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Osteoarthritis Cartilage. 2009 Nov;17(11):1448-52. doi: 10.1016/j.joca.2009.05.012. Epub 2009 May 27.

Can anatomic alignment measured from a knee radiograph substitute for mechanical alignment from full limb films?

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  • 1Clinical Epidemiology Unit, Boston University, Boston, MA 02118, USA.



To examine whether categories of anatomic alignment (varus, neutral, valgus) measured from knee X-rays agree with similar categories of mechanical alignment from the full limb film and whether varus anatomic malalignment predicts medial joint space loss on knee X-rays as well as varus mechanical alignment.


We used data from the Osteoarthritis Initiative (OAI) (full limb and flexed knee X-rays) to examine agreement of anatomic and mechanical alignment and data from Boston Osteoarthritis of the Knee Study (BOKS) to evaluate the association of full limb mechanical alignment vs knee X-ray anatomic alignment with joint space loss. A 4 degree offset was used to correct for the more valgus angulation of the anatomic alignment.


Of 143 subjects whose knee X-rays and full limb films were publicly released from the OAI, the agreement of varus, neutral and valgus alignment was only moderate (kappa=0.43, P<0.001). In BOKS, varus mechanical and anatomic alignments measured from full limb and knee X-rays respectively both predicted a high risk of medial joint space loss vs neutral alignment--for mechanical alignment, odds ratio (OR)=4.82 [95% confidence interval (CI) 1.93, 12.00] and for anatomic alignment OR=4.25 (95% CI 2.08, 8.72).


While agreement of alignment from knee X-ray to full limb film was only moderate, varus malalignment measured from a flexed knee predicted the likelihood of progression well. Flexed knee alignment may be more relevant to knee osteoarthritis (OA) risk than that of a fully extended knee, but a measurement of alignment from a short limb is an imperfect surrogate for full limb alignment.

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