# Coronal Alignment Does Not Adequately Predict Femoral Rotation Axes in Total Knee Arthroplasty: Application of a 3D Image-Based Robotic-Assisted Arthroplasty Platform

## TL;DR

This study shows that coronal limb alignment cannot reliably predict femoral rotation in knee replacement surgery, emphasizing the need for direct assessment of rotational landmarks.

## Contribution

The study demonstrates that coronal alignment does not predict femoral rotation axes, challenging current surgical assumptions.

## Key findings

- There was significant variation in femoral rotation axes between patients.
- No significant relationship was found between coronal alignment and femoral rotation axes variation.
- Valgus and varus groups showed similar mean external rotation of the sTEA relative to the PCAxis.

## Abstract

(1) Introduction: Precise femoral component rotation is critical for achieving symmetric flexion-gap balance and physiologic patellofemoral tracking in mechanically aligned total knee arthroplasty (TKA). Surgeons often infer an appropriate rotational target from the patient’s coronal limb alignment, yet the strength of this relationship remains uncertain. (2) Methods: We identified 695 consecutive patients undergoing primary TKA with a preoperative planning CT scan. The surgical transepicondylar axis (sTEA) and posterior condylar axis (PCAxis) were identified and the angle between them was measured. The angle between the mechanical axis of the femur and tibia was used to measure the coronal alignment of the limb. (3) Results: The mean sTEA was 3.0° externally rotated to the PCAxis (range 3.1° internal to 9.2° external). The mean coronal alignment was 4.3° varus (range −12.5° valgus to 24.5° varus). There were 465 patients with >2° varus and 101 patients with >2° valgus. The mean sTEA was 2.9 ± 1.9° externally rotated relative to the PCAxis in the valgus group and 2.8 ± 2.0° in the varus group, with no statistically significant difference (p = 0.7). (4) Conclusions: There is significant variation in the femoral rotation axes between patients, but no significant relationship between overall limb coronal alignment and the magnitude of femoral rotation axes variation. This reinforces the need for independent assessment of rotational landmarks when performing mechanically aligned TKA.