in patients undergoing primary total knee replacement (TKR). A series of 185 patients had their pre- and post-implant radiological and computer-navigation system measurements of coronal alignment compared using the Bland-Altman method. The study included 81 men and 104 women with a mean age of 68.5 years (32 to 87) and a mean body mass index of 31.7 kg/m. 2. (19 to 49). Pre-implant Bland–Altman limits of agreement were -9.4° to 8.6° with a repeatability coefficient of 9.0°. The Bland–Altman plot showed a tendency for the radiological measurement to indicate a higher level of pre-operative deformity than the corresponding navigation measurement. Post-implant limits of agreement were -5.0° to 5.4° with a repeatability coefficient of 5.2°. The tendency for valgus knees to have greater deformity on the radiograph was still seen, but was weaker for varus knees. . The alignment seen or measured intra-operatively during TKR is not necessarily the same as the deformity seen on a standing long-leg radiograph either pre- or post-operatively. Further investigation into the effect of weight-bearing and surgical exposure of the joint on the mechanical femorotibial angle is required to enable the most appropriate intra-operative alignment to be selected

The emergence of patient specific instrumentation has seen an expansion from simple radiographs to plan total knee arthroplasty (TKA) with modern systems using computed tomography (CT) or magnetic resonance imaging scans. Concerns have emerged regarding accuracy of these non-weight bearing modalities to assess true mechanical axis. The aim of our study was to compare coronal alignment on full length standing AP imaging generated by the EOS acquisition system with the CT coronal scout image. Eligible patients underwent unilateral or bilateral primary TKA for osteoarthritis under the care of investigating surgeon between 2017 and 2022, with both EOS X-Ray Imaging Acquisition System and CT scans performed preoperatively. Coronal mechanical alignment was measured on the supine coronal scout CT scan and the standing HKA EOS. Pre-operative lower limb coronal alignment was assessed on 96 knees prior to TKA on the supine coronal scout CT scan and the standing HKA EOS. There were 56 males (56%), and 44 right knees (44%). The mean age was 68 years (range 53-90). The mean coronal alignment was 4.7 degrees (SD 5.3) on CT scan and 4.6 degrees (SD 6.2) on EOS (p=0.70). There was a strong positive correlation of coronal alignment on CT scan and EOS (pearson. 0.927, p=0.001). The mean difference between EOS and CT scan was 0.9 degrees (SD 2.4). Less than 3 degrees variation between measures was observed in 87% of knees. On linear regression for every 1° varus increase in CT HKA alignment, the EOS HKA alignment increased by 0.93° in varus orientation. The model explained 86% of the variability. CT demonstrates excellent reliability for assessing coronal lower limb alignment compared to EOS in osteoarthritic knees. This supports the routine use of CT to plan TKA without further weight bearing imaging in routine cases

Aims. Surgeons commonly resect additional distal femur during primary total knee arthroplasty (TKA) to correct a flexion contracture, which leads to femoral joint line elevation. There is a paucity of data describing the effect of joint line elevation on mid-flexion stability and knee kinematics. Thus, the goal of this study was to quantify the effect of joint line elevation on mid-flexion laxity. Methods. Six computational knee models with cadaver-specific capsular and collateral ligament properties were implanted with a posterior-stabilized (PS) TKA. A 10° flexion contracture was created in each model to simulate a capsular contracture. Distal femoral resections of + 2 mm and + 4 mm were then simulated for each knee. The knee models were then extended under a standard moment. Subsequently, varus and valgus moments of 10 Nm were applied as the knee was flexed from 0° to 90° at baseline and repeated after each of the two distal resections. Coronal laxity (the sum of varus and valgus angulation with respective maximum moments) was measured throughout flexion. Results. With + 2 mm resection at 30° and 45° of flexion, mean coronal laxity increased by a mean of 3.1° (SD 0.18°) (p < 0.001) and 2.7° (SD 0.30°) (p < 0.001), respectively. With + 4 mm resection at 30° and 45° of flexion, mean coronal laxity increased by 6.5° (SD 0.56°) (p < 0.001) and 5.5° (SD 0.72°) (p < 0.001), respectively. Maximum increased coronal laxity for a + 4 mm resection occurred at a mean 15.7° (11° to 33°) of flexion with a mean increase of 7.8° (SD 0.2°) from baseline. Conclusion. With joint line elevation in primary PS TKA, coronal laxity peaks early (about 16°) with a maximum laxity of 8°. Surgeons should restore the joint line if possible; however, if joint line elevation is necessary, we recommend assessment of coronal laxity at 15° to 30° of knee flexion to assess for mid-flexion instability. Further in vivo studies are warranted to understand if this mid-flexion coronal laxity has negative clinical implications. Cite this article: Bone Joint J 2021;103-B(6 Supple A):87–93

Aims. The extensive variation in axial rotation of tibial components can lead to coronal plane malalignment. We analyzed the change in coronal alignment induced by tray malrotation. Methods. We constructed a computer model of knee arthroplasty and used a virtual cutting guide to cut the tibia at 90° to the coronal plane. The virtual guide was rotated axially (15° medial to 15° lateral) and with posterior slopes (0° to 7°). To assess the effect of axial malrotation, we measured the coronal plane alignment of a tibial tray that was axially rotated (25° internal to 15° external), as viewed on a standard anteroposterior (AP) radiograph. Results. Axial rotation of the cutting guide induced a varus-valgus malalignment up to 1.8° (for 15° of axial rotation combined with 7° of posterior slope). Axial malrotation of tibial tray induced a substantially higher risk of coronal plane malalignment ranging from 1.9° valgus with 15° external rotation, to over 3° varus with 25° of internal rotation. Coronal alignment of the tibial cut changed by 0.07° per degree of axial rotation and 0.22° per degree of posterior slope (linear regression, R. 2. > 0.99). Conclusion. While the effect of axial malalignment has been studied, the impact on coronal alignment is not known. Our results indicate that the direction of the cutting guide and malalignment in axial rotation alter coronal plane alignment and can increase the incidence of outliers. Cite this article: Bone Joint J 2020;102-B(6 Supple A):43–48

Aims. The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI). Methods. From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis. Results. In the study (fracture) and control groups, respectively, the mean values were: RI, 17.2° (SD 7.2°; -7° to 35°) and 25.6° (SD 2.6°; 21° to 30°); DRS-U, 13.5 mm (SD 1.7; 4.9 to 20.8) and 15.3 mm (SD 0.72; 13.8 to 16.3); DUS-R, 13.4 mm (SD 2.1; 4.8 to 18.5) and 12.0 mm (SD 0.99; 9.7 to 13.9); DRS-PC (positive value radial to DRS, negative value ulnar), 0.14 mm (SD 5.4; -10.9 to 22.7) and -6.1 mm (SD 1.6; -10.6 to -2.3); and IAD, 25.3 mm (SD 2.5; 17.6 to 31.1) and 27.1 mm (SD 1.5; 24.5 to 31.0). All means were significantly different between the study and control groups. RI correlated strongly with DRS-PC. Ulnar styloid fracture intersection with the DUS axis, reflective of ulnar translation of both radial and ulnar shafts, was associated with significantly lower RI. Conclusion. After DRF, the relationship of the proximal capitate to the DRS axis in the coronal plane correlates with the final radial inclination. Additionally, ulnar styloid intersection with the DUS axis is associated with even lower radial inclination. DRF reduction should seek to restore the normal coronal relationship of both radial and ulnar shafts to their distal counterparts. Cite this article: Bone Joint J 2023;105-B(6):688–695

Aims. A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA). Methods. A radiological analysis of 500 healthy and 500 osteoarthritic (OA) knees was used to assess the applicability of the CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (aHKA) that estimates constitutional limb alignment and joint line obliquity (JLO). Intraoperative balance was compared within each phenotype in a cohort of 138 computer-assisted TKAs randomized to KA or MA. Primary outcomes included descriptive analyses of healthy and OA groups per CPAK type, and comparison of balance at 10° of flexion within each type. Secondary outcomes assessed balance at 45° and 90° and bone recuts required to achieve final knee balance within each CPAK type. Results. There was similar frequency distribution between healthy and arthritic groups across all CPAK types. The most common categories were Type II (39.2% healthy vs 32.2% OA), Type I (26.4% healthy vs 19.4% OA) and Type V (15.4% healthy vs 14.6% OA). CPAK Types VII, VIII, and IX were rare in both populations. Across all CPAK types, a greater proportion of KA TKAs achieved optimal balance compared to MA. This effect was largest, and statistically significant, in CPAK Types I (100% KA vs 15% MA; p < 0.001), Type II (78% KA vs 46% MA; p = 0.018). and Type IV (89% KA vs 0% MA; p < 0.001). Conclusion. CPAK is a pragmatic, comprehensive classification for coronal knee alignment, based on constitutional alignment and JLO, that can be used in healthy and arthritic knees. CPAK identifies which knee phenotypes may benefit most from KA when optimization of soft tissue balance is prioritized. Further, it will allow for consistency of reporting in future studies. Cite this article: Bone Joint J 2021;103-B(2):329–337

Aims. The Coronal Plane Alignment of the Knee (CPAK) classification is a simple and comprehensive system for predicting pre-arthritic knee alignment. However, when the CPAK classification is applied in the Asian population, which is characterized by more varus and wider distribution in lower limb alignment, modifications in the boundaries of arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) should be considered. The purposes of this study were as follows: first, to propose a modified CPAK classification based on the actual joint line obliquity (aJLO) and wider range of aHKA in the Asian population; second, to test this classification in a cohort of Asians with healthy knees; third, to propose individualized alignment targets for different CPAK types in kinematically aligned (KA) total knee arthroplasty (TKA). Methods. The CPAK classification was modified by changing the neutral boundaries of aHKA to 0° ± 3° and using aJLO as a new variable. Radiological analysis of 214 healthy knees in 214 Asian individuals was used to assess the distribution and mean value of alignment angles of each phenotype among different classifications based on the coronal plane. Individualized alignment targets were set according to the mean lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) of different knee types. Results. A very high concentration, 191 from 214 individuals (89.3%), were found in knee types with apex distal JLO when the CPAK classification was applied in the Asian population. By using aJLO as a new variable, the high distribution percentage in knee types with apex distal JLO decreased to 125 from 214 individuals (58.4%). The most common types in order were Type II (n = 70; 32.7%), Type V (n = 55; 25.7%), and Type I (n = 46; 21.5%) in the modified CPAK classification. Conclusion. The modified CPAK classification corrected the uneven distribution when applying the CPAK classification in the Asian population. Setting individualized TKA alignment targets according to CPAK type may be a practical method to recreate optimal LDFA and MPTA in KA-TKA. Cite this article: Bone Jt Open 2022;3(3):211–217

Introduction. Malalignment of total knee arthroplasty components may affect implant function and lead to decreased survival, regardless of preferred alignment philosophy – neural mechanical axis restoration or kinematic alignment. A common technique is to set coronal alignment prior to adjusting slope. If the guide is not maintained in a neutral position, adjustment of the slope may alter coronal alignment. Different implant systems recommend varying degrees of slope for ideal function of the implant, from 0–7°. The purpose of this study was to quantify the change in coronal alignment with increasing posterior tibial slope comparing two methods of jig fixation. Methods. Prospective consecutive series of 100 patients undergoing total knee arthroplasty using computer navigation. First cohort of 50 patients had extramedullary cutting jig secured distally with ankle clamp and proximally with one pin and a second cohort of 50 patients with the jig secured distally with ankle clamp and proximally with two pins. The change in coronal alignment was recorded with each degree of increasing posterior slope from 0–7° using computer navigation. Mean coronal alignment and change in coronal alignment was compared between the two cohorts. Results. Utilizing one pin to secure the jig, all osteotomies drifted into increased varus with an average coronal alignment of 2.38° varus (range 0.5–4.5°varus) at 7° posterior slope with an average change of 0.34° in coronal alignment per degree increase of posterior slope. Utilizing two pins to secure the jig showed a propensity to drift into valgus with an average coronal alignment of 0.22° valgus (range 1.0° varus − 1.5° valgus) at 7° posterior slope with an average change of 0.04° in coronal alignment per degree increase of posterior slope. The observed changes in coronal alignment between the two cohorts of patients were significantly different at all recorded levels of posterior slope. Conclusion. In this study, when one pin is utilized to secure the jig increasing posterior slope resulted in varus alignment with 12.0% of patients having greater than a 3 degree increase in varus at 7 degrees posterior slope compared to zero subjects in the group where the jig was secured with two pins. In the single pin group patients started to fall outside of the ±3° safe zone for coronal alignment at 4° of posterior slope. There were no patients in the two-pin cohort that fell outside of the ±3° safe zone for coronal alignment. Excessive varus alignment may result in decreased survivorship when using extramedullary jig attached distally with ankle clamp distally and proximally with one pin. Use of more than one pin and computer navigation are beneficial to prevent deviation from desired coronal alignment in systems with increased posterior slope. Verification of tibial cut intra-op is critical, especially if using one pin fixation with extramedullary jig. The observed relationship may help to explain why alignment of TKA is more accurate with computer navigation and new mid-term studies are demonstrating superior survivorship and outcomes in patients who underwent total knee arthroplasty with computer navigation, in certain cohorts of patients especially < 65 years

Accurate evaluation of lower limb coronal alignment is essential for effective pre-operative planning of knee arthroplasty. Weightbearing hip-knee-ankle (HKA) radiographs are considered the gold standard. Mako SmartRobotics uses CT-based navigation to provide intra-operative data on lower limb coronal alignment during robotic assisted knee arthroplasty. This study aimed to compare the correlation between the two methods in assessing coronal plane alignment. Patients undergoing Mako partial (PKA) or total knee arthroplasty (TKA) were identified from our hospital database. The hospital PACS system was used to measure pre-operative coronal plane alignment on HKA radiographs. This data was correlated to the intraoperative deformity assessment during Mako PKA and TKA surgery. 443 consecutive Mako knee arthroplasties were performed between November 2019 and December 2021. Weightbearing HKA radiographs were done in 56% of cases. Data for intraoperative coronal plane alignment was available for 414 patients. 378 knees were aligned in varus, and 36 in valgus. Mean varus deformity was 7.46° (SD 3.89) on HKA vs 7.13° (SD 3.56) on Mako intraoperative assessment, with a moderate correlation (R= 0.50, p<0.0001). Intraoperative varus deformity of 0-4° correlated to HKA measured varus (within 3°) in 60% of cases, compared to 28% for 5-9°, 17% for 10-14°, and in no cases with >15° deformity. Mean valgus deformity was 6.44° (SD 4.68) on HKA vs 4.75° (SD 3.79) for Mako, with poor correlation (R=0.18, p=0.38). In this series, the correlation between weightbearing HKA radiographs and intraoperative alignment assessment using Mako SmartRobotics appears to be poor, with greater deformities having poorer correlation

Identifying and restoring alignment is a primary aim of total knee arthroplasty (TKA). In the coronal plane, the pre-pathological hip knee angle can be predicted using an arithmetic method (aHKA) by measuring the medial proximal tibial angle (MPTA) and lateral distal femoral angle (aHKA=MPTA - LDFA). The aHKA is shown to be predictive of coronal alignment prior to the onset of osteoarthritis; a useful guide when considering a non-mechanically aligned TKA. The aim of this study is to investigate the intra- and inter-observer accuracy of aHKA measurements on long leg standing radiographs (LLR) and preoperative Mako CT planning scans (CTs). Sixty-eight patients who underwent TKA from 2020–2021 with pre-operative LLR and CTs were included. Three observers (Surgeon, Fellow, Registrar) measured the LDFA and MPTA on LLR and CT independently on three separate occasions, to determine aHKA. Statistical analysis was undertaken with Bland-Altman test and coefficient of repeatability. An average intra-observer measurement error of 3.5° on LLR and 1.73° on CTs for MPTA was detected. Inter-observer errors were 2.74° on LLR and 1.28° on CTs. For LDFA, average intra-observer measurement error was 2.93° on LLR and 2.3° on CTs, with inter-observer errors of 2.31° on LLR and 1.92° on CTs. Average aHKA intra-observer error was 4.8° on LLR and 2.82° on CTs. Inter-observer error of 3.56° for LLR and 2.0° on CTs was measured. The aHKA is reproducible on both LLR and CT. CT measurements are more reproducible both between and within observers. The difference between measurements using LLR and CT is small and hence these two can be considered interchangeable. CT may obviate the need for LLRs and may overcome difficulties associated with positioning, rotation, body habitus and flexion contractures when assessing coronal alignment

Aims. The Coronal Plane Alignment of the Knee (CPAK) classification has been developed to predict individual variations in inherent knee alignment. The impact of preoperative and postoperative CPAK classification phenotype on the postoperative clinical outcomes of total knee arthroplasty (TKA) remains elusive. This study aimed to examine the effect of postoperative CPAK classification phenotypes (I to IX), and their pre- to postoperative changes on patient-reported outcome measures (PROMs). Methods. A questionnaire was administered to 340 patients (422 knees) who underwent primary TKA for osteoarthritis (OA) between September 2013 and June 2019. A total of 231 patients (284 knees) responded. The ­Knee Society Score 2011 (KSS 2011), Knee injury and Osteoarthritis Outcome Score-12 (KOOS-12), and Forgotten Joint Score-12 (FJS-12) were used to assess clinical outcomes. Using preoperative and postoperative anteroposterior full-leg radiographs, the arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) were calculated and classified based on the CPAK classification. To investigate the impact on PROMs, multivariable regression analyses using stepwise selection were conducted, considering factors such as age at surgery, time since surgery, BMI, sex, implant use, postoperative aHKA classification, JLO classification, and changes in aHKA and JLO classifications from preoperative to postoperative. Results. The preoperative and postoperative CPAK classifications were predominantly phenotype I (155 knees; 55%) and phenotype V (73 knees; 26%), respectively. The change in the preoperative to postoperative aHKA classification was a significant negative predictive factor for KOOS-12 and FJS-12, while postoperative apex proximal JLO was a significant negative predictive factor for KSS 2011 and KOOS-12. Conclusion. In primary TKA for OA, preoperative and postoperative CPAK phenotypes were associated with PROMs. Alteration in varus/valgus alignment from preoperative to postoperative was recognized as a negative predictive factor for both KOOS-12 and FJS-12. Moreover, the postoperative apex proximal JLO was identified as a negative factor for KSS 2011 and KOOS-12. Determining the target alignment for each preoperative phenotype with reproducibility could improve PROMs. Cite this article: Bone Joint J 2024;106-B(10):1059–1066

Aims. In patients undergoing medial opening wedge high tibial osteotomy (MOWHTO), soft tissue opening on the medial side of the knee is difficult to predict. When the load bearing axis is corrected beyond a certain point, the knee joint tilts open on the medial side. We therefore hypothesised that there is a tipping point and defined this as the coronal hypomochlion. Patients and Methods. In this prospective study of 150 navigated MOWHTOs (144 consecutive patients), data were collected before surgery and at three months post-operatively. In order to calculate the hypomochlion, we compared the respective changes to the joint line convergence angle (JLCA) with the post-operative axis of the leg. The change to the medial proximal tibial angle accounts for only about 80% of the change to the femorotibial angle; 20% of the correction can therefore be attributed to non-osseous, soft-tissue changes. Results. We were able to demonstrate a linear change of JLCA in a range of 0° to 5° of valgus which started when the post-operative long-leg axis was corrected beyond 2° of valgus. Conclusion. We found that the coronal hypomochlion occurs at 2° of valgus. Take home message: It is recommended to plan realignment for medial open wedge high tibial osteotomy at a maximum of 2° valgus. Cite this article: Bone Joint J 2016;98-B:628–33

In the vast majority of patients, the anatomical and mechanical axes of the tibia in the coronal plane are widely accepted to be equivalent. This philosophy guides the design and placement of orthopaedic implants within the tibia and in both the knee and ankle joints. However, the presence of coronal tibial bowing may result in a difference between these two axes and hence cause suboptimal placement of implanted prostheses. Although the prevalence of tibial bowing in adults has been reported in Asian populations, to date no exploration of this phenomenon in a Western population has been conducted. The aim of this study was to quantify the prevalence of coronal tibial bowing in a Western population. This was an observational retrospective cohort study using anteroposterior long leg radiographs collected prior to total knee arthroplasty in our high volume arthroplasty unit. Radiographs were reviewed using a Picture Archiving and Communication System. Using a technique previously described in the literature for assessment of tibial bowing, two lines were drawn, each one third of the length of the tibia. The first line was drawn between the tibial spines and the centre of the proximal third of the tibial medullary canal. The second was drawn from the midpoint of the talar dome to the centre of the distal third of the tibial medullary canal. The angle subtended by these two lines was used to determine the presence of bowing. Bowing was deemed significant if more than two degrees. The position of the apex of the bow determined whether it was medial or lateral. Measurements were conducted by a single observer and 10% of measurements were repeated by the same observer and also by two separate observers to allow calculation of intraclass correlation coefficients (ICCs). A total of 975 radiographs consecutively performed in the calendar years 2015–16 were reviewed, 485 of the left leg and 490 of the right. In total 399 (40.9%) tibiae were deemed to have bowing more than two degrees. 232 (23.8%) tibiae were bowed medially and 167 (17.1%) were bowed laterally. The mean bowing angle was 3.51° (s.d. 1.24°) medially and 3.52° (s.d. 1.33°) laterally. Twenty-three patients in each group (9.9% medial/13.7% lateral) were bowed more than five degrees. The distribution of bowing angles followed a normal distribution, with the maximal angle observed 10.45° medially and 9.74° laterally. An intraobserver ICC of 0.97 and a mean interobserver ICC of 0.77 were calculated, indicating excellent reliability. This is the first study reporting the prevalence of tibial bowing in a Western population. In a significant proportion of our sample, there was divergence between the anatomical and mechanical axes of the tibia. This finding has implications for both the design and implantation of orthopaedic prostheses, particularly in total knee arthroplasty. Further research is necessary to investigate whether prosthetic implantation based on the mechanical axis in bowed tibias results in suboptimal implant placement and adverse clinical outcomes

Aims. There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes. Patients and Methods. A total of 284 DLS patients were recruited into this study, among whom 69 patients were treated surgically and the remaining 215 patients conservatively Patients were classified based on the coronal balance distance (CBD): Type A, CBD < 3 cm; Type B, CBD > 3 cm and C7 Plumb Line (C7PL) shifted to the concave side of the curve; Type C, CBD > 3 cm and C7PL shifted to the convex side. Results. A total of 99 of the 284 (34.8%) patient presented with a pre-operative coronal imbalance (mean CBD: 48.5, standard deviation 18.7 mm). More patients with a Type B malalignment were observed than with a Type C malalignment (62 versus 37). A total of 21 pf the 69 (30.4%) surgically treated patients had a post-operative coronal imbalance, which was found to be more prevalent in Type C patients (p < 0.001). At follow-up, less improvement was observed in terms of Short Form-36 Physical Component Score and visual analogue score for back pain (p = 0.034 and 0.025, respectively) in Type C patients. Conclusion. This study shows that patients with Type C coronal malalignment may be at greater risk of post-operative coronal imbalance following posterior osteotomy. Cite this article: Bone Joint J 2016;98-B:1227–33

Abstract. Introduction. Long term survivorship in Total Knee Arthroplasty is significantly dependent on prosthesis alignment. The aim of this study was to determine, compare and analyse the coronal alignment of the tibial component of a single implant system using 3 different techniques. Method. Retrospective study of cases from a prospectively collected database. Radiological assessment included measurement of the coronal alignment of tibial components of total knee arthroplasties, and its deviation from the mechanical axis. A comparison study of intramedullary, extramedullary and tibial crest alignment methods was performed. Results. 66 consecutive patients (3 groups of 22 each). Mean BMI was 26. The mean angle of deviation from the mechanical axis was significantly lesser (p< 0.05) in the Tibial crest alignment group patients compared to the other 2 groups. Moreover, the number of outliers (+/-3 degrees) were 2 and 4 in the intra and extramedullary group, whereas there were none in the tibial crest group. The inter and intraclass correlation coefficient was 0.8 and 0.9 respectively. Conclusion. The Tibial Crest Alignment Technique is an effective technique to produce consistent results to achieve optimal coronal alignment of the tibial component in TKA, even in patients with high BMI. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Intraoperative assessment of coronal alignment is important when performing corrective osteotomies around the knee and ankle, limb lengthening and trauma surgery. The Joint Angle Tool (JAT) provides surgeons with information about the anatomic and mechanical axes intraoperatively based on true anteroposterior radiographs. Aim: Presentation of the JAT, a low-cost goniometer for intraoperative assessment of the lower limb alignment. Materials and Methods. The JAT consists of pre-printed joint orientation angles of the anatomic and mechanical axis including normal variations on a plastic sheet. It is placed on the screen of the image intensifier after obtaining a true anterior-posterior image. The pre-printed joint orientation angles can intraoperatively assist the surgeons in achieving the pre-planned axis correction. Here, its feasibility is demonstrated in four cases. Results. Here, we present the intraoperative use of JAT in four cases:. 77 mm femoral bone transport due to non-union utilizing a bone transport nail,. distal femoral osteotomy correcting coronal and torsional malalignment using a retrograde intramedullary trauma nail,. proximal / high tibial open wedge osteotomy with an intramedullary implant correcting varus malalignment in a hypophosphatemic rickets patient, and. a supramalleolar, closing wedge osteotomy realigning the anatomic axis with a plate and screws. Conclusions. The JAT is a modified goniometer which allows intraoperative assessment of the mechanical and anatomic axis. JAT is applicable throughout the entire surgical procedure irrespective of the method of internal fixation and may provide additional reassurance of correct alignment. The JAT consists of a plastic sheet with printed joint orientation angles and their normal variation. JAT is freely available from . profeedback.dk/JAT/JAT.pdf. for use and modification according to Creative Commons license (CC BY-SA 4.0)

Introduction. Patellofemoral arthroplasty (PFA) can give excellent results in well-selected patients. Axial alignment has been extensively studied in this type of surgery. However because there is no distal femoral cut, coronal alignment in PFA is less well known. The position of the patellofemoral component decides the varus or valgus alignment of the implant. Hypothesis. Coronal alignment in PFA (PFJ-Gender, Zimmer, Warsaw, US) is determined by the anterior condylar anatomy and features an important variance influencing coronal alignment. Materials and methods. Coronal alignment was measured in 57 PFAs on full leg weight bearing radiographs as the lateral distal femoral angle compared to the mechanical axis (mLDFA). In a first group of patients the anterior condylar anatomy was followed and in a second group the PFA was aligned to the Whiteside's line. Results. In the group following the condylar anatomy the mean (SD) mLDFA was 100° (9°) compared to the group where the Whiteside's line was followed, which presented a mean (SD) mLDFA was 89° (3°). Patellofemoral tracking evaluated on a Merchant view was better in the second group. Discussion. Literature shows that accurate patellofemoral alignment is 1° of valgus from the mechanical axis. Following the anterior condylar anatomy doesn't allow to recreate accurate frontal alignment with a PFA. This can be obtained by following Whiteside's line as a substitute for finding the mechanical axis. Conclusion. Whiteside's line is not only an accurate landmark for axial alignment but also for coronal alignment in PFA aligning the implant with the mechanical axis

Aims. While mechanical alignment (MA) is the traditional technique in total knee arthroplasty (TKA), its potential for altering constitutional alignment remains poorly understood. This study aimed to quantify unintentional changes to constitutional coronal alignment and joint line obliquity (JLO) resulting from MA. Methods. A retrospective cohort study was undertaken of 700 primary MA TKAs (643 patients) performed between 2014 and 2017. Lateral distal femoral and medial proximal tibial angles were measured pre- and postoperatively to calculate the arithmetic hip-knee-ankle angle (aHKA), JLO, and Coronal Plane Alignment of the Knee (CPAK) phenotypes. The primary outcome was the magnitude and direction of aHKA, JLO, and CPAK alterations. Results. The mean aHKA and JLO increased by 0.1° (SD 3.4°) and 5.8° (SD 3.5°), respectively, from pre- to postoperatively. The most common phenotypes shifted from 76.3% CPAK Types I, II, or III (apex distal JLO) preoperatively to 85.0% IV, V, or VI (apex horizontal JLO) postoperatively. The proportion of knees with apex proximal JLO increased from 0.7% preoperatively to 11.1% postoperatively. Among all MA TKAs, 60.0% (420 knees) were changed from their constitutional alignments into CPAK Type V, while 40.0% (280 knees) either remained in constitutional Type V (5.0%, 35 knees) or were unintentionally aligned into other CPAK types (35.0%; 245 knees). Conclusion. Fixed MA targets in TKA lead to substantial changes from constitutional alignment, primarily a significant increase in JLO. These findings enhance our understanding of alignment alterations resulting from both unintended changes to knee phenotypes and surgical resection imprecision. Cite this article: Bone Jt Open 2024;5(2):109–116

Background. Surgical treatment of AIS includes several purposes such as arrest deformity progression through a solid fusion, obtain a permanent correction of the deformity and others. Objectives. To evaluate the improvement of sagittal spinopelvic parameters and clinical outcomes in patients with adolescent idiopathic scoliosis 2 years after corrective surgery. Methods. Radiological and clinical data of 134 consecutive scoliosis patients including 11 boys and 124 girls with the average age of 15.37 years, with AIS Lenke 1, 2, 3, 4, 5 or 6 were included in this retrospective study with 2-year follow-up. Whole spine anterior/posterior and lateral Xray, CT scan and MRI were taken preoperatively, immediately after surgery, at 3 months and 2 years after corrective surgery. Radiological parameters were evaluated and compared pre and post operatively. Result. In coronal plan, significant reduction was observed in main curve, proximal curve and distal curve P<0.001, 2 years after corrective surgery. Meanwhile, the translation of apex vertebra decreased p<0.001. But sagittal profile of the patients did not show obvious changes such as LL, TK. The pelvic parameters indicated that PI was 50.6 degrees, PT was 13.8, SS was 37.0 and TPA was 47.5 degrees preoperatively. Vertebral body height increased dramatically just after surgery and showed further in the last follow up. Conclusion. The changes in coronal plan was significant 2 years after correction surgery for AIS patients and were not correlated with restoration of sagittal profile. Conflict of interest. None. Sources of funding. None

Aims. This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA. Methods. Prospectively collected registry data involving 264 UKAs from a single institution were analyzed. The TCCAs and FCCAs were measured on postoperative radiographs and absolute angles were analyzed. Clinical assessment at six months, two years, and ten years was undertaken using the Knee Society Knee score (KSKS) and Knee Society Function score (KSFS), the Oxford Knee Score (OKS), the 36-Item Short-Form Health Survey questionnaire (SF-36), and range of motion (ROM). Fulfilment of expectations and satisfaction was also recorded. Implant survivorship was reviewed at a mean follow-up of 14 years (12 to 16). Multivariate regression models included covariates, TCCA, FCCA, and two-way interactions between them. Partial residual graphs were generated to identify angles associated with the best outcomes. Kaplan-Meier analysis was used to compare implant survivorship between groups. Results. Significant two-way interaction effects between TCCA and FCCA were identified. Adjusted for each other and their interaction, a TCCA of between 2° and 4° and a FCCA of between 0° and 2° were found to be associated with the greatest improvements in knee scores and the probability of fulfilling expectations and satisfaction at ten years. Patients in the optimal group whose TCCA and FCCA were between 2° and 4°, and 0° and 2°, respectively, had a significant survival benefit at 15 years compared with the non-optimal group (optimal: survival = 100% vs non-optimal: survival = 92%, 95% confidence interval (CI) 88% to 96%). Conclusion. Significant two-way interactions between the TCCA and FCCA demonstrate the importance of evaluating the alignment of the components concomitantly in future studies. By doing so, we found that patients who concomitantly had both a TCCA of between 2° and 4° and a FCCA of between 0° and 2° had the best patient-reported outcome measures at ten years and better survivorship at 15 years. Cite this article: Bone Joint J 2021;103-B(2):338–346