Rotational Alignment of Femoral Component for Minimal Medial Collateral Ligament Release in Total Knee Arthroplasty

PURPOSE: We attempted to determine the degree of rotation of the femoral component to achieve an ideal rectangular flexion gap with minimal medial collateral ligament (MCL) release using a modified measured technique. MATERIALS AND METHODS: Group I consisted of 60 osteoarthritis patients (72 cases) who underwent total knee arthroplasty (TKA) with minimal MCL release and Group II consisted of 48 patients without osteoarthritis (61 cases). We performed computed tomography (CT) scanning of the knee with 90 degree flexion in all of the patients and analyzed the angles between the distal femur landmarks and the tibial mechanical axis using a Picture Archiving Communication system. External rotation of the femoral component from the Whiteside line and posterior condylar line was measured in group I who underwent TKA with minimum MCL release. The variance in the mediolateral flexion gap according to the degree of rotation was also measured using an Auto-Computer Aided Design program. RESULTS: The CT scans showed that the Whiteside line, posterior condylar line, and transepicondylar line was more internally rotated on average from the longitudinal axis of tibia by 4.12°, 5.54°, and 4.64°, respectively, in group I compared to group II. In group I, the femoral component was inserted with an average external rotation of 5.6° from the posterior condylar line and with an average external rotation of 2.0° from the Whiteside line with minimal MCL release. From the measurements of the femoral component size and the variance in the degree of rotation using an Auto-CAD program, it was found that the change in the mediolateral flexion gap was greater when the rotation angle was greater and it was greater when the size of femoral component was larger at the same rotation angle. CONCLUSIONS: The average rotation angle of the femoral component to achieve an ideal rectangular flexion gap with minimal MCL release in TKA was an external rotation of 5.6° from the posterior condylar line and an external rotation of 2.0° from the Whiteside line. We concluded that when a femoral component is small in size, greater than average external rotation needs to be applied and when a femoral component is large in size, less than average external rotation needs to be applied.