Guidelines for Instrumentation for Total Knee Replacement Based on Frontal Plane Radiographs

The objective of this study was to measure the dimensions and the angulations of the femur and tibia for arthritic knees that were scheduled for total knee surgery. The purpose was to provide information for the design of surgical instruments such as cutting guides. Instruments made using three-dimensional printing were a particular consideration because of the variations in sizing that are possible.

Sixty-six frontal plane EOS radiographs were obtained of patients with osteoarthritis who were under consideration for total knee arthroplasty. The images were imported into computer-assisted design software. The anatomic and mechanical axes and the joint lines were constructed for the femur and tibia. The angles between the axes and lines and key dimensions including the femoral canal diameters were measured.

The angle between the anatomic and mechanical axes was 5.5° ± 1.4°, the femoral joint line sloped 2.2°, and the tibial joint line 4.3° to the mechanical axes. The values were similar to non-arthritic knees except for a higher tibial slope. The femoral canal diameter at 150 mm from distal was 19 ± 5 mm.

In a total knee replacement procedure, aligning perpendicular to the mechanical axis results on average about 2° more valgus and 2° to 3° tilt of the joint line. Instruments could be calibrated for individual patients, but the maximum variations based on long-term follow-up should be recognized. A multi-diameter system is needed for the femoral intramedullary rod to limit errors to 1° or less.