The relationship between the midpoints connecting the tibial attachments of the anterior and posterior cruciate ligaments and the transepicondylar axis: In vivo three-dimensional measurement in the Chinese population

Tibia rotational alignment in total knee arthroplasty: Delphi consensus statements from European Knee Society (EKS)

Rotational alignment of the tibial component during total knee arthroplasty (TKA) is critical for ensuring optimal tibiofemoral and patellofemoral joint function. Proper alignment minimizes the risk of tibiofemoral mismatch and patellofemoral instability, which can lead to increased joint stress and compromised kinematics. Traditionally, the tibial tubercle axis (TTA) has been the primary landmark for alignment. However, recent insights into knee three-dimensional anatomy reveal significant variability in TTA positioning, challenging its reliability. This study employs a Delphi consensus methodology among European Knee Society (EKS) experts to address key questions regarding tibial rotational alignment in TKA. Through a systematic literature review and expert discussions, a strong consensus was achieved on three main points: (1) optimal alignment should target both the perpendicularity of the anteroposterior tibial axis to the femoral flexion/extension axis and the accurate positioning of the tibial tubercle relative to the femoral trochlea; (2) while the TTA is effective in 70% of cases, its variability in 30% of knees necessitates alternative strategies; (3) current computer-assisted and robotic technologies do not significantly enhance alignment outcomes. These findings emphasize the importance of individualized assessment of rotational deformities and highlight the potential of advanced data analytics to improve future alignment strategies. The consensus underscores the complexity of achieving optimal tibial alignment and the need for continued research to refine surgical techniques and technologies.

High variability exists in 3D leg alignment analysis, but underlying principles that might lead to agreement on a universal framework could be identified: A systematic review

PURPOSE

To (1) investigate the hypothesis that there is high variability in the reported methods to derive axes and joint orientations from three-dimensional (3D) bone models to (a) perform 3D knee-related leg alignment analysis and (b) define coordinate systems for the femur, tibia and leg and (2) identify underlying principles that might lead to agreement on a universal 3D leg alignment analysis framework.

METHODS

A systematic review of the literature between January 2006 and June 2024 was performed. Articles explicitly reporting methods to derive axes and joint orientations from CT-based 3D bone models for alignment parameters and/or coordinate systems of the femur, tibia and leg were included. Study characteristics and reported methods were extracted and presented as a qualitative synthesis.

RESULTS

A total of 93 studies were included. There was high variability in the reported methods to derive axes and joint orientations from 3D bone models. Nevertheless, the reported methods could be categorized into four groups, and several underlying principles of the four groups could be identified. Furthermore, the definitions of femoral and tibial coordinate systems were most frequently based on the mechanical axis (femoral, 13/19 [68%]; tibial, 13/26 [50%]) and a central medial-lateral axis (femoral, 16/19 [84%]; tibial, 12/26 [46%]); no leg coordinate system was reported. Interestingly, of the included studies that reported on leg alignment parameters (76/93, 82%), only a minority reported expressing these in a complete coordinate system (25/76, 33%).

CONCLUSION

There is high variability in 3D knee-related leg alignment analysis. Therefore, universal 3D reference values for alignment parameters cannot yet be defined, and comparison of alignment parameter values between different studies is impossible. However, several underlying principles to the reported methods were identified, which could serve to reach more agreement on a future universal 3D framework for leg alignment analysis.

LEVEL OF EVIDENCE

Level I (1).

The Definition of the Tibial Sagittal Plane and the Paradox of Imageless Navigation and Robotics: A Cadaveric Study

BACKGROUND

The accuracy, precision, and repeatability by which the tibial sagittal plane can be found with imageless technology is currently unknown. The purpose of this study was to identify any differences between imageless and image-based technology to define the sagittal plane of the tibia.

METHODS

A computed tomography (CT) was obtained of 18 cadavers with the knee fully extended. The surgical trans-epicondylar axis and several tibial rotation references were acquired on the CT scan. After a medial parapatellar approach, the same anatomical landmarks were acquired in vivo. In the horizontal plane, the angle between the surgical trans-epicondylar axis and the tibial rotational axes was assessed.

RESULTS

Highest accuracy was found for posterior cruciate ligament (PCL)-anterior cruciate ligament (ACL, -1.48°, standard deviation [SD] 13.64; imageless), tibial medial condyle (TMC)-tibial lateral condyle (TLC, 1.72°, SD 4.24; image-based), the ACL-medial border of tibial tuberosity (MTT, -2.89°, SD 18.86; image-based). Highest precision was acquired with image-based technology: TMC-TLC (SD 4.24), PCL-ACL (SD 5.86), and PCL-medial third of tibial tuberosity (M3TT, SD 7.10). Excellent intraobserver and interobserver correlation coefficients were observed with image-based technology: PCL-MTT, anterior medial condyle (AMC)-anterior lateral condyle (ALC), and TMC-TLC (Intraobserver and interobserver correlation coefficients 0.90-0.98).

CONCLUSION

The tibial sagittal plane could be defined with highest accuracy, precision, and repeatability on a preoperative CT. Imageless methodology lacked the precision and repeatability of image-based technology. With the current pursuit of high accuracy and precision in total knee arthroplasty, the reference frame used to quantify implant position should be highly accurate and precise as well.

LEVEL OF EVIDENCE

IV, Case Series.

A New Reference Axis for Tibial Component Rotation in Total Knee Arthroplasty: A Three-dimensional Computed Tomography Analysis

The purpose of this study was to introduce a new reference axis for tibial rotation in total knee arthroplasty (TKA) and verify its reliability. A consecutive series of 80 knees that underwent TKA from 2018 to 2020 as well as 80 healthy knees were analyzed using a three-dimensional tibial model. A coordinate system was established based on the standard TKA tibial cut. The line connecting the lateral-tibial eminence and the medial 1/3rd of the tibial tubercle or the medial border of the tibial tubercle was identified as the lateral eminence line (LE line) and the medial lateral eminence line (MLE line), respectively. To evaluate the reliability of the new reference axis, Akagi's line, the medial third of the tibial tubercle (1/3 line) was compared with the LE and MLE lines by measuring the angle between the lines and the Z-axis. In the coronal view, the intersection angle (TPA), which is composed of the line connecting the center of the medial and lateral tibial plateau with the Z-axis, was measured. The mean angle between Akagi's line and the Z-axis in the healthy group and the osteoarthritis (OA) group was 87.57 ± 3.48° and 87.61 ± 3.47°, respectively. The mean angle between the LE line and Z-axis in the healthy and OA groups was 87.15 ± 4.13° and 86.78 ± 3.95°, respectively. A weak correlation was found between the TPA and Akagi's line and the 1/3 line. A moderate correlation was observed between the TPA and LE lines. There were no significant differences between the healthy and OA groups (P > 0.05) in any of the four reference axes. The LE line showed excellent intra- and inter-observer reliability and reproducibility. The novel and easily drawn LE line is a preferable option for tibial component rotational alignment in TKA.

Three-point Method to Guide the Tibial Resection and Component Placing in Total Knee Arthroplasty

Objective

To introduce a three‐point method combining the midpoint of the posterior cruciate ligament (PCL), the midsulcus of the tibial spines, and the midpoint of the anterior cruciate ligament (ACL) to determine appropriate tibial resection and component placing during TKA and to compare this method with Insall's 1/3 method.

Methods

A consecutive series of 128 knees that underwent TKA from January 2015 to August 2018 were analyzed. In one group (64 knees), the medial 1/3 of tibial tubercle (the Insall's traditional method) was used for tibial component alignment. In the other group (64 knees), the three‐point line connecting the midpoint of the PCL, the midpoint of the tibial spines, and the midpoint of the ACL was used for tibial component alignment. Both groups used the anterior tibial tendon as the distal reference for tibial resection. The coronal alignment error of the tibial component was determined by the angle between the line parallel to the tibial component platform and the tibial mechanical axis measured on postoperative radiograph. The axial rotation error of the femoral or tibial component was the intersection angle between the transepicondylar axis (TEA) and a line tangent to the posterior edge of the femoral or tibial component measured on CT. The coronal and axial alignment errors were compared between the two groups.

Results

The average coronal alignment error of the tibial component in the three‐point method group was 0.2° ± 1.4° versus − 0.9° ± 1.8°in the Insall's 1/3 method group (P < 0.001), and the mean absolute value in the three‐point method group reduced by 37.3% compared to Insall's traditional method group. The average axial rotation error of the femoral component was 0.2° ± 1.2° in the three‐point method group versus − 1.1° ± 1.7° in the Insall's 1/3 method group (P < 0.001), and the mean absolute value in three‐point method group decreased by 43.9% compared to Insall's traditional method group. The average axial rotation error of the tibial component was 0.4° ± 1.4° versus − 1.4° ± 1.8° in the Insall's 1/3 method group (P < 0.001), and the mean absolute value in the three‐point method group reduced by 35.5% compared to the Insall's traditional method group. The rates of rotation outliers were significantly lower in the three‐point method group (P < 0.05).

Conclusion

The line connecting the midpoint of the PCL, the midsulcus of the tibial spines, and the midpoint of the ACL could be used as the reference for the tibial resection and component placing. This method appears to be more accurate than Insall's 1/3 method. The results of this study provide a candidate method for component orientation with little error.

Popliteal neurovascular bundle is safe during inside-out repair of medial meniscus without a safety incision

PURPOSE

There is a theoretical risk of injury to neurovascular structures during inside-out meniscal repair without a safety incision, although there are limited studies assessing this risk. This simulation study on archival MRI films was performed to assess the risk for the popliteal neurovascular bundle and the peroneal nerve during passage of needles for inside-out meniscus repair without a "safety incision", thereby defining a "safe zone" of the menisci that can be safely repaired using this technique.

METHODS

Archival MRI scans (n = 50) were retrieved and axial sections through the menisci were used for simulation. The needle passage was simulated for different points on the posterior horn and body of lateral and medial menisci at "half-hour" intervals using clock method (15° intervals) with three different portals and two different needle cannulas, resulting in six different scenarios of needle passage for each point on the meniscus. The distance of the needle in each scenario was measured from popliteal vessels (n = 50) and peroneal nerve (n = 10). The value "mean-3SD" was calculated for positive means and "Mean + 3SD" was calculated if the mean was negative. An additional 2 mm was defined as "safe distance". Thus, simulation models in which the mean - 3SD was less than 2 mm (or mean + 3SD was greater than - 2 mm for negative means) were labelled as "unsafe".

RESULTS

Needle passage through medial meniscus at and medial to 1 o'clock position for a right knee (or 11 o'clock position for a left knee) was safe, irrespective of the portal and needle type. For the lateral meniscus, only the equatorial region was found to be safe with this method.

CONCLUSIONS

The popliteal neurovascular bundle is safe during the inside-out medial meniscal repair without a safety incision. For the terminal-most part of the posterior horn, the AM portal and the straight cannula should be avoided. However, this method without safety incision cannot be recommended for lateral meniscus because of the risk to the popliteal vessels and the peroneal nerve. Instead, the inside-out method with a safety incision, or an all-inside method should be used for lateral meniscus.

LEVEL OF EVIDENCE

III.