Alignment Strategies in Total Knee Arthroplasty and How to Effectively Achieve Them

Orthopedic surgeons now have multiple alignment strategies for total knee arthroplasty. Unlike the era dominated by mechanical alignment, the availability of diverse paradigms introduces both flexibility and potential uncertainty in selecting optimal lower limb alignment. The published literature does not show marked differences in outcomes between standard mechanical and newer alternative alignment strategies, which is at once reassuring and frustrating. Reassuring because the reliability and durability of total knee arthroplasty appears similar and yet frustrating because comparisons among the techniques often hinge on individual surgeon preferences more than objective data. This review focuses on surgical techniques, highlights differences between mechanical alignment principles and constitutional alignment principles, and compares and contrasts those strategies that primarily focus on coronal plane alignment versus those that deliberately consider three-dimensional alignment. We consider mechanical and anatomic alignment strategies to primarily target coronal plane alignment, whereas kinematic and functional alignment focus on three-dimensional constitutional knee alignment. A clear analysis of the advantages, limitations, and the latest clinical outcomes of each alignment strategy is presented. Using surgical illustrations and insightful tips and tricks, this review aims to serve as a technical guidebook, offering useful insights for clinicians to achieve their desired knee alignment goals.