 INSTRUCTIONAL REVIEW: KNEE

Coronal alignment in total knee replacement

HISTORICAL REVIEW, CONTEMPORARY ANALYSIS, AND FUTURE
DIRECTION

M. P. Abdel, Substantial healthcare resources have been devoted to computer navigation and patient-
S. Oussedik, specific instrumentation systems that improve the reproducibility with which neutral
S. Parratte, mechanical alignment can be achieved following total knee replacement (TKR). This choice
S. Lustig, of alignment is based on the long-held tenet that the alignment of the limb post-operatively
F. S. Haddad should be within 3° of a neutral mechanical axis. Several recent studies have demonstrated
no significant difference in survivorship when comparing well aligned versus malaligned
From Mayo Clinic, TKRs. Our aim was to review the anatomical alignment of the knee, the historical and
Rochester, contemporary data on a neutral mechanical axis in TKR, and the feasibility of kinematically-
Minnesota, United aligned TKRs.
States Review of the literature suggests that a neutral mechanical axis remains the optimal
guide to alignment.
Cite this article: Bone Joint J 2014;96-B:857–62.

 M. P. Abdel, MD, Assistant
Professor of Orthopedic
Surgery and Orthopedic
Surgeon
Mayo Clinic, Department of
Orthopedic Surgery, 200 First
Street SW, Rochester,
Minnesota 55905, USA.
 S. Oussedik, FRCS(Orth),
Orthopedic Surgeon
University College London
Hospital, Department of
Trauma and Orthopaedics, 235
Euston Road, London NW1
2BU, UK.
 S. Parratte, MD, PhD,
Orthopedic Surgeon
Institute for Locomotion,
Department of Orthopedic
Surgery, Aix-Marseille
University, 270 Boulevard
Sainte Marguerite, BP 29, 13274
Marseille, France.
 S. Lustig, MD, PhD,
Orthopedic Surgeon
Service de Chirurgie
Orthopédique, Centre Albert-
Trillat, CHU de Lyon-Nord,
Lyon, France.
 F. S. Haddad , BSc MCh(Orth),
FRCS(Orth), FFSEM, Editor-in-
Chief
The Bone & Joint Journal, 22
Buckingham Street, London,
WC2N 6ET, UK.
Correspondence should be sent
to Dr M. P. Abdel; e-mail:
abdel.matthew@mayo.edu
©2014 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.96B7.
33946 $2.00
Bone Joint J
2014;96-B:857–62.
The number of primary total knee replace-
ments (TKRs) carried out every year in the
United States (US) is estimated to increase by
673% before 2030.1 In contrast with patients
who undergo primary total hip replacement
(THR), approximately 20% of those who
undergo TKR are not satisfied with the
outcome2,3: the causes of dissatisfaction
remain elusive.
TKR is a bony and soft-tissue procedure;
much attention has been given to the alignment
of the components, which is relatively easily
quantifiable, particularly in the coronal plane.
Recently, substantial healthcare resources have
been devoted to the development and use of
computer navigation and patient-specific
instrumentation systems that achieve neutral
mechanical alignment.4-6 This choice of align-
ment is based on the long-held tenet that post-
operative alignment of the lower limb should
be within 3° of a neutral mechanical axis.7-16
With modern implants and fixation tech-
niques, some have debated describing align-
ment as a dichotomous variable (aligned or
malaligned) on the basis of a mechanical
axis goal of 0° (SD 3°).4,6,17-20 Others have
supported the concept of a kinematically-
aligned TKR.21-23
Our aims were to review firstly, the relevant
anatomy and alignment of the knee; secondly,
the historical literature of neutral mechanical
alignment in TKR; thirdly, the contemporary
debate on coronal alignment in TKR and
fourthly, the evidence, or lack thereof, support-
ing the use of kinematic alignment.
Anatomy and alignment
It is important, firstly, to clarify that alignment
in the lower limb is referenced from a vertical
midline through the pubic symphysis.24 The
anatomical axes are lines drawn along the
length of the intramedullary canals of the
femur and tibia. The anatomical axes of the
joint surfaces refer to lines drawn perpendicu-
lar to a line joining the most distal femoral or
most proximal tibial points of the joint sur-
faces of either bone. The mechanical axis is a
line drawn from the centre of the femoral head
to the centre of the talus, and is commonly
referred to as Maquet’s line.13,25
With this in mind, the anatomical alignment
of the femoral joint surface is about 9° of val-
gus from the midline, whereas the anatomical
alignment of the tibia is about 3° of varus from
the midline. Typically, the mechanical align-
ment of the tibia is equivalent to the mechani-
cal alignment of the limb and the tibial
mechanical-anatomical (TMA) angle is 0°, or
neutral. The mechanical alignment of the fem-
oral joint surface is about 3° of valgus from the
vertical midline and the femoral joint surface
mechanical-anatomical (FMA) angle is about
6° of valgus. Considering these definitions,
overall alignment can be described in two
ways, either by the anatomical femoral-tibial
(AFT) angle or the mechanical femoral-tibial

VOL. 96-B, No. 7, JULY 2014 857

858 M. P. ABDEL, S. OUSSEDIK, S. PARRATTE, S. LUSTIG, F. S. HADDAD
(MFT) angle. The AFT angle is simply the difference
between the anatomical alignment of the femoral joint sur-
face (9° of valgus) and tibia (3° of varus), and is usually
about 6° of valgus. Likewise, the MFT angle is the differ-
ence between the mechanical alignment of the femoral joint
surface (3° of valgus) and tibia (3° of varus), resulting in 0°
or neutral mechanical alignment.
While the AFT angle can be estimated from short- or
long-leg radiographs, accurate measurement of the MFT
angle requires long-leg radiographs. Critics of older studies,
which support the use of a ‘coronal safe zone’, often note
that such investigations are limited by the use of short-leg
radiographs.4,20,26-28 Peterson and Engh28 studied the
anteroposterior (AP) radiographs of 50 knees and recorded
that the mean difference between the tibiofemoral AFT
angle on short- and long-leg radiographs was 1.4° (SD −3°
to 5°; p < 0.001).20,28 However, some studies show a corre-
lation between the anatomical and mechanical axes, sup-
porting the use of short-leg radiographs.10,11,26,28,29 In our
opinion, standing long-leg radiographs should be used as
they do not require a surrogate mechanical axis to be deter-
mined from the anatomical axis.
Historical review. It has long been suggested that restoration
of a neutral mechanical axis improves durability following
TKR. Data from many clinical, simulator, finite element, and
retrieval studies have led to this belief.7-16,30-35 However, a
closer analysis of these studies is required as many involved
small numbers of patients, early designs of components, and/
or used short-leg radiographs.4,15,30,32-34,36
In 1977, Lotke and Ecker32 showed that good clinical
results were associated with a geometric TKR anatomically
positioned between 3° and 7° of valgus. Hood et al37 and
Hvid and Nielsen34 defined the ideal range of anatomical
alignment as between 2° and 12° of valgus, whereas More-
land et al27 recommended between 0° and 10°of valgus.
Mallory, Smalley and Danyi38 recommended a target of
± 10° from the long-axis based on short-leg radiographs. In
a clinical and cadaveric study, Bargren et al36 found that the
Freeman–Swanson (ICLH) knee failed at lower compres-
sive loads and had a higher rate of failure when aligned in
varus. Insall et al31 believed that the mechanical axis should
lie lateral to the centre of the knee producing valgus,
whereas Townley39 believed that the mechanical axis
should lie medial to the centre of the knee, in varus. Ritter
et al15 showed that the posterior cruciate condylar TKR
should be aligned in neutral or slight valgus (5° to 8° of
anatomical valgus) for improved survival. All of the studies
mentioned above used short-leg radiographs and older
designs of components.
Jeffery et al13 popularised the restoration of the mechan-
ical axis to 0° (SD 3°) referenced from Maquet’s line with
the use of long-leg radiographs. While a rather unique
design of implant was used in their study, many subsequent
finite model analyses and laboratory investigations includ-
ing simulator studies and those in cadavers, have supported
this target.8,9,12,16,30,35
A landmark article by Hsu et al30 in 1990 studied 120
normal subjects of various ages and both genders with full-
length weight-bearing radiographs of the lower limb and
noted several intriguing findings. Foremost, they found that
the angle formed by femoral and tibial mechanical axes was
1.2° of varus; thus it was difficult to rationalise the place-
ment of a tibial component in 3° of varus. Secondly, they
noted that the normal anatomical-mechanical angle of the
femoral joint surface was between 4° and 5° depending on
whether short- or long-leg radiographs were used. Finally,
they found that with a single-leg stance, 75% of load
passed through the medial tibial plateau.
Contemporary analysis
The current understanding of the native, arthritic, and
replaced knees has significantly improved. Combined with
recent advances in technology, this has led to the further
investigation of coronal alignment4,6,10,11,15,19,20 Several
recent studies have reported no significant difference in sur-
vivorship when a traditionally held safe zone of 0° (SD 3°)
was used to define aligned versus malaligned knees.4,6,19,20
In one of the most influential studies, Parratte et al4 ret-
rospectively reviewed the clinical and radiological data of
398 cemented primary TKRs undertaken with one of three
contemporary designs. All patients had pre- and post-
operative full-length standing radiographs. They found that
a post-operative mechanical axis of 0° (SD 3°) did not
improve the rate of survival 15 years post-operatively, and
concluded that the description of alignment as a dichoto-
mous variable (aligned vs malaligned) provided little value
in regards to durability. However, they also stated that:
until additional data can be generated to more accurately
determine the ideal post-operative limb alignment in indi-
vidual patients, a neutral mechanical axis remains a reason-
able target and should be considered as the standard for
comparison if other alignment targets are introduced.4
Bonner et al19 subsequently completed a similar study
that described knees as either aligned, with a mechanical
axis of 0° (SD 3°), or malaligned, with a mechanical axis
deviated from neutral by > 3°, at 15 years. Similar to Par-
ratte et al,4 the authors found that the relationship between
coronal alignment and survivorship was weak.19
In a smaller study, Matziolis et al6 found no difference in
survival or outcome between aligned TKRs and a subset of
varus outliers. However, only 30 ‘malaligned’ TKRs were
examined, and there were no revisions in either group. The
authors emphasised that “correct component alignment
should be intended in every case”.6
Similarly, Morgan et al20 described 197 TKRs, which
were divided into three groups based on the AFTs: neutral
(4° to 9° of valgus), valgus (> 9.1° of valgus), and varus
(< 3.9° of valgus), and found no difference in survivorship
when they compared anatomical alignment based on long-
leg radiographs.
On the other hand, Berend et al7 reported a statistically
increased rate of failure of tibial components positioned in
THE BONE & JOINT JOURNAL
 CORONAL ALIGNMENT IN TOTAL KNEE REPLACEMENT
> 3.9° of varus. This was accentuated statistically if the
body mass index was > 33 kg/m2. In 2009, Fang et al11
expanded on this data set with six further years of follow-
up and examined all, not just tibial-sided, failures. They
found that in 6070 TKRs, the best survival was in those
with an overall anatomical alignment of between 2.4° and
7.2° of valgus. However, the difference in the rate of revi-
sion between the well-aligned and poorly aligned groups
was only 1%. They used short-leg radiographs to assess
alignment. More recently, Ritter et al14 looked at this
cohort to record survivorship further as it relates to the
anatomical alignment of each component, the overall ana-
tomical alignment, and neutral alignment with both com-
ponents malpositioned. They found an increased rate of
failure in those with a femoral component in > 8° of ana-
tomical valgus, in those with a varus tibial component rel-
ative to the tibial axis, or when one component was
introduced in such a way as to compensate for malalign-
ment of the other component, resulting in neutral align-
ment. Finally, Collier et al40 reported a significantly greater
loss of thickness of polyethylene in the medial compartment
when the limb was aligned in > 5° of varus.
While the emphasis of this paper is not the clinical and
functional outcomes related to alignment, it is important to
briefly mention recent findings on the topic. While
Magnussen et al41 found no difference in International
Knee Society scores between TKRs which were in neutral
versus varus mechanical alignment, two recent studies have
noted improvements in the one year functional outcomes
for those with coronal alignment within 3° of neutral.42,43
Choong et al42 found better International Knee Society and
Short-Form-12 physical scores at six weeks, and at three,
six and 12 months after surgery for those with a neutral
mechanical axis of 0° (SD 3°). Similarly, Longstaff et al43
found that patients with aligned TKRs had improved Knee
Society Scores one year post-operatively.
Kinematically-aligned TKR
The concept of constitutional varus was popularised by Bel-
lemans et al,17,18 who studied 250 asymptomatic adult vol-
unteers between the ages of 20 and 27 years. They found that
32% of men and 17% of women had constitutional varus of
their knees, with a natural mechanical alignment of > 3°
varus. They suggested that restoration of neutral mechanical
alignment in these patients might not be desirable.
The concept of a single flexion axis for the knee is also
becoming more widely recognised.44 However, how to best
find this axis intra-operatively remains controversial. The
single axis around which the tibia rotates is not captured in
any of the traditional coronal, sagittal, or transverse planes.
As such, a surrogate axis passing through the most medial
and lateral portions of the epicondyles, the transepicondy-
lar axis (TEA), has been proposed to represent the best
approximation of the actual flexion-extension axis (FEA)
of the knee.44,45 Using two- dimensional analysis, Churchill
et al45 concluded there was a statistically insignificant
VOL. 96-B, No. 7, JULY 2014
859
difference of 3° (SD 1°) between the TEA and the true FEA.
However, recent work by Eckhoff et al46 suggested that the
TEA might be an unsatisfactory surrogate of the FEA
because it lies anterior and superior to the FEA. Moreover,
it has been suggested that the cylindrical axis, defined as a
line equidistant from contact points on the medial and lat-
eral condylar surfaces between 10° and 120° of flexion,
forms angles more orthogonal to the mechanical axes of the
thigh and leg than the TEA.3,36,44, 46-51
For similar reasons, Howell et al21-23 have promoted
‘kinematically-aligned’ TKRs with the goal of restoring the
alignment to that which it would have been before the onset
of arthritis, and avoiding release of the collateral ligaments.
They reported on 214 kinematically-aligned, cruciate-
retaining TKRs at a mean follow-up of 31 months. The
patients were divided into three groups: limbs in the neutral
range (0°, SD 3°), varus (> 3°), or valgus alignment (> 3°).
They found no catastrophic failures in the short-term, and
concluded that in kinematically-aligned TKRs a “high risk
for catastrophic failure is unfounded and should be of inter-
est to surgeons committed to cutting the tibia perpendicular
to the mechanical axis of the tibia”.22
However, we should be cautious for several reasons.
Firstly, while malalignment may not cause ‘catastrophic’
failure in the very short-term (at a mean of 31 months),
such data cannot be extrapolated to the mid- or long-term.
Secondly, kinematically-aligned TKRs require the use of
patient-specific instrumentation. Finally, these findings are
yet to be widely reproduced.
The popularity surrounding kinematically-aligned TKRs
reflect concern with the high rate of dissatisfaction after
TKR.2 While alignment certainly may contribute to these
results, there are many other host, surgeon, and environ-
mental factors that play a significant, but as yet undefined,
role. From a conceptual standpoint, it is certainly intriguing
to reproduce the anatomy of patients. However, as previ-
ously noted, the clinical and basic science data on which
such an approach is based, is sparse.
To our knowledge, there is one randomised controlled
trial (RCT) by a group other than Howell et al3,21-23
Dossett et al3 compared kinematically-aligned TKRs with
mechanically-aligned TKRs in a RCT of 82 patients. They
found that the angle of the femoral component was a mean
of 2.4° more valgus and the angle of the tibial component
was a mean of 2.3° more varus than the mechanically-
aligned group.3 Moreover, they noted that at six months
post-operatively, the mean Western Ontario and McMaster
Universities Osteoarthritis Index score was 16 points better,
the mean Oxford Knee Score was seven points better, the
mean combined Knee Society Score was 25 points better
and the mean range of flexion was 5.0° greater in the kine-
matically-aligned group.3 While no reason for the differ-
ences is presented, contributory factors might include the
fact that only 66% of the randomised patients were ana-
lysed, the study was powered for alignment and not for
clinical outcomes, and patient-specific instrumentation was
860 M. P. ABDEL, S. OUSSEDIK, S. PARRATTE, S. LUSTIG, F. S. HADDAD
used in the kinematically-aligned group. Their findings are
in contrast to other reports.42,43
It should also be noted that hitherto, the focus for research
and development has involved the assessment of coronal
alignment of the lower limb in full extension. Activities of
daily living require the lower limbs to transmit force
throughout the range of movement. On flexion of a TKR,
the coronal alignment varies with axial alignment, soft-tissue
tension and the design of the components. If the goal of TKR
is to reposition the flexion-extension axis in such a way as to
minimise strain on the surrounding soft tissues, one can
understand how the position of the components in all three
planes will influence both function and survival.
Although more difficult to achieve and measure repro-
ducibly, the goals of alignment in the sagittal and axial
planes remain poorly understood. While many authors
have claimed that it is more difficult to obtain appropriate
sagittal alignment than coronal alignment,52-54 few have
evaluated the effects of sagittal alignment on function and
survival. However, sagittal instability does occur due to
malalignment.55,56 Kim et al53 found that flexion of the
femoral component of > 3° or sagittal alignment of the tib-
ial component of < 0° or a tibial slope of > 7° were risk fac-
tors for failure.
Likewise, there is little reliable evidence of the effect of
rotational alignment on survival because the techniques for
measuring it intra- and post-operatively are often inaccu-
rate, and the optimal rotational alignment has not been
defined.6,53 However, axial rotation of the femoral compo-
nent is crucial for obtaining well-balanced flexion gaps and
tibiofemoral and patellofemoral congruency during flex-
ion.57-59 In addition, rotational alignment is critical to the
outcome of TKR.15,27,57,58 Kim et al53 reported that exter-
nal rotation of the femoral component of < 2° or > 5°
increased the rate of failure significantly. Furthermore,
external rotation of the tibial component of < 2° or > 5°
also increased the rate of failure significantly.
The rotation of the components may have a greater role
on the outcome after TKR than is measurable. Thus, the
relationship between internal rotation of the components
and patellar maltracking was well demonstrated by Berger
et al60 using axial CT scans to evaluate rotational align-
ment. He recorded a direct correlation between internal
rotation of the components and patellar maltracking. Mild
combined internal rotation of between 1° and 4° caused lat-
eral patellar tracking and patellar tilting, whereas moderate
internal rotation of between 5° and 8° caused subluxation,
and marked internal rotation of between 7° and 17° caused
patellar dislocation or failure. Rotation of the tibia is also
critical.61-63 If the tibial component is internally rotated rel-
ative to the cut surface of the tibial plateau, the tibia will be
externally rotated relative to the femur. The tibial tubercle
will then be lateralised and the Q angle increased, predis-
posing to lateral patellar subluxation.64 This occurs when
the surgeon is trying to introduce a symmetrical tibial com-
ponent that is larger than ideal. Several studies have
reported higher rates of revision and less favorable clinical
results in patients with rotational malalignment of the tibial
component.65,66
Finally, it is important to highlight that even with com-
puter-assisted navigation, there is significant human error
that does not allow for perfect reproducibility of resection
of the bone or positioning of the components. In a meta-
analysis of alignment in computer-assisted surgery, Mason
et al67 found 9% tibiofemoral, 4.9% femoral component,
and 4% tibial component mechanical outliers. Thus, aim-
ing for a ‘slight degree’ of varus requires the surgeon to be
willing to accept 3° of intended varus, in addition to a
potential human error of 3° to 4° of varus, resulting in
unacceptable alignment.26
While some surgeons have advocated a paradigm shift in
defining optimal coronal alignment, neutral alignment and
classic bone cuts, remain the gold standard. This is based
on the fact that there is sufficient data advocating neutral
mechanical alignment with approximately 5° to 7° of ana-
tomical valgus, but only minimal support for other targets.
Although the precision of surgery can be improved with
technical advances, human error will remain. Neutral
mechanical alignment should remain the ‘safe zone’, even
though it is becoming apparent that alignment cannot be
described as a dichotomous variable.
The authors did not receive any outside funding or grants in support of their
research for or preparation of this work. One of the authors (FSH), or a member
of his immediate family, received, in any one year, payments or other benefits
in excess of $10,000 or a commitment or agreement to provide such benefits
from a commercial entity (Smith & Nephew) for products not discussed in this
chapter. One of the authors (MPA) works in a department that receives institu-
tional research support from multiple commercial entities (Biomet, DePuy,
Stryker, and Zimmer), while another author (FSH) works in a department that
receives institutional research support from multiple commercial entities
(Biomet, DePuy, Smith & Nephew, Stryker, and Zimmer).
The author or one or more of the authors have received or will receive bene-
fits for personal or professional use from a commercial party related directly or
indirectly to the subject of this article. In addition, benefits have been or will be
directed to a research fund, foundation, educational institution, or other non-
profit organisation with which one or more of the authors are associated.
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