Mechanical Alignment in Total Knee Arthroplasty for Varus Knee Osteoarthritis Leads to Significant Tibial Bone Loss

Background Obtaining a neutral postoperative alignment is said to be a guiding principle for performing a successful total knee arthroplasty (TKA). There are many different alignment philosophies and surgical techniques to attain the goal of proper alignment. This study aimed to radiologically measure the difference in the amount of tibial bony resection required to perform a mechanical alignment versus an anatomic alignment TKA. Methods Two observers retrospectively reviewed the long leg radiographs of 100 patients (61 females and 39 males) listed for TKA between 2015 and 2018, measuring the amount of tibial bony resection required to achieve mechanical or anatomic alignment TKA. Results These radiographs' overall lower limb mechanical axis ranged between 16° varus and 17.6° valgus (mean 4.4° varus, standard deviation (SD) 6.64). By referencing 4 mm from the worn side, the mean resection needed from the normal side of the tibial plateau is 7.6 mm in the mechanical alignment measurement and 5.2 mm in the anatomical alignment measurement (p<0.0001). Therefore, 17% of mechanical alignment cuts require a tibial cut of more than 10 mm (mean 12.382 mm). No anatomical alignment measurements exceed 10 mm. When a virtual tibial cut >10 mm is required, the medial proximal tibial angle (MPTA) is a stronger predictor of deformity than the mechanical axis. Conclusion This radiological study shows that an anatomical alignment tibial cut is more bone conserving on the tibia than a mechanical alignment tibial cut and may lead to less asymmetry of the bony cuts and greater bony preservation, but clinical correlation is needed.