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Knee Surg Sports Traumatol Arthrosc. 2018 Nov;26(11):3351-3361. doi: 10.1007/s00167-018-4891-9. Epub 2018 Mar 8.

3D patient imaging and retrieval analysis help understand the clinical importance of rotation in knee replacements.

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Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK.
Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK.
Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.



The purpose of the present study was to correlate highly accurate CT measurements of pre-revision total knee arthroplasty (TKA) implant position with findings of retrieval analysis post-revision, to understand the clinical relevance of TKA orientation.


This study involved 53 retrieved TKA implants with pre-revision 3D-CT scans used to determine coronal (varus-valgus), sagittal (tibial slope) and rotational (internal rotation-external rotation) TKA orientation as well as tibiofemoral leg axis. Differences between femoral and tibial angles to describe the "relative rotational mismatch" were also calculated. All tibial inserts were forensically analyzed using the Hood score. Statistical analysis was performed to investigate correlations between TKA component orientation and surface damage (p < 0.05).


Femoral components were found to have axial rotations mainly within ± 3° (68%), whilst 45% of the tibial components and 66% of the relative rotational mismatches were > 3° and < - 3°, respectively. The majority of femoral and tibial components (87% in both cases), as well as the femorotibial angle (70%), showed coronal orientations within ± 3°. The 64% of the tibial components showed posterior tibial slopes out of both the 0°-3° and 5°-7° ranges. There was a significant correlation between tibial slope and damage score on polyethylene tibial inserts (r = 0.2856; p = 0.0382) as well as a significant correlation between implants' position in the axial plane and damage score on polyethylene tibial inserts (r = 0.6537, p = 0.0240).


This is the first study to use accurate measurements from pre-revision 3DCT to compare tibial and femoral orientation in all three planes with retrieval findings in total knee replacements. A significant correlation between implant position and polyethylene surface damage was found. These results showed the importance of optimizing component position to minimize polyethylene damage. Further analysis involving more accurate polyethylene wear measurements are fundamental to fully understand the role of components' orientation in TKAs.


3D computed tomography; Implant orientation; Malalignment; Polyethylene surface damage; Total knee arthroplasty; Total knee replacement

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