Valgus alignment of the femoral component is associated with higher revision rates 10 years after TKA

Appropriate positioning and alignment of tibial and femoral component in primary total knee arthroplasty (TKA) are factors of major importance directly related to patient satisfaction and implant survival. Most literature works elaborate on overall post-operative alignment and its correlation to implant survival. However, less is known about the impact of individual component alignment. The purpose of this study was to investigate the effect of undercorrection of overall alignment as well as the effect of individual tibial and femoral component alignment on the post-operative failure rate after total knee arthroplasty.

Clinical and radiographic data of primary TKA cases from 2002 to 2004, with a minimum of 10-year follow-up, were retrospectively reviewed. The pre- and post-operative hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were measured on weight-bearing, full-length antero-posterior lower limb radiographs. Statistical analysis was performed to establish the correlation between both overall and implant alignment and revision rate.

In total, 379 primary TKA cases were evaluated. The mean time of follow-up was 12.9 years (range 10.3-15.9 years, SD = 1.8). Nine out of 379 cases were revised due to aseptic loosening; the mean time to revision was 5.5 years (range 1.0-15.5 years, SD = 4.6). Varus undercorrection of overall alignment was not associated with a higher rate of revision (p = 0.316). Post-operative valgus femoral alignment (mLDFA < 87°) contributed to a significant decreased prosthesis survival in contrast to neutral femoral alignment (revision rate valgus group: 10.7% and neutral group: 1.7%; p = 0.003). Post-operative tibial mechanical alignment was not identified as a significant predictor for implant survival (revision rate varus group: 2.9% and neutral group: 2.4%; p = 0.855).

Primary TKA showed significantly higher revision rates when the femoral component was placed in > 3° of valgus (mLDFA < 87°). In contrast, postoperative overall residual varus alignment (HKA) and varus alignment of the tibial component were not related to higher revision rates at a minimum 10-year follow-up after TKA. These findings should be considered when choosing component position in individualised TKA.

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