Total knee arthroplasty in patients with marked coronal femoral bowing deformities: A systematic review

To review existing strategies for managing coronal femoral bowing deformity in total knee arthroplasty (TKA) and assess their effectiveness in enhancing postoperative mechanical alignment (MA) and the femoral component positioning.

A systematic literature review was performed across PubMed, Embase, the Cochrane Library, and Google Scholar up to August 2025. It included studies on surgical techniques for coronal femoral bowing in primary TKA, focusing on pre- and postoperative radiographic outcomes.

Thirteen studies were included in the final analysis. Individualized distal femoral valgus correction angles (VCAs) are more effective than fixed angles in restoring MA. Lateralizing the femoral entry point enables deeper, straighter insertion of the intramedullary rod (IM), resulting in better MA and more precise component placement. Intra-articular bone resection can be an effective alternative when lateralization is not feasible; however, it is limited by the severity of the deformity and technical complexity. Computer-assisted surgery (CAS) improves alignment accuracy and reduces outliers. Robotic-assisted TKA offers potential advantages but lacks specific data. Although patient-specific instrumentation has been suggested to enhance alignment in TKA, current evidence indicates no significant benefit over traditional methods. Extramedullary femoral guides provide more accurate alignment and lower outlier rates.

Coronal femoral bowing is common among Asian patients and influences TKA outcomes. A full-length standing scanogram of the lower extremities is vital for preoperative planning. Depending on the patient's condition, combining an IM cutting device, individualized VCA, lateralization of the entry point, intra-articular resection, and CAS may improve alignment and component positioning.