Intra‑ and postoperative assessment of femoral component rotation in total knee arthroplasty: an EKA knee expert group clinical review

Purpose Malrotation of the femoral component after primary total knee arthroplasty (TKA) is one of the most important problems leading to painful TKA requiring revision surgery. Methods A comprehensive systematic review of the literature was performed to present current evidence on how to optimally place the femoral component in TKA. Several landmarks and techniques for intraoperative determination of femoral component placement and examination of their reliability were analyzed. Results 2806 articles were identifed and 21 met the inclusion criteria. As there is no unquestioned gold standard, numerous approaches are possible which come along with specifc advantages and disadvantages. In addition, imaging modalities and measurements regarding postoperative femoral component rotation were also investigated. Femoral component rotation measurements on three-dimensional (3D) reconstructed computerised tomography (CT) images displayed intraclass correlation coefcients (ICC) above 0.85, signifcantly better than those performed in radiographics or two-dimensional (2D) CT images. Thus, 3D CT images to accurately evaluate the femoral prosthetic component rotation are recommended, especially in unsatisfed patients after TKA. Conclusion The EKA Femoral Rotation Focus Group has not identifed a single best reference method to determine femoral component rotation, but surgeons mostly prefer the measured resection technique using at least two landmarks for crosschecking the rotation. Level of evidence III

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