Application of transverse tibial axis reference method in rotational positioning of femoral prosthesis in total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WEI Xinlei , WEI Qiang , YANG Hao , HAO Lin , ZHANG Hui , YIN Zongsheng ,  LI Yetian

Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230031, P. R. China;

Corresponding?author：

LI Yetian, Email: yfy1091987@fy.ahmu.edu.cn

Keywords：

Knee osteoarthritis; total knee arthroplasty; femoral prosthesis rotation; transverse tibial axis; gap balancing technique; surgical epicondylar axis

DOI：

10.7507/1002-1892.202604010

Video：

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Objective To investigate the reliability of determining rotational positioning of femoral prosthesis using the coronal transverse tibial axis at 90° of knee flexion as the reference in total knee arthroplasty (TKA). Methods Fifty-five patients with knee osteoarthritis undergoing TKA between November 2020 and February 2026 who met the selection criteria were enrolled. There were 14 males and 41 females, aged 54-82 years, with a mean age of 66.4 years. Preoperative knee CT and full-length lower-extremity X-ray films were performed to measure the hip-knee-ankle angle (HKA) and posterior condylar angle (PCA). During surgery, after distal femoral osteotomy, the knee was maintained at 90° of flexion, and the tibial transverse axis (line a) perpendicular to the coronal projection of the tibial mechanical axis was marked on the osteotomy surface. Following tibial osteotomy and gap balancing, the external rotation line of the femoral component (line b) was determined. The final external rotation osteotomy angle was established based on the above references, and four-in-one positioning pins were fixed according to this angle. The line connecting the positioning pins served as the known external rotation reference line (line r). Accordingly, the external rotation angles of Line a and Line b relative to the posterior condylar line of the femur (∠A, ∠B) were calculated separately. The differences among PCA, ∠A, and ∠B were compared, and the correlation between ∠A and ∠B,∠A and HKA were analyzed. In addition, the distribution of ∠A in and around the “safe zone” (between PCA and ∠B) was counted. Results Preoperative HKA was (7.3±3.7)°, and PCA, ∠A, and ∠B were (3.1±1.4)°, (4.6±2.4)°, and (4.7±2.1)°, respectively. Compared with PCA, both ∠A and ∠B demonstrated greater external rotation, with significant differences (P<0.05); no significant difference was found between ∠A and ∠B (P>0.05). Correlation analysis revealed significant correlations between ∠A and ∠B, as well as between ∠A and HKA (r=0.674, P<0.001; r=0.350, P=0.009). In 45% (25/55) of patients, ∠A was between PCA and ∠B, which was within the “safe zone”. Conclusion The transverse tibial axis at 90° of knee flexion during TKA serves as a reliable reference for determining rotational positioning of femoral prosthesis. The severity of preoperative knee varus deformity correlates with the external rotation angle defined by this transverse tibial axis, and this angle shows high consistency with that derived from the gap balancing technique.

Citation： WEI Xinlei, WEI Qiang, YANG Hao, HAO Lin, ZHANG Hui, YIN Zongsheng, LI Yetian. Application of transverse tibial axis reference method in rotational positioning of femoral prosthesis in total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(8): 1222-1227. doi: 10.7507/1002-1892.202604010 Copy

1.	Miyasaka T, Neyatani T, Omori T, et al. Posterior condylar cartilage thickness determines accuracy of femoral component rotation during total knee arthroplasty in valgus knees: Comparison with varus knees[J/OL]. J Exp Orthop, 2025, 12(4): e70486. doi: 10.1002/jeo2.70486.
2.	Le DH, Goodman SB, Maloney WJ, et al. Current modes of failure in TKA: infection, instability, and stiffness predominate[J]. Clin Orthop Relat Res, 2014, 472(7): 2197-2200.
3.	Skowronek P, Arnold M, Starke C, et al. Intra- and postoperative assessment of femoral component rotation in total knee arthroplasty: an EKA knee expert group clinical review[J]. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 772-782.
4.	Hofmann S, Tecame A, Seitlinger G, et al. Femur rotational alignment in total knee arthroplasty: Delphi consensus statements from European knee society (EKS)[J/OL]. Arch Orthop Trauma Surg, 2025, 145(1): 287. doi: 10.1007/s00402-025-05898-6.
5.	Panicker J, Thilak J. A computed tomographic evaluation of femoral and tibial rotational reference axes in total knee arthroplasty[J/OL]. SICOT J, 2023 9: 4. doi: 10.1051/sicotj/2023002.
6.	Avci ?, ?ztürk A, Akal?n Y, et al. Does the gap balance technique really elevate the joint line in total knee arthroplasty? A single-center, randomized study[J]. Jt Dis Relat Surg, 2025, 36(2): 350-357.
7.	Sheth NP, Husain A, Nelson CL. Surgical techniques for total knee arthroplasty: Measured resection, gap balancing, and hybrid[J]. J Am Acad Orthop Surg, 2017, 25(7): 499-508.
8.	趙剛領, 張曲娣, 郝非凡, 等. 測量截骨技術與間隙平衡技術對膝關節骨性關節炎全膝關節置換術后加速康復的影響[J]. 中國骨與關節損傷雜志, 2026, 41(1): 96-100.
9.	Yau WP, Chiu KY, Tang WM. How precise is the determination of rotational alignment of the femoral prosthesis in total knee arthroplasty: an in vivo study[J]. J Arthroplasty, 2007, 22(7): 1042-1048.
10.	Babazadeh S, Dowsey MM, Stoney JD, et al. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection[J]. J Arthroplasty, 2014, 29(5): 950-954.
11.	Tigani D, Sabbioni G, Ben Ayad R, et al. Comparison between two computer-assisted total knee arthroplasty: gap-balancing versus measured resection technique[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(10): 1304-1310.
12.	Lee DH, Park JH, Song DI, et al. Accuracy of soft tissue balancing in TKA: comparison between navigation-assisted gap balancing and conventional measured resection[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(3): 381-387.
13.	Neirynck J, Vanlaer L, Bobbaers D, et al. Coronal alignment in osteoarthritic knees, does it change in flexion?[J]. Acta Orthop Belg, 2020, 86(3): 440-446.
14.	McAuliffe MJ, Roe J, Garg G, et al. The varus osteoarthritic knee has no coronal contractures in 90 degrees of flexion[J]. J Knee Surg, 2017, 30(4): 297-303.
15.	Stiehl JB, Cherveny PM. Femoral rotational alignment using the tibial shaft axis in total knee arthroplasty[J]. Clin Orthop Relat Res, 1996, (331): 47-55.
16.	Luyckx T, Moreels R, Geernaert H, et al. Valgus alignment of the femoral component is associated with higher revision rates 10 years after TKA[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(10): 4171-4178.
17.	Fang C, Luan Y, Wang Z, et al. Moderate external rotation of tibial component generates more natural kinematics than internal rotation after total knee arthroplasty[J/OL]. Front Bioeng Biotechnol, 2022, 10: 910311. doi: 10.3389/fbioe.2022.910311.
18.	Pujol O, Hinarejos P, Pons A, et al. Functional alignment improves femoral joint line obliquity preservation in comparison with the classical measured resection technique[J]. Knee Surg Sports Traumatol Arthrosc, 2026, 34(6): 2121-2129.
19.	Jerosch J, Peuker E, Philipps B, et al. Interindividual reproducibility in perioperative rotational alignment of femoral components in knee prosthetic surgery using the transepicondylar axis[J]. Knee Surg Sports Traumatol Arthrosc, 2002, 10(3): 194-197.
20.	Lee JK, Lee S, Chun SH, et al. Rotational alignment of femoral component with different methods in total knee arthroplasty: a randomized, controlled trial[J/OL]. BMC Musculoskelet Disord, 2017, 18(1): 217. doi: 10.1186/s12891-017-1574-5.
21.	Yu M, Yang X, Xu Y, et al. Comparison between ligament balancing and measured resection in robot-assisted total knee arthroplasty: a 2-year follow up cohort study[J/OL]. BMC Musculoskelet Disord, 2025, 26(1): 152. doi: 10.1186/s12891-025-08388-3.
22.	Matziolis G, Boenicke H, Pfiel S, et al. The gap technique does not rotate the femur parallel to the epicondylar axis[J]. Arch Orthop Trauma Surg, 2011, 131(2): 163-166.
23.	Nikolaides AP, Kenanidis EI, Papavasiliou KA, et al. Measured resection versus gap balancing technique for femoral rotational alignment: a prospective study[J]. J Orthop Surg (Hong Kong), 2014, 22(2): 158-162.
24.	Katz MA, Beck TD, Silber JS, et al. Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques[J]. J Arthroplasty, 2001, 16(3): 301-305.
25.	Tan KG, Sathappan SS, Teo YH, et al. Alignment analyses in the varus osteoarthritic knee using computer navigation[J]. Am J Orthop (Belle Mead NJ), 2015, 44(6): 277-283.
26.	Bellemans J, Vandenneucker H, Vanlauwe J, et al. The influence of coronal plane deformity on mediolateral ligament status: an observational study in varus knees[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(2): 152-156.

1. Miyasaka T, Neyatani T, Omori T, et al. Posterior condylar cartilage thickness determines accuracy of femoral component rotation during total knee arthroplasty in valgus knees: Comparison with varus knees[J/OL]. J Exp Orthop, 2025, 12(4): e70486. doi: 10.1002/jeo2.70486.
2. Le DH, Goodman SB, Maloney WJ, et al. Current modes of failure in TKA: infection, instability, and stiffness predominate[J]. Clin Orthop Relat Res, 2014, 472(7): 2197-2200.
3. Skowronek P, Arnold M, Starke C, et al. Intra- and postoperative assessment of femoral component rotation in total knee arthroplasty: an EKA knee expert group clinical review[J]. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 772-782.
4. Hofmann S, Tecame A, Seitlinger G, et al. Femur rotational alignment in total knee arthroplasty: Delphi consensus statements from European knee society (EKS)[J/OL]. Arch Orthop Trauma Surg, 2025, 145(1): 287. doi: 10.1007/s00402-025-05898-6.
5. Panicker J, Thilak J. A computed tomographic evaluation of femoral and tibial rotational reference axes in total knee arthroplasty[J/OL]. SICOT J, 2023 9: 4. doi: 10.1051/sicotj/2023002.
6. Avci ?, ?ztürk A, Akal?n Y, et al. Does the gap balance technique really elevate the joint line in total knee arthroplasty? A single-center, randomized study[J]. Jt Dis Relat Surg, 2025, 36(2): 350-357.
7. Sheth NP, Husain A, Nelson CL. Surgical techniques for total knee arthroplasty: Measured resection, gap balancing, and hybrid[J]. J Am Acad Orthop Surg, 2017, 25(7): 499-508.
8. 趙剛領, 張曲娣, 郝非凡, 等. 測量截骨技術與間隙平衡技術對膝關節骨性關節炎全膝關節置換術后加速康復的影響[J]. 中國骨與關節損傷雜志, 2026, 41(1): 96-100.
9. Yau WP, Chiu KY, Tang WM. How precise is the determination of rotational alignment of the femoral prosthesis in total knee arthroplasty: an in vivo study[J]. J Arthroplasty, 2007, 22(7): 1042-1048.
10. Babazadeh S, Dowsey MM, Stoney JD, et al. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection[J]. J Arthroplasty, 2014, 29(5): 950-954.
11. Tigani D, Sabbioni G, Ben Ayad R, et al. Comparison between two computer-assisted total knee arthroplasty: gap-balancing versus measured resection technique[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(10): 1304-1310.
12. Lee DH, Park JH, Song DI, et al. Accuracy of soft tissue balancing in TKA: comparison between navigation-assisted gap balancing and conventional measured resection[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(3): 381-387.
13. Neirynck J, Vanlaer L, Bobbaers D, et al. Coronal alignment in osteoarthritic knees, does it change in flexion?[J]. Acta Orthop Belg, 2020, 86(3): 440-446.
14. McAuliffe MJ, Roe J, Garg G, et al. The varus osteoarthritic knee has no coronal contractures in 90 degrees of flexion[J]. J Knee Surg, 2017, 30(4): 297-303.
15. Stiehl JB, Cherveny PM. Femoral rotational alignment using the tibial shaft axis in total knee arthroplasty[J]. Clin Orthop Relat Res, 1996, (331): 47-55.
16. Luyckx T, Moreels R, Geernaert H, et al. Valgus alignment of the femoral component is associated with higher revision rates 10 years after TKA[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(10): 4171-4178.
17. Fang C, Luan Y, Wang Z, et al. Moderate external rotation of tibial component generates more natural kinematics than internal rotation after total knee arthroplasty[J/OL]. Front Bioeng Biotechnol, 2022, 10: 910311. doi: 10.3389/fbioe.2022.910311.
18. Pujol O, Hinarejos P, Pons A, et al. Functional alignment improves femoral joint line obliquity preservation in comparison with the classical measured resection technique[J]. Knee Surg Sports Traumatol Arthrosc, 2026, 34(6): 2121-2129.
19. Jerosch J, Peuker E, Philipps B, et al. Interindividual reproducibility in perioperative rotational alignment of femoral components in knee prosthetic surgery using the transepicondylar axis[J]. Knee Surg Sports Traumatol Arthrosc, 2002, 10(3): 194-197.
20. Lee JK, Lee S, Chun SH, et al. Rotational alignment of femoral component with different methods in total knee arthroplasty: a randomized, controlled trial[J/OL]. BMC Musculoskelet Disord, 2017, 18(1): 217. doi: 10.1186/s12891-017-1574-5.
21. Yu M, Yang X, Xu Y, et al. Comparison between ligament balancing and measured resection in robot-assisted total knee arthroplasty: a 2-year follow up cohort study[J/OL]. BMC Musculoskelet Disord, 2025, 26(1): 152. doi: 10.1186/s12891-025-08388-3.
22. Matziolis G, Boenicke H, Pfiel S, et al. The gap technique does not rotate the femur parallel to the epicondylar axis[J]. Arch Orthop Trauma Surg, 2011, 131(2): 163-166.
23. Nikolaides AP, Kenanidis EI, Papavasiliou KA, et al. Measured resection versus gap balancing technique for femoral rotational alignment: a prospective study[J]. J Orthop Surg (Hong Kong), 2014, 22(2): 158-162.
24. Katz MA, Beck TD, Silber JS, et al. Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques[J]. J Arthroplasty, 2001, 16(3): 301-305.
25. Tan KG, Sathappan SS, Teo YH, et al. Alignment analyses in the varus osteoarthritic knee using computer navigation[J]. Am J Orthop (Belle Mead NJ), 2015, 44(6): 277-283.
26. Bellemans J, Vandenneucker H, Vanlauwe J, et al. The influence of coronal plane deformity on mediolateral ligament status: an observational study in varus knees[J]. Knee Surg Sports Traumatol Arthrosc, 2010, 18(2): 152-156.

Chinese Journal of Reparative and Reconstructive Surgery

Application of transverse tibial axis reference method in rotational positioning of femoral prosthesis in total knee arthroplasty

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