Title:
Mismatch between femur and tibia coronal alignment in the knee joint: classification of five lower limb types according to femoral and tibial mechanical alignment.

Abstract:
Reasons for dissatisfaction with total knee arthroplasty (TKA) include unequal flexion or extension gap, soft tissue imbalance, and patella maltracking, which often occur with mismatch between femoral and tibial coronal bony alignment in the knee joint or extremely varus or valgus alignment. However, lower limb coronal alignment classification is based only on hip-knee-ankle angle (HKAA), leading to oversight regarding a mismatch between femoral and tibial coronal alignment. We aimed to classify alignment of the lower limbs according to the mechanical alignment of the femur and tibia in a healthy population.
All 214 normal triple films were reviewed retrospectively. HKAA, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), angle between the femoral anatomical axis and the mechanical axis (AA-MA), and knee alignment angle (KAA) were measured. Subjects were categorized into one of five types based on the mechanical alignment of femur and tibia.
Mean HKAA, mLDFA, and mMPTA of all subjects were 1.2°, 87.3°, and 85.8°, respectively. All subjects were classified into one of five types with significant differences (p < 0.001). About 61% of subjects showed neutral alignment, of which nearly 40% were type 2 (valgus of the femur and varus of the tibia with oblique joint line: mLDFA 85.0° ± 1.4°, mMPTA 85.1° ± 1.2°, TJLA 2.7° ± 2.4°) and 60% exhibited neutral alignment with a neutral femur and tibia (type 1). In varus and valgus types, mismatch between the mechanical angle of the femur and tibia was common. Varus alignment, including types 3 (varus of the tibia: mLDFA 88.0° ± 1.4°, mMPTA 83.5° ± 1.6°) and 4 (varus of both the tibia and femur: mLDFA 91.4° ± 1.4°, mMTPA 85.2° ± 2.0°), was found in 30% of subjects. Valgus alignment (type 5 valgus of femur: mLDFA 84.6° ± 1.6°, mMPTA 88.8° ± 2.0°) accounted for 8.9% of all subjects.
Mismatch between mechanical alignment of the femur and tibia was common in varus and valgus alignment types. Joint line obliquity was also observed in 40% of the neutral alignment population. This classification provides a quick, simple interpretation of femoral and tibial coronal alignment, and more detailed guidance for preoperative planning for TKA than the traditional varus-neutral-valgus classification.