Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 2, pp 249–254 | Cite as

Suboptimal patellofemoral alignment is associated with poor clinical outcome scores after primary total knee arthroplasty

  • Rapeepat Narkbunnam
  • Ali J. Electricwala
  • James I. HuddlestonIII
  • William J. Maloney
  • Stuart B. Goodman
  • Derek F. AmanatullahEmail author
Knee Arthroplasty



Proper patellofemoral alignment is an important goal in total knee arthroplasty (TKA). Acceptable patellar alignment is defined as patellar tilt less than or equal to 5° and patellar displacement less than or equal to 5 mm. Previous studies reported an incidence of post-operative patellar malalignment in TKA from 7 to 35%. However, correlation between patellar malalignment and clinical outcome after TKA remains unclear. The purpose of the present study was to evaluate the effect of patellar tilt and displacement on the clinical outcome of TKA.


A retrospective review of 138 primary TKAs with a minimum of 2 year follow-up is reported. Pre-operative and post-operative mechanical axis, patellar tilting angle and patellar displacement were measured. Clinical outcomes were evaluated by the knee functional scores including the Knee Society Score (KSS), Knee injury and Osteoarthritis Outcome Score (KOOS), and Western Ontario McMaster University Osteoarthritis Index (WOMAC) at final follow-up.


Forty-two (30%) primary TKAs had suboptimal patellofemoral alignment with a patellar tilt angle greater than 5° or lateral patellar displacement of more than 5 mm. There was no statistical difference in pre-operative mechanical axis, pre-operative patellar tilt angle, or pre-operative lateral patellar displacement between the primary TKAs with proper patellofemoral alignment and those with suboptimal alignment. Patients with post-operative patellar tilt or displacement had clinically significant reductions in KSS, KOOS, and WOMAC when compared with patients without post-operative patellar tilt or displacement. The odds of having a fair or poor post-operative result, an odds ratio of 3.4 (95% CI 1.6–7.2) for KSS, 6.4 (95% CI 2.9–14.2) for KOOS, and 5.9 (95% CI 2.6–13.5) for WOMAC, were associated with suboptimal patellofemoral alignment.


Establishing proper patellofemoral alignment remains an essential goal of primary TKA. There is a strong association between suboptimal post-operative patellofemoral alignment and poor clinical outcome scores after primary TKA.


Patellofemoral alignment Total knee arthroplasty Patellar tilting Patellar displacement 


Compliance with ethical standards

Ethics approval

Ethics committee approvals were obtained.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Rapeepat Narkbunnam
    • 1
  • Ali J. Electricwala
    • 2
  • James I. HuddlestonIII
    • 3
  • William J. Maloney
    • 3
  • Stuart B. Goodman
    • 3
  • Derek F. Amanatullah
    • 3
    Email author
  1. 1.Siriraj HospitalMahidol UniversityBangkokThailand
  2. 2.Sancheti Institute of Orthopaedics and RehabilitationPuneIndia
  3. 3.Stanford University Medical Center Outpatient CenterRedwood CityUSA

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