Surgical Transepicondylar Axis Is Not a Reliable Reference when there Was Lateral Femoral Bowing

Abstract

Objective: The surgical transepicondylar axis (sTEA) is believed to be a consistent reference for femoral rotation axis, and the reliability of its orientation seriously affects the accuracy and outcome of total knee arthroplasty (TKA). This study was designed to investigate the relationship between the orientation of sTEA and femoral bowing angle (FBA) and posterior condylar line (PCL) using three-dimensional (3D) computed tomography (CT) reconstruction models to verify its reliability.

Methods: This study retrospectively collected lower extremity images of 443 southern Chinese osteoarthritic patients (347 women, 96 men; 234 left, 209 right; mean age 66.5 ± 9.3 years) from August 2016 to June 2018. The hip-knee-ankle angle (HKA) was measured on anteroposterior weight-bearing full lower extremity standing radiographs. Measurements on 3D CT models of the femurs included lateral angle between the femoral mechanical axis and sTEA coronal angle, angle between sTEA and distal joint line (distal condylar axis angle, DCA); angle between sTEA and PCL (sTEA axial angle); angle between anatomical axis of proximal femur and anatomical axis of distal femur in the plane they form (actual FBA) and its projection on the coronal (lateral FBA) and sagittal (anterior FBA) planes. The correlations between sTEA coronal angle, sTEA axial angle and actual FBA, lateral FBA, anterior FBA, HKA, DCA were explored using the Spearman correlation test.

Results: The mean value of actual FBA is (14.4 ± 3.6)°, of lateral FBA is (6.0 ± 4.0)°, and of anterior FBA is (12.7 ± 3.0)°. The mean value of sTEA coronal angle is (88.7 ± 3.6)°, of sTEA axial angle is (2.1 ± 2.8)°. The sTEA coronal angle was positively correlated with actual FBA (r = 0.320, P < 0.01), lateral FBA (r = 0.448, P < 0.01), anterior FBA (r = 0.113, P < 0.05), HKA (r = 0.482, P < 0.01) and DCA (r = 0.486, P < 0.01). The sTEA axial angle was positively correlated with DCA (r = 0.168, P < 0.01), but not significantly correlated with all FBAs and HKA (NS).

Conclusion: The sTEA cannot be used as a stable reference when there was an obvious femoral bowing deformity. As the lateral femoral bowing increases, the orientation of sTEA becomes more varus, no matter the knee is varus or valgus.

Keywords: Computed tomography; Femoral bowing angle; Knee; Surgical transepicondylar axis; Total knee arthroplasty.