Comparison of post-operative three-dimensional and two-dimensional evaluation of component position for total knee arthroplasty

PURPOSE: The purpose of this study was to evaluate the post-operative three-dimensional (3D) femoral and tibial component positions in total knee arthroplasty (TKA) by the same co-ordinates’ system as for pre-operative planning and to compare it with a two-dimensional (2D) evaluation. MATERIALS AND METHODS: Sixty-five primary TKAs due to osteoarthritis were included. A computed tomography (CT) scan of the femur and tibia was obtained and pre-operative 3D planning was performed. Then, 3D and 2D post-operative evaluations of the component positions were performed. KneeCAS (LEXI, Inc., Tokyo, Japan), a lower-extremity alignment assessment system, was used for the 3D post-operative evaluation. Standard short-knee radiographs were used for the 2D post-operative evaluation. Differences between the pre-operative planning and post-operative coronal and sagittal alignment of components were investigated and compared with the results of the 3D and 2D evaluations. RESULTS: According to the 3D evaluation, the difference between the pre-operative planning and actual post-operative sagittal alignment of the femoral component and the coronal and sagittal alignments of the tibial component were 2.6° ± 1.8°, 2.2° ± 1.8° and 3.2° ± 2.4°, respectively. Using the 2D evaluation, they were 1.9° ± 1.5°, 1.3° ± 1.2° and 1.8° ± 1.4°, making the difference in 3D evaluation significantly higher (p = 0.013, = 0.003 and < 0.001). For the sagittal alignment of the femoral component and the coronal and sagittal alignment of the tibial component, the outlier (> ± 3°) ratio for the 3D evaluation was also significantly higher than that of the 2D evaluation (p < 0.001, = 0.009 and < 0.001). CONCLUSIONS: The difference between the pre-operative planning and post-operative component alignment in the 3D evaluation is significantly higher than that of the 2D, even if the same cases have been evaluated. Two-dimensional evaluation may mask or underestimate the post-operative implant malposition. Three-dimensional evaluation using the same co-ordinates’ system as for pre-operative planning is necessary to accurately evaluate the post-operative component position.