No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty

  • Roland Becker
  • Katharina Bäker
  • Hagen Hommel
  • Manfred Bernard
  • Sebastian Kopf



It was hypothesized that malrotation of femoral component in total knee arthroplasty (TKA) will significantly impact clinical outcome.


Eighty-eight consecutive patients with primary osteoarthritis of the knee were prospectively evaluated. They received a cemented posterior stabilized TKA (NexGen, Zimmer/Biomet® Inc., Warsaw, IN, USA). The femoral component was placed in 3° of external rotation referenced to the posterior condylar line. Postoperatively, a CT scan was performed to evaluate rotation of femoral component in the transverse plane. SF-36, KSS, and WOMAC, as well as their range of motion was assessed prior to surgery, after 6 and 24 months. Data are presented as mean and standard deviation (SD), as well as range if applicable. Correlation analysis was performed between the placement of the femoral component in the transverse plane and the clinical outcome.


Femoral component placement was on average 0.1° [SD 2.5°, range − 6.5° to + 6.5°] referenced to the surgical transepicondylar line showing a wide range between the two landmarks after surgery. After 6 months, WOMAC category ‘physical function’ correlated significantly with femoral component rotation (r = − 0.28, p = 0.007). After 24 months, WOMAC categories ‘physical function’ and ‘pain’ correlated significantly with femoral rotation (r = − 0.41, p < 0.001; and r = − 0.33, p = 0.001). No significant correlations were found between femoral component rotation and range of motion (r = 0.04), WOMAC category “stiffness”, KSS, as well as SF-36 questionnaires. These reported formally significant correlations were without any clinical relevance.


The study showed that there is a significant patients specific femoral component placement in the transverse plane. Internal or external malrotation of the femoral component does not correlate automatically with poor knee function. The lack of correlation between femoral component position and clinical as well as functional outcome underlines complexity and significant individuality of each patient. The surgeon should be aware of the finding and attention should be paid during surgery when significant divergency is seen between the two landmarks. Soft tissue balancing might be very crucial in these specific patients, which needs to be studied in depth in the future.

Level of evidence



Femoral component placement Rotation Clinical outcome Total knee arthroplasty Total knee replacement TKA Observational study 



There was no funding.

Compliance with ethical standards

Conflict of interest

I have no potential conflict of interest.

Ethical standard

The study was approved by the ethical committee of the Medical Council of Brandenburg, Germany (AS 67(bB)/2014).


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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Roland Becker
    • 1
  • Katharina Bäker
    • 2
  • Hagen Hommel
    • 3
  • Manfred Bernard
    • 4
  • Sebastian Kopf
    • 1
  1. 1.Department of Orthopaedics and TraumatologyBrandenburg Medical Scholl Theodor FontaneBrandenburgGermany
  2. 2.Department of TraumatolgyHelios HospitalBurg bei MagdeburgGermany
  3. 3.Department of OrthopaedicsHospital-MOL GmBHWriezenGermany
  4. 4.Hospital Sanssouci PotsdamPotsdamGermany

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