The tibial cut in total knee arthroplasty influences the varus alignment, the femoral roll-back and the tibiofemoral rotation in patients with constitutional varus



Different alignment types for a better outcome after TKA were described. However, it is not clear how kinematic alignment influences knee joint kinematic. The purpose of this study was to analyze whether adapted tibial cuts in constitutional varus knees affect knee joint kinematics regarding femoral roll-back, varus/valgus angle, and femorotibial rotation.


Seven cadaveric knees with constitutional varus alignment were examined in the native state and after implantation of a cruciate retaining (CR)-TKA with 0°, 3° and 6° tibia cuts using an established knee joint simulator. The effects of varus alignment on femorotibial rollback and rotation was determined. In addition, the native knee joint and different tibial cuts in CR-TKA were compared with Student’s t test.


Total knee replacement with a 3° and 6° varus tibia cut had the greatest varus deviation to the native knee (mean 1.6° ± 0.09°, respectively); while, knees with a 0° (mean 0.2° ± 0.01°) tibia cut were most similar to the constitutional varus knee joint. The femoral roll-back in the medial compartment was increased in the native knee (5.7–12.5 mm). A 6° varus cut had a restricted translation in the medial compartment (2–3.2 mm). In the lateral compartment, the extensive translation was observed with a 0° varus cut, followed by 3° and 6° and the native knee. All cuts showed significantly different mean values. Only the cuts at 3° and at 6° in the medial compartment and the cuts at 0° and at 3° in the lateral compartment did not differ significantly. In respect to tibiofemoral rotation, 0° and 3° varus cuts across all loads had the least difference to the native knee (3.4°), with a 0° varus cut showing a higher absolute internal rotation of the tibia than the native knee. Changes in knee kinematics of the tibiofemoral rotation showed significantly different mean values.


The potentially improved outcome parameters in TKA with adapted tibia cuts in constitutional varus knees cannot be completely explained by the changes to knee kinematics. Mechanical alignment seems to result in more balanced load distribution and kinematics more closely resembling the native knee. From a kinematic point of view, it is not recommended to place the tibia in more than 3° of varus.

Level of evidence

Biomechanical study.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3.
Fig. 4
Fig. 5
Fig. 6


  1. 1.

    Bellemans J, Colyn W, Vandenneucker H, Victor J (2012) Is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 470:45–53

    Article  Google Scholar 

  2. 2.

    Belvedere C, Tamarri S, Ensini A (2015) Better joint motion and muscle activity are achieved using kinematic alignment than neutral mechanical alignment in total knee replacement. Gait posture 42:S19–20

    Article  Google Scholar 

  3. 3.

    Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM, Redelman R et al (2004) The Chetranjan Ranawat Award: tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res 428:26–34

    Article  Google Scholar 

  4. 4.

    Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M (2017) PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 25:1743–1748

    Article  Google Scholar 

  5. 5.

    Dossett HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG (2014) A randomised controlled trial of kinematically and mechanically aligned total knee replacements: 2-year clinical results. Bone Joint J 96-b:907–913

    CAS  Article  Google Scholar 

  6. 6.

    Dossett HG, Swartz GJ, Estrada NA, LeFevre GW, Kwasman BG (2012) Kinematically versus mechanically aligned total knee arthroplasty. Orthopedics 35:e160–169

    PubMed  Google Scholar 

  7. 7.

    Ghomrawi HM, Mancuso CA, Dunning A, Gonzalez Della Valle A, Alexiades M, Cornell C et al (2017) Do surgeon expectations predict clinically important improvements in WOMAC Scores After THA and TKA? Clin Orthop Relat Res.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Hatfield GL, Hubley-Kozey CL, Astephen Wilson JL, Dunbar MJ (2011) The effect of total knee arthroplasty on knee joint kinematics and kinetics during gait. J Arthroplasty 26:309–318

    Article  Google Scholar 

  9. 9.

    Hirschmann MT, Hess S, Behrend H, Amsler F, Leclercq V, Moser LB (2019) Phenotyping of hip–knee–ankle angle in young non-osteoarthritic knees provides better understanding of native alignment variability. Knee Surg Sports Traumatol Arthrosc.

    Article  PubMed  Google Scholar 

  10. 10.

    Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclercq V, Hess S (2019) Phenotyping the knee in young non-osteoarthritic knees shows a wide distribution of femoral and tibial coronal alignment. Knee Surg Sports Traumatol Arthrosc.

    Article  PubMed  Google Scholar 

  11. 11.

    Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclerq V, Hess S (2019) Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non-osteoarthritic patients. Knee Surg Sports Traumatol Arthrosc.

    Article  PubMed  Google Scholar 

  12. 12.

    Howell SM, Papadopoulos S, Kuznik KT, Hull ML (2013) Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc 21:2271–2280

    Article  Google Scholar 

  13. 13.

    Insall JN, Binazzi R, Soudry M, Mestriner LA (1985) Total knee arthroplasty. Clin Orthop Relat Res 192:13–22

    Google Scholar 

  14. 14.

    Ishikawa M, Kuriyama S, Ito H, Furu M, Nakamura S, Matsuda S (2015) Kinematic alignment produces near-normal knee motion but increases contact stress after total knee arthroplasty: a case study on a single implant design. Knee 22:206–212

    Article  Google Scholar 

  15. 15.

    Ji HM, Han J, Jin DS, Seo H, Won YY (2016) Kinematically aligned TKA can align knee joint line to horizontal. Knee Surg Sports Traumatol Arthrosc 24:2436–2441

    Article  Google Scholar 

  16. 16.

    Johal P, Williams A, Wragg P, Hunt D, Gedroyc W (2005) Tibio-femoral movement in the living knee. A study of weight bearing and non-weight bearing knee kinematics using 'interventional' MRI. J Biomech 38:269–276

    CAS  Article  Google Scholar 

  17. 17.

    Lange T, Schmitt J, Kopkow C, Rataj E, Gunther KP, Lutzner J (2017) What do patients expect from total knee arthroplasty? A Delphi consensus study on patient treatment goals. J Arthroplasty 32:2093–2099.e2091

    Article  Google Scholar 

  18. 18.

    Lee YS, Howell SM, Won YY, Lee OS, Lee SH, Vahedi H et al (2017) Kinematic alignment is a possible alternative to mechanical alignment in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25(11):3467–3479

    Article  Google Scholar 

  19. 19.

    Magnussen RA, Weppe F, Demey G, Servien E, Lustig S (2011) Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res 469:3443–3450

    Article  Google Scholar 

  20. 20.

    Matsumoto T, Takayama K, Ishida K, Hayashi S, Hashimoto S, Kuroda R (2017) Radiological and clinical comparison of kinematically versus mechanically aligned total knee arthroplasty. Bone Joint J 99-b:640–646

    CAS  Article  Google Scholar 

  21. 21.

    McEwen PJ, Dlaska CE, Jovanovic IA, Doma K, Brandon BJ (2020) Computer-assisted kinematic and mechanical axis total knee arthroplasty: a prospective randomized controlled trial of bilateral simultaneous surgery. J Arthroplasty 35:443–450

    Article  Google Scholar 

  22. 22.

    Morgan SS, Bonshahi A, Pradhan N, Gregory A, Gambhir A, Porter ML (2008) The influence of postoperative coronal alignment on revision surgery in total knee arthroplasty. Int Orthop 32:639–642

    Article  Google Scholar 

  23. 23.

    Niki Y, Nagura T, Kobayashi S, Udagawa K, Harato K (2020) Who will benefit from kinematically aligned total knee arthroplasty? Perspectives on patient-reported outcome measures. J Arthroplasty 35(438–442):e432

    Google Scholar 

  24. 24.

    Parratte S, Pagnano MW, Trousdale RT, Berry DJ (2010) Effect of postoperative mechanical axis alignment on the 15-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am 92:2143–2149

    Article  Google Scholar 

  25. 25.

    Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA (2011) The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am 93:1588–1596

    Article  Google Scholar 

  26. 26.

    Riviere C, Iranpour F, Auvinet E, Howell S, Vendittoli PA, Cobb J et al (2017) Alignment options for total knee arthroplasty: a systematic review. Orthop Traumatol Surg Res 103:1047–1056

    CAS  Article  Google Scholar 

  27. 27.

    Shelton TJ, Gill M, Athwal G, Howell SM, Hull ML (2019) Outcomes in patients with a calipered kinematically aligned TKA that already had a contralateral mechanically aligned TKA. J Knee Surg.

    Article  PubMed  Google Scholar 

  28. 28.

    Suh D-S, Kang K-T, Son J, Kwon O-R, Baek C, Koh Y-G (2017) Computational study on the effect of malalignment of the tibial component on the biomechanics of total knee arthroplasty. Bone Joint Res 6:623–630

    Article  Google Scholar 

  29. 29.

    Theodore W, Twiggs J, Kolos E, Roe J, Fritsch B, Dickison D et al (2017) Variability in static alignment and kinematics for kinematically aligned TKA. Knee 24:733–744

    Article  Google Scholar 

  30. 30.

    Vanlommel L, Vanlommel J, Claes S, Bellemans J (2013) Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 21:2325–2330

    Article  Google Scholar 

  31. 31.

    Victor J, Labey L, Wong P, Innocenti B, Bellemans J (2010) The influence of muscle load on tibiofemoral knee kinematics. J Orthop Res 28:419–428

    PubMed  Google Scholar 

  32. 32.

    Victor J, Van Glabbeek F, Vander Sloten J, Parizel PM, Somville J, Bellemans J (2009) An experimental model for kinematic analysis of the knee. J Bone Joint Surg Am 91(Suppl 6):150–163

    Article  Google Scholar 

  33. 33.

    Wallace AL, Harris ML, Walsh WR, Bruce WJM (1998) Intraoperative assessment of tibiofemoral contact stresses in total knee arthroplasty. J Arthroplasty 13:923–927

    CAS  Article  Google Scholar 

  34. 34.

    Yoon JR, Han SB, Jee MK, Shin YS (2017) Comparison of kinematic and mechanical alignment techniques in primary total knee arthroplasty: a meta-analysis. Medicine (Baltimore) 96:e8157

    Article  Google Scholar 

  35. 35.

    Young SW, Walker ML, Bayan A, Briant-Evans T, Pavlou P, Farrington B (2017) The Chitranjan S. Ranawat Award: no difference in 2-year functional outcomes using kinematic versus mechanical alignment in TKA: a randomized controlled clinical trial. Clin Orthop Relat Res 475:9–20

    Article  Google Scholar 

Download references


Funding was provided by Deutsche Arthrosehilfe e.V.

Author information



Corresponding author

Correspondence to Martin Faschingbauer.

Ethics declarations

Conflict of interest

We certify that we have not signed any agreement with commercial interest related to this study, which would in any way limit publication of any and all data generated for the study or to delay publication for any reason. Dr. Faschingbauer reports personal fees from Deutsche Arthrosehilfe e.V. during the conduct of the study.

Ethical approval

The authors’ institutional review board approved this study.

Study conduct and appointment

FM: planning/conception of the study, collection of data, analysis and interpretation, statistical analysis, writing and revising article; (orthopedic surgeon). HS: collection of data, analysis and interpretation, statistical analysis; (Dr. bio. hum.). SA, DL: interpretation of data, critical revision of the article; (Dr. bio. hum.). BF: critical revision of the article, final approval of the article, overall responsibility; (senior surgeon Hospital for Special Surgery). RH: critical revision of the article, final approval of the article, overall responsibility; (surgeon in chief University of Ulm).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Faschingbauer, M., Hacker, S., Seitz, A. et al. The tibial cut in total knee arthroplasty influences the varus alignment, the femoral roll-back and the tibiofemoral rotation in patients with constitutional varus. Knee Surg Sports Traumatol Arthrosc 29, 641–651 (2021).

Download citation


  • Knee
  • Total knee replacement
  • Mechanics