Background Computer navigation has improved accuracy and reduced the percentage of alignment outliers in TKA. However, the characteristics of outliers and the risk factors for limb malalignment after TKA are still unclear. Questions/Purposes We therefore addressed the following questions: (1) What is the incidence and characteristics of outliers for postoperative limb mechanical axis (hip-knee-ankle [HKA] angle outside the conventional 180°± 3°range) and component alignment in TKA? And (2) what are the preoperative clinical or radiographic risk factors for limb mechanical axis malalignment in TKA? Methods We retrospectively reviewed the clinical and radiographic records of 1500 computer-assisted TKAs to identify outliers for postoperative HKA axis and component alignment and determined risk factors for malalignment. Full-length hip-to-ankle and knee radiographs were used to measure preoperative HKA angle, femoral coronal bowing, joint divergence angle, tibial subluxation, and tibial bone loss and postoperative HKA angle and femoral and tibial component angle. Results The incidence of outliers for postoperative limb mechanical axis, femoral component alignment, and tibial component alignment was 7% (112 of 1500 TKAs), 7%, and 8%, respectively, with 70% of limbs placed in excessive varus and 30% in excessive valgus. Preoperative varus deformity of more than 20°and femoral bowing of more than 5°were associated with increased risk of placing the limb mechanical axis outside the acceptable ± 3°range after computer-assisted TKA. Conclusions The presence of preoperative radiographic risk factors should alert the surgeon to increased chance of malalignment and every measure should be undertaken in such at-risk knees to ensure proper limb and component alignment and soft tissue balance.

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We retrospectively reviewed the records of 1150 computer-assisted total knee replacements and analysed the clinical and radiological outcomes of 45 knees that had arthritis with a pre-operative recurvatum deformity. The mean pre-operative hyperextension deformity of 11° (6° to 15°), as measured by navigation at the start of the operation, improved to a mean flexion deformity of 3.1° (0° to 7°) post-operatively. A total of 41 knees (91%) were managed using inserts ≤ 12.5 mm thick, and none had mediolateral laxity > 2 mm from a mechanical axis of 0° at the end of the surgery. At a mean follow-up of 26.4 months (13 to 48) there was significant improvement in the mean Knee Society, Oxford knee and Western Ontario and McMaster Universities Osteoarthritis Index scores compared with the pre-operative values. The mean knee flexion improved from 105° (80° to 125°) pre-operatively to 131° (120° to 145°), and none of the limbs had recurrent recurvatum. These early results show that total knee replacement using computer navigation and an algorithmic approach for arthritic knees with a recurvatum deformity can give excellent radiological and functional outcomes without recurrent deformity.

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