Validation and modification of the Coronal Plane Alignment of the Knee classification in the Asian population

Cheng-En Hsu; Chao-Ping Chen; Shun-Ping Wang; Jen-Ting Huang; Kwok-Man Tong; Kui-Chou Huang

doi:10.1302/2633-1462.33.BJO-2022-0001.R1

Validation and modification of the Coronal Plane Alignment of the Knee classification in the Asian population

Bone Jt Open. 2022 Mar;3(3):211-217. doi: 10.1302/2633-1462.33.BJO-2022-0001.R1.

Authors

Cheng-En Hsu^{1

2}, Chao-Ping Chen^{2

3}, Shun-Ping Wang^{1

2}, Jen-Ting Huang^{4

5}, Kwok-Man Tong^{4

5}, Kui-Chou Huang^{4

5}

Affiliations

¹ Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, Taiwan.
² Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan.
³ Course Database of General Education TW, Chaoyang University of Technology, Taichung, Taiwan.
⁴ Department of Orthopedics, Asia University Hospital, Taichung, Taiwan.
⁵ Department of Occupational Therapy, Asia University, Taichung, Taiwan.

PMID: 35274982
PMCID: PMC8965787
DOI: 10.1302/2633-1462.33.BJO-2022-0001.R1

Abstract

Aims: The Coronal Plane Alignment of the Knee (CPAK) classification is a simple and comprehensive system for predicting pre-arthritic knee alignment. However, when the CPAK classification is applied in the Asian population, which is characterized by more varus and wider distribution in lower limb alignment, modifications in the boundaries of arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO) should be considered. The purposes of this study were as follows: first, to propose a modified CPAK classification based on the actual joint line obliquity (aJLO) and wider range of aHKA in the Asian population; second, to test this classification in a cohort of Asians with healthy knees; third, to propose individualized alignment targets for different CPAK types in kinematically aligned (KA) total knee arthroplasty (TKA).

Methods: The CPAK classification was modified by changing the neutral boundaries of aHKA to 0° ± 3° and using aJLO as a new variable. Radiological analysis of 214 healthy knees in 214 Asian individuals was used to assess the distribution and mean value of alignment angles of each phenotype among different classifications based on the coronal plane. Individualized alignment targets were set according to the mean lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA) of different knee types.

Results: A very high concentration, 191 from 214 individuals (89.3%), were found in knee types with apex distal JLO when the CPAK classification was applied in the Asian population. By using aJLO as a new variable, the high distribution percentage in knee types with apex distal JLO decreased to 125 from 214 individuals (58.4%). The most common types in order were Type II (n = 70; 32.7%), Type V (n = 55; 25.7%), and Type I (n = 46; 21.5%) in the modified CPAK classification.

Conclusion: The modified CPAK classification corrected the uneven distribution when applying the CPAK classification in the Asian population. Setting individualized TKA alignment targets according to CPAK type may be a practical method to recreate optimal LDFA and MPTA in KA-TKA. Cite this article: Bone Jt Open 2022;3(3):211-217.

Keywords: CPAK classification; Kinematic alignment; Kinematically aligned; Phenotype of the knee; Total knee arthroplasty; Total knee replacement; arthritic knee; distal femur; hip-knee-ankle angle; joint line obliquity; knees; lateral distal femoral angle; limb alignment; medial proximal tibial angle; total knee arthroplasty (TKA); varus deformity.