Variability of Sagittal Plane Proximal Tibial Morphology and Its Effect on Stem Placement in Total Knee Arthroplasty

The tibial joint line is offset posteriorly relative to the tibial sagittal anatomic axis. This can have consequences when using stemmed implants during total knee arthroplasty. We retrospectively analyzed native knee lateral radiographs in 100 patients. The distance between the sagittal anatomic axis and the center of a simulated tibial resection was calculated as a percentage of overall tibial width. Analysis of 5 manufacturers' baseplates showed that the tibial stem attached on average 10% anterior to the midline. We measured the impingement point of a 12-mm-diameter stem starting from this position. The tibial joint surface was offset posteriorly from the anatomic axis in all patients by an average of 23.5% of the tibial width (range: 13.1%-33.2%). A 12-mm tibial stem would impinge within 40 mm in 2% (2/100) of patients and within 60 mm in 19% (19/100). There was a weak but statistically significant correlation between proximal tibial offset and distance to impingement. During total knee arthroplasty, the center of the cut tibia is offset posteriorly from the sagittal anatomic axis. In patients with high offset, tibial stem extensions can impinge against the posterior tibia, causing baseplate malpositioning, diminished cement mantle, or fracture.