Arch Orthop Trauma Surg
DOI 10.1007/s00402-014-1934-7
Orthopaedic Surgery
Intramedullary control of distal femoral resection results
in precise coronal alignment in TKA
Tilman Pfitzner · Philipp von Roth · Carsten Perka ·
Georg Matziolis
Received: 6 October 2013
© Springer-Verlag Berlin Heidelberg 2014
Abstract
Introduction There is still a relevant rate of outliers in
coronal alignment >3° when the conventional technique is
used, potentially accompanied by a poorer long-term clini-
cal outcome and a reduced longevity of the implant. Intra-
operative implementation of preoperative planning and
above all checking of the bone resections carried out are
decisive for reinstating a straight leg axis. Intramedullary
control of femoral resection has not been described to date.
The objective of this study was to present a new technique
for the intramedullary control of femoral resection and the
results obtained using this method.
Methods All patients who underwent primary total knee
arthroplasty with the new intramedullary control of femo-
ral resection were included in this retrospective study. The
frequency of the need for correction of the saw cuts was
documented. The radiological assessment included pre-
and postoperative whole-leg standing radiographs. In the
process, the whole-leg axis, AMA, entry point, LDFA and
MPTA were evaluated preoperatively. On the postoperative
radiographs, the whole-leg axis and the alignment of the
femoral and tibial components were evaluated.
Results One hundred and sixty-two total knee arthroplas-
ties (TKAs) were included in the study. The average age
was 68.7 years. The preoperative malalignment was on the
T. Pfitzner (*) · P. von Roth · C. Perka
Orthopedic Department, Center for Musculoskeletal Surgery,
Charité, Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin,
Germany
e-mail: tilman.pfitzner@charite.de
G. Matziolis
Orthopaedic Department, Waldkrankenhaus “Rudolf Elle”
GmbH, Friedrich Schiller University Jena, Klosterlausnitzer
Straße 81, 07607 Eisenberg, Germany
average 8.2° ± 4.7° (23.8° varus to 17.3° valgus). The post-
operative whole-leg axis was on the average 1.3° ± 1.1°
(5.5° varus to 4.3° valgus). The femoral component showed
a deviation from the mechanical axis of 0.1° ± 1.2° (4.3°
varus to 3.7° valgus) and the tibial component a deviation
from the mechanical tibial axis of 0.3° ± 1.2° (4.2° varus
to 2.5° valgus).
Conclusions The new technique of intramedullary control
of distal femoral resection, together with preoperative plan-
ning, leads to a precise alignment of the femoral compo-
nent in the coronal plane. Thus, for the first time, a simple
and effective tool for checking distal femoral resection is
available for standardized use.
Keywords Alignment · Total knee arthroplasty ·
Preoperative planning
Introduction
Despite the knowledge gained and advances made in knee
arthroplasty, relevant rates of outliers in coronal alignment
(14–32 %) are still described for the conventional technique
[1–4]. However, reconstruction of the leg axis belongs to
the decisive parameters for a good long-term clinical out-
come and the longevity of the implant [5–11]. If there is a
deviation above the accepted cut-off value of ±3°, a poorer
outcome is to be expected [1, 2, 10, 12, 13].
In the case of intramedullary (IM) alignment, the angle
between the anatomical and mechanical femoral axis
(AMA) permits orthogonal resection in relation to the
mechanical axis of the femur. Despite precise preoperative
planning, execution of the resection remains a source of
error for later implant alignment [14–16]. A control of the
resections is therefore crucial.
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 Arch Orthop Trauma Surg

While extramedullary (EM) control of resections is

unproblematic on the tibia, an EM control of distal femoral
resections is rarely performed. Since the hip center is not
directly palpable, an intraoperative control of the mechani-
cal femoral axis is imprecise, complicated and associated
with an increased radiation exposure [17, 18]. A method for
intramedullary control of distal femoral resection has not
been described to date.
In the present manuscript, the authors present a new,
simple technique for IM control of distal femoral resection
and the results obtained using this method. The hypothesis
of this study was that IM control and if necessary correc-
tion of distal femoral resection up to achievement of preop-
erative planning leads to a precise coronal alignment of the
femoral component.

Materials and methods

All patients who received a primary total knee replace-

ment (SIGMA P.F.C., J&J Depuy, Warsaw, USA) using the
“High-Performance” instrumentation in the conventional,
new technique in 2010/2011 were included in this retro-
spective investigation.
Inclusion criteria were primary or secondary osteoar-
thritis of the knee as the indication for surgery as well as
the availability of digital pre- and postoperative whole-leg
standing/lateral radiographs. Exclusion criteria were the
inability to assess the radiographs as a result of malrotation
or flexion when imaged [13, 19].
Pre- and postoperative radiographs were performed
under standardized conditions based on the technique
described by Cooke et al. [20]. Patients were positioned
standing upright with their backside to the cassette and
equally distributed weight bearing between both legs. For
correct rotation, the tibial tubercle was positioned straight
forward so that the sagittal flexion axis was parallel to the
X-ray beam [13, 20]. The feet were positioned touching
each other if possible. The X-ray beam was centered to the
joint line level [21].
Criteria for a correct rotation of the radiograph were
central patellar tracking, coverage of the fibular head by the
tibia (2/3:1/3) and the position of the upper ankle/foot upon
imaging [22, 23]. In addition, the patients’ age, side and
implant were analyzed.
Preoperative planning
Before each operation, standardized planning was con-
ducted by the surgeon on the basis of the preoperative
whole-leg standing radiograph. In this process, the whole-
leg axis, AMA, lateral distal femoral angle (LDFA),
medial proximal tibial angle (MPTA) and femoral entry
Fig. 1  Individual preoperative planning on digital radiographs
point were determined. In addition, for the femoral entry
point, the distance from the center of the knee was meas-
ured in mm.
Finally, the resection planes were inscribed at 90° to the
femoral and tibial mechanical axis (Fig. 1).
Surgical technique
All knee joints were treated using the conventional tech-
nique (femur first) by three experienced surgeons. The
SIGMA P.F.C. (J&J Depuy, Warsaw, USA) with a rotating
platform was used in all cases. The decision as to a cruciate
retaining or substituting design was made intraoperatively,
depending on the surgeons’ preference.
Distal resection of the femur was performed after IM
alignment with a long rod according to the AMA planned
individually in advance on the basis of the whole-leg stand-
ing radiograph and the distal femoral alignment guide
(Fig. 2).
After resection, the IM control of the saw cut developed
by the authors was performed. For this purpose, the medul-
lary rod and the distal femoral alignment guide were put
back in place (Fig. 3).

13
Arch Orthop Trauma Surg
Fig. 2  High-performance instrumentation with long intramedullary
rod (1) and distal femoral alignment guide (2)
Fig. 3  Placement of distal femoral alignment guide for control of
resection
After releasing the locking device, the position of the
resection plane in relation to the anatomical femoral axis
was now read off (Fig. 4). If this deviated by more than 0.5°
from the planned resection, the resection was corrected and
the control repeated until the resection was consistent with
the preoperative planning. The remainder of the operation
was performed in accordance with the conventional surgi-
cal technique.
Fig. 4  Evaluation of the performed distal femoral resection with free
angulation
Since the introduction of this new technique, it has been
documented for each operation whether a correction of the
initial saw cut of the femur or tibia was necessary.
Postoperative assessment
Postoperative assessment comprised the radiological evalu-
ation of the postoperative whole-leg standing radiographs.
Patients whose postoperative radiographs could not be
evaluated as a result of rotation or flexion were excluded
from the study.
On these images, the deviation of the mechanical axis,
the position of the femoral component in relation to the
mechanical femoral axis and the position of the tibial
component in relation to the mechanical tibial axis were
determined.
Statistics
Descriptive statistics (mean, minimum, maximum and
standard deviations) were calculated from the measured
data.
Results
One hundred and seventy-two patients fulfilled the inclu-
sion criteria of this study. Sixteen patients were sub-
sequently excluded as their radiographs could not be
assessed due to flexion or malrotation of the limb. The
13

average age of the remaining 156 patients (162 TKAs) was
68.7 ± 9.4 years (45–91). The ratio of right to left knee
joints was 90:72, and that of female to male was 112:50.
Surgical procedure
All knee joints were operated on with the SIGMA P.F.C.
(J&J Depuy, Warsaw, USA) and the “High-Performance”
instruments. A cruciate retaining design was used in 68 cases
and a cruciate substituting (posterior stabilized) design in 94
cases. The extramedullary alignment guide was used for the
tibial cut in all cases. After resection, the accuracy of the cut
was verified extramedullary using a drop down rod. A cor-
rection of the saw cut was necessary in 35 cases (22 %).
The control of the IM aligned distal femoral cut was per-
formed IM with the distal femoral alignment guide in all
knee joints. An intraoperative correction of the previously
executed saw cut had to be performed in 96 (59 %) of the
cases.
Radiological investigation
The preoperative malalignment was on the average
8.2° ± 4.7° (23.8° varus to 17.3° valgus). The LDFA
was 88.5° ± 2.6° (78.2°–94.2°), the MPTA 86.6° ± 3.8°
(74.5°–95.2°).
The AMA in the investigated patient population was on
the average 7.2° ± 1.1° (3.9°–9.5°). A standard resection
between 5° and 7° would have led to a correct reinstate-
ment of the mechanical axis in only 36 % of the patients.
The entry point for the intramedullary rod was on the
average 5.4 ± 4.5 mm (6.8 mm lateral to 16.6 mm medial)
from the mechanical femoral axis.
The deviation of the mechanical whole-leg axis evalu-
ated on the postoperative whole-leg standing radiographs
was 1.3° ± 1.1° (5.5° varus to 4.3° valgus).
If one considers the deviations separately for the indi-
vidual components, this yields an average deviation of the
femoral component of 0.1° ± 1.2° (4.3° varus to 3.7° val-
gus) in relation to the mechanical femoral axis (Fig. 5a) and
an average deviation of the tibial component of 0.3° ± 1.2°
(4.2° varus to 2.5° valgus) in relation to the mechanical tib-
ial axis (Fig. 5b).
The rate of outliers >3° in the whole-leg axis was 6.8 %.
In relation to the individual components, the rate of outli-
ers >3° was 1.2 % for the femoral component and 1.9 % for
the tibial component.
Discussion
The main result of the present investigation was that the
intramedullary control of distal femoral resection described
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Arch Orthop Trauma Surg
for the first time by the authors led to a precise alignment
of the femoral component in the coronal plane. In addition,
the postoperative overall mechanical axis and the position
of the tibial component also showed smaller deviations
from the neutral compared with the available literature
[3, 4, 9, 24, 25]. The rate of outliers >3° (6.8 %) was also
lower than that described in the literature and, at 6.8 %, was
within a comparable range to that of navigation-assisted
TKA [1–4, 26–28]. These results question the necessity of
navigation-assisted TKA. Potential advantages are rather a
more sophisticated soft tissue balancing, than superiority in
coronal leg alignment.
Beside navigation-assisted TKA, patient-specific instru-
mentation (PSI) is another competing technique in com-
parison to the conventional technique. It was introduced
to overcome inaccuracies in the transfer of the preopera-
tive planning to the intraoperatively performed bone resec-
tions and to eliminate outliers in alignment [29, 30]. Apart
from their theoretical advantages there are some limita-
tions using PSI. Because of the necessity of preoperative
CT/MRI scans this procedure needs more time for planning
of the surgery, manufacturing of the guides and additional
costs. The operation room time is only slightly shorter so
this is not a cost-effective procedure today [31]. Moreover,
an improvement in the coronal alignment in comparison to
the conventional technique that was used in this study has
not been demonstrated up to now [29, 31].
Conventional preoperative planning, with which the
individual anatomical conditions can be imaged and taken
into account, is responsible for this. With the standard-
ized use of whole-leg standing radiographs, extra-articular
deformities can be identified and in particular the indi-
vidual configuration of the AMA can be determined. The
standard resection of 5°–7° AMA that in the past often had
to be “estimated”, as only short radiographs of the knee
joint were available, can thus be dispensed with. Even in
the absence of a consensus in the literature as to whether
an individual adjustment of the AMA leads to an improve-
ment in alignments [32, 33], we were able to show in the
present study that a standard resection of 5°–7° would
have led to a correct distal femoral resection in just 36 %
of the patients. Therefore, individual distal femoral resec-
tion on the basis of the previously planned AMA seems to
be more precise.
Moreover, the entry point for the intramedullary align-
ment rod and its placement within the intramedullary canal
is very important for coronal alignment of the femoral
component. Previous studies showed an incorrect imaging
of the anatomical femoral axis, if the entry point was not
precisely in the extension of the intramedullary canal or
opening of the medullary canal was performed routinely at
the center of the notch [34, 35]. Furthermore a significant
deflection of up to 3.3° varus or valgus was observed as a
Arch Orthop Trauma Surg
Fig. 5  a Postoperative devia-
tion of the femoral component
from the femoral mechanical
axis (valgus displayed by nega-
tive, varus by positive values).
b Postoperative deviation of
the tibial component from the
tibial mechanical axis (valgus
displayed by negative, varus by
positive values)
result of a too thin and short intramedullary rod [34–36].
With the use of the correct entry point and a long rod, the
accuracy of the intramedullary rod in displaying the ana-
tomical femoral axis was improved [34, 35]. Taking these
potential causes of failure into consideration for both, the
application of intramedullary alignment and the control of
the femoral resection, we used the individual planned entry
point and a long intramedullary rod bridging the femoral
diaphysis in each patient.
Perfect preoperative planning is of no use if it cannot be
precisely implemented intraoperatively [16]. To achieve a
perpendicular resection to the mechanical axis, the resec-
tions are aligned with reference to the axes of the femur
and tibia. The distal femoral resection is mainly aligned IM
on the basis of the anatomical femoral axis, making use of
the previously radiologically planned AMA [30, 37].
Apart from the correct alignment of the resection guides,
control of the resections is of decisive importance, since
marked deviations between planning and executed resec-
tion can occur, precisely in the case of scleroses [14–16,
38].
In contrast to femoral resection, the EM control of tibial
resection is unproblematic, due to the well-exposed upper
ankle joint. A technique for IM control has yet to be estab-
lished for femoral resection [39].
The technique for IM control of distal femoral resec-
tion presented here offers the advantage that it can be
performed quickly and reproducibly, with little additional
effort. The need for such a technique for controlling
resections is demonstrated by the fact that 59 % of the
resections had to be corrected after they had been con-
trolled. The postoperative radiological results confirm
13

this observation with a very high precision of component
alignment. Comparable studies showed markedly higher
deviations of the femoral component, averaging 1.2°–
2.4° [1–3, 12].
One limitation of the present study is that a comparison
of the patient population was only made with data from
the literature. The reason for this is that digital whole-leg
standing radiographs were not available for the historical
patient populations available to us. Another limitation is
that this technique can only be performed for specific spe-
cial instrumentations.
Conclusion
With this investigation, we were able to demonstrate that
the new technique of intramedullary control of femoral
resection using the SIGMA P.F.C. leads to a precise align-
ment of the femoral component in the coronal plane. Thus,
for the first time, a simple and effective tool is available
for controlling distal femoral resection for standardized
application.
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