Determining the Rotational Alignment of the
Femoral Component in Total Knee Arthroplasty
Using the Epicondylar Axis
RICHARDA. BERGER,M.D., HARRYE. RUBASH,M.D., MICHAELJ. SEEL,M.D.,
WARRENH. THOMPSON, AND LAWRENCE S. CROSSETT,
M.D.
The posterior condylar surfaces of the femur are
routinely used as the reference for the rotational
orientation of the femoral component during most
primary total knee arthroplasties. The purpose of
this investigation was to identify a clearly discern-
ible, reproducible secondary anatomic axis useful
for determining the rotational orientation of the
femoral component when the posterior condylar
surfaces cannot be used. Seventy-five embalmed
anatomic specimen femurs were studied. A surgi-
cal epicondylar axis was defined as the line con-
necting the lateral epicondylar prominence and the
medial sulcus of the medial epicondyle. The poste-
rior condylar angle was measured as the angle be-
tween the posterior condylar surfaces and the sur-
gical epicondylar axis. Measurement of the poste-
rior condylar angle referenced from the surgical
epicondylar axis yielded a mean posterior condylar
angle of 3.5" (k1.2") of internal rotation for males
and a mean posterior condylar angle of 0.3"
(k1.2") of internal rotation for females. Thus, ro-
tational alignment of the femoral component can
be accurately estimated using the posterior condy-
lar angle. The posterior condylar angle, referenced
from the surgical epicondylar axis, provides a vi-
sual rotational alignment check during primary
arthroplasty and may improve alignment of the
femoral component at revision.
From the Department oforthopaedic Surgery. Univer-
sity of Pittsburgh. Pittsburgh. Pennsylvania.
Presented at the Seventh Open Scientific Meeting of
The Knee Society, Washington. D.C.. February 23.
1992.
Reprint requests to Richard A. Berger. M.D.. c/o Dr.
Harry E. Rubash, M.D.. University Orthopaedics, 3601
Fifth Ave., Pittsburgh. PA 152 13.
Received and accepted: May 15. 1992.
40
A successful surgical outcome in total knee
arthroplasty ( T K A ) depends on multiple fac-
tors, including proper rotational and transla-
tional alignment of the femoral and tibia1
component^.'.'^.^^,'^ Although the impor-
tance ofjoint line restoration has been univer-
sally appreciated, the significance of proper
rotational alignment of the femoral compo-
nent has only more recently been increas-
ingly recognized as ~ i t a l . * * " ~I 7..'~ . ~Poor
-
femoral component rotational alignment
may lead to many complications, ranging
from gross alteration of the foot progression
angle during gait to the more common com-
plications associated with the patellofemoral
joint. Patellofemoral complications such as
subluxation, dislocation. patellar clunk, ec-
centric wear, and anterior knee pain have
been reported to result from poor patellar
tracking. Several authors have suggested that
altering the rotation of the femoral compo-
nent during TKA may significantly improve
patellar tracking and reduce these complica-
t i o n ~ . ~ . ~In. ~particular,
." Rhoads et d . I 7 and
Figgie ef af.' concluded that small amounts of
external rotation relative to the neutral posi-
tion significantly improves patellar tracking
in anatomic specimens and may reduce patel-
lofemoral complications after TKA.
The posterior condylar surfaces of the fe-
mur are normally used as the reference for
the neutral rotational alignment of the femo-
Number 286
January, 1993
ral component during most primary poste-
rior cruciate retaining TKA cases. From this
neutral orientation, additional rotational
changes may be made by the surgeon de-
pending on the individual needs of the pa-
tient. On occasion, the posterior condylar
surfaces may be distorted, partially resected,
or otherwise unusable to the surgeon as refer-
ence landmarks. This may occur, for exam-
ple, in primary TKA cases complicated by a
markedly deformed arthritic knee or a knee
previously injured by trauma. The posterior
condylar surfacesare almost universally unus-
able in revision TKA. In the revision setting,
removal of the femoral component fre-
quently further complicates rotational align-
ment by distorting the previous posterior
condylar cuts. The resection of additional
bone from the posterior condyle makes
proper femoral component rotational place-
ment even more difficult during revision.
The difficulties inherent in aligning the femo-
ral component at revision are reflected, in
part, by a revision complication rate as high
as 4517~in series.6,7,10,11.15.17.20
The purpose of this investigation was to
identify a reproducible secondary anatomic
axis useful as a reference for the rotational
orientation of the femoral component during
revision or complex primary TKA when the
posterior femoral condylar surfaces cannot
be used. This study focused on the use of epi-
condylar landmarks to define this secondary
anatomic axis because the femoral epicon-
dyles are preserved in all but the most com-
plex TKA cases.
MATERIALS AND METHODS
Seventy-five embalmed anatomic specimen fe-
murs without arthritic or other gross anatomic ab-
normalities were obtained. Forty femurs of un-
known gender and 35 femurs of known gender. 20
male and I5 female, were harvested. All soft tissue
about the distal femur was carefully dissected from
the bone. Each femur was then mounted on a cus-
tom-designed testing apparatus. The testing appa-
ratus used a standard 8-mm diameter, 25-cm long
intramedullary guide for alignment as in TKA.
Determining Femoral Rotation in TKA 41
The device allowed each specimen to be precisely
positioned and held while linear and angular mea-
surements were recorded. All measurements taken
were referenced to the intramedullary guide. The
reproducibility of the data was k0.5" for angular
measurements and + I m m for linear measure-
ments. based on a validation technique in which
multiple measurements were made o n the same
specimen by two of the authors.
Two distinct angular parameters. the posterior
condylar angle and the condylar twist angle, were
The posterior condylar angle was de-
fined as the angle between the posterior condylar
line and the surgical epicondylar axis. This is
shown schematically in Figure 1. The posterior
condylar line was defined as the line tangent to the
femoral posterior condylar surfaces as seen by the
surgeon during TKA with the knee flexed at 90".
The surgical epicondylar axis was specified as the
line connecting the lateral epicondylar promi-
nence and the medial sulcus of the medial epicon-
dyle (Fig. I ). Careful inspection of the medial epi-
condyle reveals that within the medial sulcus is the
attachment for the deep fibers of the medial collat-
eral ligament (Figs. 2A and 2B). The sulcus. while
not palpable through the skin. is easily located
during surgical exposure for TKA. This medial
sulcus was also easily used in the testing apparatus
to define the medial point of the surgical epicon-
dylar axis (Fig. 2C).
The condylar twist angle was previously defined
by Yoshioki c/ as the angle between the poste-
rior condylar line and the clinical epicondylar
axis. The clinical epicondylar axis was defined as
the line connecting the lateral epicondylar promi-
nence and the most prominent point ofthe medial
epicondyle (Fig. 3). This prominent point is lo-
cated on the crescent ridge that serves as the at-
tachment for the superficial fibers of the medial
collateral ligament (Figs. 2A and 2B). These two
epicondylar prominences can be felt through the
skin and soft tissue about the knee.
The linear dimensions were measured based on
predetermined anatomic landmarks on the distal
end of each specimen after the work of Yoshioki ef
The linear dimensions and the landmarks
used for measurement are indicated by the letters
on Figure 4. These dimensions included lateral
(A-B) and medial (C-D) condylar depth, interepi-
condylar width (E-F). posterior condylar distance
(G-H). intercondylar notch width (J-K). and lat-
eral (I-J) and medial (K-L) condylar width. As an
example of one of the dimensions measured, the
posterior condylar distance was taken as the dis-
tance from the posterior condylar line, a line tan-
gent to the posterior condyles, to the center of the
intramedullary canal.
 Clinical Orthopaedics
42 Berger et al. and Related Research

Lateral Epicondylar Medial

Prominence

surgical
+Epicondylar
Axis

Posterior Condylar
Line

FIG. 1. Posterior condylar angle. Schematic of the axial view of the right distal femur as seen from below
by the surgeon during TKA with the knee flexed at 90". The posterior condylar angle is the angle between
the posterior condylar surfaces and the surgical epicondylar axis, defined using the medial sulcus on the
medial epicondyle.

RESULTS tween the male and female groups. The mean

posterior condylar angle for males was 4.7"
Measurement of the posterior condylar an-
of internal rotation with a standard deviation
gle using the surgical epicondylar axis in the
of 3.5". For females, the mean posterior con-
group of 40 anatomic specimen femurs of un-
dylar angle was 5.2" with a standard devia-
known gender resulted in a bimodal distribu-
tion of 4.1 ". The intraobserver variation was
tion. Peaks located at approximately 1 " and
1.5" and the interobserver variation was 4".
3.5" of internal rotation were noted. Subse-
The linear measurements are presented in
quent measurement of the posterior condylar
Table 2 for the group of 35 femurs of known
angle in the group of 35 femurs of known
gender. These parameters include medial and
gender revealed that the male posterior con-
lateral condylar width, the intercondylar
dylar angles had a mean value of 3.5" of in-
notch width, the interepicondylar width, the
ternal rotation, whereas the female group had
posterior condylar distance, and the medial
an average of 0.3". The standard deviation
and lateral condylar depth. The linear mea-
was 1.2" for both males and females (Table
surements were statistically significantly dif-
1). The male and female groups were statisti-
ferent between males and females for all pa-
cally significantly different (p < 0.000 1 using
rameters except the posterior condylar dis-
a two-way ANOVA). The intraobserver vari-
tance.
ability was 0.5" and the interobserver variabil-
ity was less than 1.0".
DISCUSSION
Measurement of the condylar twist angle
(using the clinical epicondylar axis) yielded The linear geometry of the human femur
no statistically significant differences be- has been well described, and many quantita-
>
FIGS.2A-2C. Medial sulcus of the medial epicondyle. (A) Artist's depiction of the bony anatomy of the
medial sulcus of the medial epicondyle and the crescent-shaped prominence encircling it. On this crescent
is the highest point of the medial epicondyle, but this highest point is a variable landmark. (B) Artist's
depiction of the soft-tissue covering of the medial sulcus, showing the attachment of the deep fibers of the
medial collateral ligament in the medial sulcus and the superficial fibers attaching to the crescent-shaped
prominence. (C) Alignment of a skeletonized femur in the testing apparatus to the surgical epicondylar
axis is shown. The medial point for the surgical epicondylar axis is the medial sulcus.
Number 286
January. 1993 Determining Femoral Rotation in TKA 43
 Clinical Orthopaedics
44 Berger et al. and Related Research

Lateral Medial

Lateral
Epicondylar A Prominence on
Prominence the Medial Epicondyle

clinical Epicondylar

-
Axis

Posterior Condylar
CondylarTwist Line
hBle ---------------
FIG. 3. Condylar twist angle (schematic), Axial view of distal right femur as seen from below by the
surgeon during TKA with the knee flexed at 90". The condylar twist angle is the angle between the
posterior condylar line and the clinical epicondylar axis, defined using the most prominent point on the
medial epicondyle.

tive studies have provided specific data on ear measurements reported here for both the
the shape and size of this long bone.3,4,13.15-19group of known gender and the group of un-
Distal femoral anatomic parameters have known gender agree with these prior studies.
also been reported for the purpose of defining This general agreement of the linear parame-
the ranges required for the design of anatomi- ters confirms that there were no gross ana-
cally suitable total knee implants.'5 The lin- tomic abnormalities among the specimens in

Lateral

E
I
- Surgical
Epicondylar Axis

Posterior Condylar
Line
FIG.4. Distal right femur (schematic). Axial view of distal femur as seen from below by the surgeon
during TKA with the knee flexed at 90". Letters indicate landmarks used for the linear and angular
measurements taken. These letters correspond to the parameters indicated in Table 2 . A and C, anterior
most projections of the lateral and medial femoral condyles, respectively: B and D, posterior most projec-
tions of the lateral and medial femoral condyles, respectively: E and F. the lateral and medial epicondyles;
G. center ofthe intramedullary canal: H. point on posterior condylar line in line with centerofintramedul-
lary canal; I and L, most lateral and medial points on the respective condyles; J. most medial point on
lateral femoral condyle: K, most lateral point on medial femoral condyle.
Number 286
January. 1993 Determining Femoral Rotation in TKA 45

TABLE 1. Condylar Angular Measurements

Posterior condylar angle (measured using the

surgical epicondylar axis) 3.5" (k1.2") 0.3" (k1.2") 0.000 I
Condylar twist angle (measured using the
clinical epicondylar axis) 4.7" (k3.5") 5.2" (24. I ") *
* Not statistically significant.

either group and that these specimens were
representative of normal adult human fe-
murs.
This study identified the surgical epicon-
dylar axis as a reproducible secondary ana-
tomic axis useful as a reference for the rota-
tion orientation of the femoral component in
TKA when the posterior condylar surfaces
cannot be used. The surgical epicondylar axis
was defined as the line connecting the lateral
epicondylar prominence and the medial sul-
cus of the medial epicondyle. The selection of
the medial sulcus of the medial epicondyle as
the medial landmark to define this axis was
based on careful scrutiny of the distal femur.
The medial sulcus is a clearly discernible, re-
producible landmark with minimal interob-
server and intraobserver variability. This sul-
cus serves as the attachment for the deep
fibers of the medial collateral ligament and,
although not palpable through the skin, is eas-
ily located by finger palpation during surgical
exposure for TKA.
Measurement of the posterior condylar an-
gle, the angle subtended by the surgical epi-
condylar axis and the posterior condylar line
in the group of 35 specimens of known
gender, revealed two narrow ranges based on
male-female differences. For the males, the
mean posterior condylar angle was 3.5"
(+ 1.2") of internal rotation; for females, the
mean angle was 0.3" (& 1.2"). This difference
is statistically significant 0, < 0.0001). Mea-
surement of the posterior condylar angle for
the group of 40 femurs of unknown gender
revealed nearly identical results with peaks at
1" and 3.5" of internal rotation. This bi-
modal distribution of the posterior condylar
angle ofthe femurs with unknown gender fur-
ther supports the usefulness of this angle as a
reference for the rotational orientation of the
femoral component.
The only article to date that has reported
measurement of an angle similar to the poste-
rior condylar angle was the work of Yoshioki
ct al.," who described a condylar twist angle.
This angle was measured using the posterior
condylar line and an epicondylar axis defined
as the line connecting the lateral epicondylar
prominence to the most prominent point of

TABLE 2. Distal Femoral Linear Measurements

Medial condylar width (K-L) 27.9 (k1.3) 26.2 (k3.8) 0.05

Lateral condylar width (I-J) 32.2 (k2.0) 27.2 (*1.3) 0.0005
Intercondylar notch width (J-K) 19.8 (k3.0) 16.1 ( k l . 8 ) 0.0005
Posterior condylar distance (G-H) 37.1 (k3.0) 36.1 (k3.0) *
Interepicondylar width (E-F) 85.6 (k5.1) 15.4 (k2.3) 0.0005
Lateral condylar depth (A-B) 67.6 (k3.0) 58.4 (k4.3) 0.0005
Medial condvlar deDth (C-D) 68.1 (k4.6) 60.2 (t2.0) 0.0005

* Not statistically significant.


46 Berger et al.
the medial epicondyle. Measurements in the
current study of the condylar twist angle
based on these landmarks yielded results simi-
lar in nature to those reported by Yoshioki.
Specifically, the mean angle in the current
study was 4.7" (k3.5") of internal rotation
for males and 5.2" (k4.1") for females. This
was in agreement with Yoshioki's reported
condylar twist angle of 5" (k1.8") for males
and 6" (k2.4") for females. Significantly,
measurement of the condylar twist angle
based on these landmarks had an intraob-
server variability of I .5" and an interobserver
variability of 4".
The condylar twist angle was not useful as
a secondary femoral rotational alignment pa-
rameter. Measurement of the condylar twist
angle was inconsistent because no clearly dis-
cernible single prominence was routinely se-
lected as the medial landmark. Different indi-
viduals would identify different positions as
the medial prominence, and the same individ-
ual would frequently select different posi-
tions on repeated examination. This variabil-
ity in the clinical epicondylar axis led to in-
consistencies in the determination of the
condylar twist angle. The variations inherent
in the landmarks chosen may explain why
Yoshioki c/ u / . ~found
' no statistically signifi-
cant difference between males and females in
their measurement of the condylar twist an-
gle. Findings in this current study of no statis-
tically significant difference between males
and females in this angle confirms this rea-
son i ng.
In conclusion, the surgical epicondylar
axis is a useful tool in determining the native
neutral rotational orientation of the femoral
component during TKA when the posterior
condylar surfaces cannot be used. The surgi-
cal epicondylar axis is based on the medial
sulcus of the medial epicondyle, a clearly dis-
cernible, reproducible landmark that is pres-
ent in all but the most complex situations.
Neutral rotational alignment can be accu-
rately estimated using the posterior condylar
angle. For males. the mean angle is 3.5" of
Clinical Orthopaedics
and Related Research
internal rotation: for females, the mean poste-
rior condylar angle is 0.3" of internal rota-
tion. The relatively small standard error
(0.4") indicates that more than 95% of pa-
tients would fall within l " of the mean values
for each group. Careful and consistent a e of
the posterior condylar angle may provide a
visual rotational alignment check during pn-
mary arthroplasty and improve alignment of
the femoral component at revision. Further-
more, this angular information may be used
to supplement existing knee alignment sys-
tems to guide those cuts related to femoral
rotation in cases where the posterior condylar
surface cannot be used.
ACKNOWLEDGMENTS
The authors thank Jan Hart for his constant assistance
with orthopedic research. Marianne Schleiden. and the
Upjohn company for their continued help and support
of this study.
REFERENCES
I . Bargren. J. H.. Blaha. J. D.. and Freeman, M. A. R.:
Alignment in total knee arthroplasty: Correlated
biomechanical and clinical observations. Clin.
Orthop. 173:178. 1983.
-.
7 Buechel. F. F.: Treatment of the patella in revision
total knee surgery using a rotating bearing patellar
replacement. Orthop. Rev. 19(Suppl.):76, 1990.
3. Burr. D. B.. Cook, L. T.. Cilento. E. V.. Martin,
N. L.. Lark. D., and Asher. M.: A method for radio-
graphically measuring true femoral rotation. Clin.
Orthop. 167:139. 1982.
4. Dunlap. K.. Shands. A. R.. Jr.. Hollister. L. C.. Jr..
Gaul. J. S., and Streit. H. A.: A new method for
determination oftorsion ofthe femur. J. Bone Joint
Surg. 35A:289. 1953.
5. Figgie. H. E.. Goldberg. V. M.. Hieple. K. G..
Moller, H. S.. and Gordon. N. H.: The influence of
tibial-patellofemoral location on the function of the
knee in patients with the posterior stabilized condy-
lar knee prosthesis. J. Bone Joint Surg. 68A:1035.
1986.
6 . Friedman. R. J.: Revision of failed aseptic total knee
replacements: Long term results. Orthop. Trans.
I 1:69. 1987.
7 . Goldberg. V. M.. Figgie. M. P.. Figgie. H. E.. 111. and
Sobel, M.: The results of revision total knee arthro-
plasty. Clin. Orthop. 22636. 1988.
8. Comes, L. S. M.. Bechtold, J. E., and Gustilo. R. B.:
Patellar prosthesis positioningin TKA: A roentgeno-
graphic study. Clin. Orthop. 236:72. 1988.
9. Huberti. H. H.. and Hayes, W. C.: Patellofemoral
Number 286
January, 1993
contact pressures. J. Bone Joint Surg. 66A:715,
1984.
10. Insall. J. N.. and Dethmers. D. A,: Revision of total
knee arthroplasty. Clin. Orthop. 170:123, 1982.
1I. Jacobs, M. A., Hungerford, D. S.. Krackow. K. A,.
and Lennox, D. W.: Revision of septic total knee
arthroplasty. Clin. Orthop. 238: 159, 1989.
12. Jiang. C. C.. and Insall. J. N.: Effect of rotation on
the axial alignment ofthe femur: Pitfalls in the use of
femoral intramedullary guides in total knee arthro-
plasty. Clin. Orthop. 24850. 1989.
13. Kapandii. A. 1.: The Physiology of the Joints, ed. 2.
New York. Churchill Livingstone. 1970, pp. 232-
233.
14. Lotke. P. A,. and Ecker. M. L.: Influence of posi-
tioning of prosthesis in total knee replacement. J.
Bone Joint Surg. 59A:77. 1977.
15. Mensch, J. S.. and Amstutz. H. C.: Knee morphol-
ogy as a guide to knee replacement. Clin. Orthop.
112231. 1975.
Determining Femoral Rotation in TKA 47
16. Moreland. J. R.: Mechanisms of failure in total knee
arthroplasty. Clin. Orthop. 226:49. 1988.
17. Rhoads, D. D.. Noble. P. C.. Reuben. J. D.. Ma-
honey. 0. M.. and Tullos. H. s.:The effect of femo-
ral component position on patellar tracking after to-
tal knee arthroplasty. Clin. Orthop. 260:43. 1990.
18. Rosenberg. A. G.. Andriacchi. T. P.. Barden. R.. and
Galante. J. 0.: Patellar comDonent failure in ce-
mentless total knee arthroplasty. Clin. Orthop.
236:106. 1988.
19. Ruby. L.. Mital. M. A,. OConner. J.. and Patel. U.:
Anteversion of the femoral neck. Comparison of
methods of measurement in patients. J. Bone Joint
Surg. 6 I A:46. 1979.
20. Thornhill. T. S., Dalziel. R. W.. and Sledge. C. B.:
Alternatives to arthrodesis for the failed total knee
arthroplasty. Clin. Orthop. 170:I3 I . 1982.
21. Yoshioki. Y.. Siu. D., and Cooke. D. V.: The anat-
omy and functional axes ofthe femur. J. Bone Joint
Surg. 69A:873. 1987.