title: Effects of tibial torsion on distal alignment of extramedullary instrumentation in total knee arthroplasty.
abstract: OBJECTIVE
  Whether tibial torsion affects the positioning of extramedullary instrumentation and is a possible factor in malalignment of the tibial component in total knee arthroplasty (TKA) is unknown. We assessed the influence of tibial torsion on distal alignment of extramedullary systems for TKA, using the center of the intermalleolar distance as anatomical reference at the ankle joint.
  
  
  METHODS
  We analyzed CT scans of knee and ankle joints of 50 patients with knee osteoarthritis (mean age 73 years, 52 legs). The tibial mechanical axis was identified and translated anteriorly at the level of the medial one-third (proximal AP axis 1), at the medial border of the tibial tuberosity (proximal AP axis 2), and at the level of the talar dome (distal AP axis). The center of the intermalleolar distance and the width of the medial and lateral malleolus were calculated. The proximal AP axes 1 and 2 were translated at the level of the ankle joint and any difference between their alignment and the distal AP axis was calculated as angular and linear values.
  
  
  RESULTS
  The center of the ankle joint was located, on average 2 mm medial to that of the intermalleolar distance. The distal AP axis was externally rotated by 18° and 27° compared to the proximal AP axes 1 and 2, respectively. Overall, the center of the ankle joint was shifted laterally by 9-11 mm with respect to the proximal AP tibial axes.
  
  
  CONCLUSIONS
  To avoid a varus tibial cut in TKA, extramedullary alignment systems should be aligned more medially at the ankle joint than previously thought, due to the effect of tibial torsion and-to a lesser extent-to the different malleolar width.
authors.affiliation: Department of Anatomy, Histology, Medico Legal and Orthopaedic Science, University La Sapienza, Rome, Italy. md3581@mclink.it
authors.forename: Gianluca
authors.initials: G
authors.lastname: Cinotti
authors.forename: Pasquale
authors.initials: P
authors.lastname: Sessa
authors.forename: Antonello Della
authors.initials: AD
authors.lastname: Rocca
authors.forename: Francesca Romana
authors.initials: FR
authors.lastname: Ripani
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Giannicola
mesh_terms: D000328:Adult; D000368:Aged; D000843:Ankle Joint / Q000000981:diagnostic imaging / Q000473:pathology; D019645:Arthroplasty, Replacement, Knee / Q000295:instrumentation* / Q000379:methods; D005260:Female; D006801:Humans; D007719:Knee Joint / Q000000981:diagnostic imaging / Q000473:pathology; D007720:Knee Prosthesis; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000150:complications / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D014057:Tomography, X-Ray Computed / Q000379:methods; D014102:Torsion Abnormality / Q000150:complications / Q000000981:diagnostic imaging* / Q000473:pathology