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Association between femorotibial rotational mismatch and early clinical outcomes after bi-cruciate retaining total knee arthroplasty

BMC Musculoskeletal Disorders volume 26, Article number: 251 (2025) Cite this article

Abstract

Background

Bi-cruciate retaining (BCR) total knee arthroplasty (TKA) is considered to provide improved clinical function and kinematics compared with conventional TKA, but it is unclear which factors affect clinical outcomes after BCR TKA. This study aimed to investigate whether rotational alignment of the femoral and tibial components and rotational mismatch between the femoral and tibial components affected early clinical outcomes after BCR TKA, according to the 2011 version of the Knee Society Score (2011KSS).

Methods

This retrospective cohort study included 39 knees that underwent BCR TKA. Rotational alignment of the femoral and tibial components and rotational mismatch between the components were measured by computed tomography based three-dimensional evaluation software. 2011KSS was obtained at 3, 6, and 12 months postoperatively. The relationship of each of rotational alignment and rotational mismatch with 2011KSS was analyzed.

Results

Rotational alignment of the femoral and tibial components was not correlated with symptoms, patient satisfaction, patient expectations, or functional activities at 3, 6, or 12 months postoperatively. Rotational mismatch was negatively correlated with symptoms, patient satisfaction and functional activities at 3 months; negatively correlated with symptoms and functional activities at 6 months; and negatively correlated with symptoms, patient satisfaction, patient expectations and functional activities at 12 months postoperatively.

Conclusions

Rotational mismatch between the femoral and tibial components was negatively correlated with 2011KSS, whereas no relationship of rotational alignment of the femoral and tibial components with 2011KSS was observed. Excessive external rotation of the tibial component relative to the femoral component resulted in worse early clinical outcomes.

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Background

Conventional total knee arthroplasty (TKA), as cruciate retaining (CR) or posterior stabilized (PS) designs, offer good long-term results in terms of survival and clinical outcomes [1, 2]. However, patient-reported outcome measures indicate that many patients remain dissatisfied after TKA [3, 4]. Simultaneous medial and lateral tibiofemoral osteoarthritis could be treated with bi-cruciate retaining (BCR) TKA and bi-unicompartmental knee arthroplasty (Bi UKA) as an alternative to total knee arthroplasty (TKA) [5,6,7]. BCR TKA is an alternative technique for TKA [8]. Its design enables preservation of both the anterior and posterior cruciate ligaments, with the aims of restoring joint kinematics to near normal, restoring posterior femoral rollback, preserving normal proprioception, and reproducing medial pivot rotation [9,10,11,12]. Several studies have reported patient preference for BCR TKA over the conventional TKA designs [13, 14]. However, there are concerns regarding technical difficulties, risks of complications, long term survival, and functional outcomes [15, 16].

Rotational malalignment of components is reportedly associated with inferior outcome, severe knee stiffness, knee pain, abnormal gait patterns, and early revision arthroplasty in conventional TKA [17,18,19,20,21,22,23,24]. Alternatively, in BCR TKA, both the anterior and posterior cruciate ligaments are retained and it is unclear whether femorotibial rotational parameters are associated with clinical outcomes. The authors hypothesized that rotational mismatch between the femoral and tibial components was associated with inferior clinical outcome after BCR TKA. The aim of this study was to investigate whether rotational alignment of the femoral and tibial components and rotational mismatch between the femoral and tibial components after BCR TKA were correlated with the new 2011 version of the Knee Society Scoring System (2011KSS).

Methods

Patient selection

This retrospective case series was approved by the ethics committee of our institution (No.H2018-083) and the 1964 Helsinki Declaration and its later amendments [25]. Our institution performed consecutive TKAs between April 2017 and February 2019. The inclusion criteria were knees with primary varus osteoarthritis and with both cruciate ligaments intact and functional. The retention of both cruciate ligaments were confirmed by magnetic resonance imaging and visualized intraoperatively. The exclusion criteria were knees with flexion contracture ≥ 20°, valgus deformity, and revision TKA. Ultimately, the study analyzed 39 consecutive knees of 33 patients who underwent primary BCR TKA (Vanguard XP Total Knee System; Biomet, Warsaw, IN). All preoperative and postoperative evaluations were performed by the author (ST) and all operations were performed by a senior surgeon (MH).

Radiological analysis

All patients underwent pre- and postoperative computed tomography (CT) for assessment of component alignment. Postoperative CT was performed 2 weeks after surgery. Helical CT was performed from the hip to the ankle with a 1-mm slice interval in all cases. Pre- and postoperative CT data were imported into Zed Knee System (LEXI Co., Tokyo, Japan), a validated CT-based three-dimensional (3D) preoperative planning and post-operative evaluation software program for TKA [26,27,28,29]. On preoperative CT, seven reference points were plotted on the femur to define the mechanical axis in the sagittal and coronal planes, the surgical epicondylar axis (SEA), and the posterior epicondylar axis. Twelve reference points were then plotted on the tibia to define the mechanical axis in the sagittal and coronal planes, as well as the anteroposterior axis (from the medial third of the patellar tendon attachment to the middle of the posterior cruciate ligament). Reference points defined on preoperative CT were then transferred to the postoperative CT by matching the preoperative and postoperative CT images. Therefore, the component positions and rotations could be evaluated using common perioperative reference points.

Baselines of the femoral and tibial components were defined in the coronal and sagittal planes relative to the mechanical axis; and those of rotational alignment were defined relative to the SEA of the femur and anteroposterior axis of the tibia. Postoperative rotational alignment of each of the femoral and tibial components was measured as the angle relative to baseline (Fig. 1a, b). Postoperative rotational mismatch was measured as the angle of the tibial component relative to the femoral component (Fig. 1c). A positive alignment value indicated valgus alignment with the component in the coronal plane, flexion, or posterior tilt in the sagittal plane. A positive rotational alignment value indicated an externally rotated position of the femoral or tibial component relative to baseline. A positive value of rotational mismatch indicated an externally rotated position of the tibial component relative to the femoral component.

Fig. 1
figure 1

Assessment of rotational alignment and rotational mismatch. (a) Rotational alignment of the femoral component, (b) rotational alignment of the tibial component, and (c) rotational mismatch between the femoral and tibial components

Full size image

Surgical procedure

The Vanguard XP system used in this study is a recently developed TKA with a U-shaped symmetrical tibial component that retains the anterior and posterior cruciate ligaments. The anterior portion of the tibial component consists of a broad bar to provide sufficient rotating-beam fatigue strength. The femoral component has a new-generation design with a narrowed and funnel-shaped anterior femoral flange.

BCR TKA was performed by the mid-vastus approach after inflating the tourniquet to 300 mmHg at the beginning of the procedure. Distal femoral osteotomy was performed perpendicular to the mechanical axis in the coronal plane identified on preoperative 3D-CT planning, using an accelerometer-based portable navigation system. Femoral rotational alignment was adjusted to the surgical epicondylar axis of the femur. An extramedullary resection guide was used for the tibial osteotomy. The osteotomy angle aimed to be perpendicular to the mechanical axis in the coronal plane. In the sagittal plane, the osteotomy angle was decided by the native tibial posterior slope of each patient. If a patient had a tibial posterior slope of ≥ 10°, the osteotomy angle was set to 10° in the sagittal plane. Tibial rotational alignment was adjusted to the medial third of the patellar tendon attachment. The anterior and posterior cruciate ligaments were protected during femoral preparation and the tibia was prepared with a guide designed to preserve a bone island with the anterior cruciate ligament insertion. The patella was resurfaced during all TKAs. The thickness of patellar resection was determined by the thickness of the patellar component to be used. The patellar components were positioned medially and superiorly to the center of the patellar cut surface to prevent patellar maltracking. All TKAs were confirmed to have no intraoperative patellar maltracking. On the first day after BCR TKA, patients were allowed to walk with full weight bearing after the drainage tube had been removed.

Clinical evaluation

The 2011 KSS was developed in 2011 that included a current patient-reported outcome section that also measures satisfaction, functional activities, and expectations. The 2011 KSS has been validated in terms of reliability and consistency [30]. The 2011 KSS has been widely adopted worldwide, and several translation and validation studies have been published in other languages [31,32,33,34]. The patient-reported outcome measurement portion of the Japanese version of the 2011KSS was evaluated at 3, 6, and 12 months postoperatively. The 2011KSS comprises 3 questions regarding symptoms, 5 regarding satisfaction, 3 regarding expectations, and 18 regarding functional activities [29, 35]. Patients graded the 2011KSS items as follows: symptoms, maximum 25 points; satisfaction, maximum 40 points; expectations, maximum 15 points; and functional activities, maximum 100 points [36].

Statistical analysis

All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). Simple linear regression analysis between the alignment of the femoral and tibial components in the coronal, sagittal, and rotational planes and each parameter of the 2011KSS were analyzed. Simple linear regression analysis between rotational mismatch between the femoral and tibial components and each parameter of the 2011KSS were also analyzed. Continuous data were analyzed using the nonparametric Spearman’s rank correlation coefficient. Values of P < 0.05 were considered significant.

Multivariate logistic regression analysis was performed to evaluate the predictive factors of poor clinical outcomes based on each parameter of the 2011KSS at 12 months. The results are presented as odds ratios with 95% confidence intervals.

According to a previous study, the following cut-off values of the 2011KSS were defined as a indicative of a poor clinical outcome: symptoms, ≤ 17 points; satisfaction, ≤ 20 points; expectations, ≤ 9 points; and functional activities, ≤ 43 points [26].

A post hoc power analysis was performed with G*Power version 3.1.9 (University of Kiel, Germany). A prior power analysis showed that 34 knees were required to detect a moderate correlation (0.40), with a power of 0.80 and alpha error of 0.05.

The reproducibility of rotational alignment and rotational mismatch was confirmed. For intra-observer reliability, each parameter was randomly measured twice in 10 knees, at an interval of ≥ 4 weeks, by one orthopedic surgeon (ST). For inter-observer reliability, two orthopedic surgeons (ST and YN) measured each parameter twice in 10 knees, at an interval of ≥ 4 weeks. Intra-class and inter-class correlation coefficients were calculated to analyze variability between observers. Values of 0.81–1.00 indicated excellent correlation; 0.61–0.80, substantial correlation; 0.41–0.60, moderate correlation; 0.21–0.40, fair correlation; and 0.00–0.20, poor correlation.

Results

The patient demographics are listed in Table 1. The intra-class and inter-class correlation coefficients for rotational alignment of the femoral component were 0.90 and 0.99, respectively. The intra-class and inter-class correlation coefficients for rotational alignment of the tibial component were 0.99 and 0.99, respectively. The intra-class and inter-class correlation coefficients for rotational mismatch between the femoral and tibial components were 0.99 and 0.99, respectively.

Table 1 Patient demographics
Full size table

Mean rotational alignment angle of the femoral component was 1.7 ± 1.7° (range, − 1.9° to 5.6°). Mean rotational alignment angle of the tibial component was − 2.8 ± 5.0° (range, − 17.3° to 5.5°). Mean rotational mismatch angle between the femoral and tibial components was 1.7 ± 1.7 (range, − 9.0° to 16.1°). Mean values of symptoms, patient satisfaction, patient expectations and functional activities at 3, 6, and 12 months postoperatively were shown in Table 2.

Table 2 Mean values of clinical parameters of the 2011KSS at 3, 6, and 12months postoperatively
Full size table

No correlation was found for component alignment in either the coronal or sagittal plane with symptoms, patient satisfaction, patient expectations, or functional activities at 3, 6, or 12 months postoperatively. Tables 3, 4 and 5 show the correlation between each rotational parameter and 2011KSS at 3, 6, and 12 months postoperatively. Rotational alignment of the femoral and tibial components was not significant difference with all parameters at 3, 6, and 12 months postoperatively. Rotational mismatch between the femoral and tibial components was negatively correlated with symptoms, patient satisfaction and functional activities at 3 months postoperatively, with symptoms and functional activities at 6 months postoperatively, and with all parameters of 2011KSS at 12 months postoperatively. Figure 2 shows the distributions between rotational mismatch and each 2011KSS category at 12 months postoperatively. External rotation of the tibial component relative to the femoral component reduced the score in all parameters of 2011KSS at 12 months postoperatively. The multivariate logistic regression analysis for each parameter of the 2011KSS revealed that rotational mismatch between femoral and tibial component was an independent risk factor for poor symptoms of the 2011KSS at 12 months. The odds ratio was 1.69 (Table 6).

Table 3 Correlation between rotational parameters and 2011KSS at 3 months postoperatively
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Table 4 Correlation between rotational parameters and 2011KSS at 6 months postoperatively
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Table 5 Correlation between rotational parameters and 2011KSS at 12 months postoperatively
Full size table
Fig. 2
figure 2

Correlation between rotational mismatch and 2011KSS at 12 months postoperatively. Rotational mismatch was negatively correlated with all clinical parameters of the 2011KSS

Full size image
Table 6 Multivariate logistic regression analysis for poor symptoms of the 2011 KSS at 12months
Full size table

Discussion

The main finding of this study was the negative correlation between rotational mismatch of the tibial component relative to the femoral component and most of the 2011KSS parameters at 3, 6, and 12 months after BCR TKA. Specifically, excessive external rotation of the tibial component relative to the femoral component caused worse early clinical results. Namely, excessive external rotation of the tibial component relative to the femoral component affected pain worsening and decreased satisfaction. On the other hand, no rotational mismatch and internal rotation of the tibial component relative to the femoral component tended not to result in pain worsening and decreased satisfaction.

Implants that can preserve both the anterior and posterior cruciate ligaments include BCR TKA and Bi UKA, both of which have reported good clinical outcomes. Pritchett reported that survival analysis of BCR TKA designs with follow-up of up to 24 years showed a survival rate of 89% [37]. Sabouret et al. showed similarly good results using BCR TKA on 163 knees with a mean follow-up of 22.4 years [38]. On the other hand, Confalonieri et al. reported similar survivorship and better outcomes for Bi UKA at a minimum follow-up of 4 years compared to TKA [39]. However, there are no reports that have mentioned rotational alignment and rotational mismatch of the components that preserve both the anterior and posterior cruciate ligaments.

Several studies have reported the relationship between rotational alignment of the femoral component and clinical outcomes after conventional TKA. Kawahara et al. reported that internal rotation of the femoral component relative to the surgical epicondylar axis significantly decreased the score of functional activities and slightly decreased the score of satisfaction in 2011KSS for PS TKA with fixed bearing [40]. Thielemann et al. reported that both internal and external rotational femoral malalignment exceeding 3° was associated with significantly poorer Knee Society Score and Knee Injury and Osteoarthritis Outcome Score at 5 to 7 years after CR TKA with fixed bearing [41]. Regarding rotational alignment of the tibial component, Nicoll et al. reported that internal rotational errors of the tibial component were a major cause of pain and functional deficit after CR and PS TKA with fixed bearing.

In contrast, few reports have investigated the relationship between rotational mismatch and clinical outcome after conventional TKA [42]. Lutzner et al. reported that rotational mismatch of beyond ± 10° among the femoral and tibial components resulted in worse functional scores using the Knee Society score after CR TKA with rotating platform [43]. In our previous study, postoperative rotational mismatch of the femoral and tibial components was correlated with postoperative numerical rating scale scores at one year in BCR TKA [44].

To the best of our knowledge, no previous report has investigated the relationship of rotational mismatch between the femoral and tibial components with early clinical outcomes using patient-reported outcome measures after BCR TKA. Therefore, this study is the first to report the factors affecting early clinical outcomes after BCR TKA. This finding of the study is in disagreement with those of previous studies in conventional TKA. The difference can be attributed to the retention of both cruciate ligaments, which may affect the reduction of rotational permittance between the components. It is known that SEA is a useful reference axis for determining the rotational alignment of the femoral component, whereas there is disagreement regarding the reference axes for rotational alignment of the tibial component because of the high variability in rotational alignment of the tibial component among the axes [20, 45,46,47,48,49,50]. Moreover, the rotational position of the tibial baseplate in BCR TKA might depend on the tibial attachment of the anterior cruciate ligament. Therefore, it is difficult to determine the rotational reference axis of the tibial component in BCR TKA; i.e., the rotational position of the appropriate components is unknown. However, the present results suggest that minimizing postoperative rotational mismatch between the femoral and tibial components might improve clinical outcomes.

There were several limitations in this study. First, this study had a small cohort size. Second, CT scans deliver a higher radiation dose compared to the patient compared with conventional radiography [51]. However, the present results confirm the usefulness of CT evaluation, which enables evaluation of the rotational alignment of the components that is difficult to achieve with conventional radiography. Third, CT scans were performed in the supine position without weight bearing. Therefore, it is unclear whether the same results would be obtained in the standing position with weight bearing. Fourth, since the only clinical parameter used in this study was the 2011KSS, it is difficult to compare the results of this study to other clinical studies because the results of this study may not necessarily align with other clinical parameters. Fifth, the 2011 KSS was reported to have high clinical quality but low completion rates [52]. However, omissions did not occur because the patients’ completion status was monitored in this study. When using the 2011 KSS as a clinical outcome, it is important to check for omissions.

Conclusion

The study evaluated whether rotational alignment of the femoral and tibial components and rotational mismatch of the components were associated with 2011KSS following BCR TKA. Rotational mismatch between the femoral and tibial components was negatively correlated with 2011KSS. Excessive external rotation of the tibial component relative to the femoral component resulted in worse early clinical outcomes.

Data availability

The datasets used and analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

TKA:

Total knee arthroplasty

CR:

Cruciate retaining

PS:

Posterior stabilized

BCR:

Bi-cruciate retaining

2011KSS:

New 2011 version of the Knee Society Scoring System

CT:

computed tomography

3D:

Three-dimensional

SEA:

Surgical epicondylar axis

References

  1. Abdel MP, Morrey ME, Jensen MR, Morrey BF. Increased long-term survival of posterior cruciate-retaining versus posterior cruciate-stabilizing total knee replacements. J Bone Joint Surg Am. 2011;93:2072–8.

    Article  PubMed  Google Scholar 

  2. Christen B, Kopjar B. Second-generation bi-cruciate stabilized total knee system has a lower reoperation and revision rate than its predecessor. Arch Orthop Trauma Surg. 2011;138:1591–9.

    Article  Google Scholar 

  3. Bullens PH, van Loon CJ, de Waal Malefijt MC, Laan RF, Veth RP. Patient satisfaction after total knee arthroplasty: a comparison between subjective and objective outcome assessments. J Arthroplasty. 2001;16:740–7.

    Article  CAS  PubMed  Google Scholar 

  4. Dunbar MJ, Richardson G, Robertsson O. I can’t get no satisfaction after my total knee replacement: rhymes and reasons. Bone Joint J. 2013;95–B:148–52.

    Article  PubMed  Google Scholar 

  5. Rossi SMP, Perticarini L, Clocchiatti S, Ghiara M, Benazzo F. Mid- to long-term follow-up of combined small implants. Bone Joint J. 2021;103–B:840–5.

    Article  PubMed  Google Scholar 

  6. Parratte S, Ollivier M, Lunebourg A, Abdel MP, Argenson JN. Long-term results of compartmental arthroplasties of the knee: long term results of partial knee arthroplasty. Bone Joint J. 2015;97–B:9–15.

    Article  PubMed  Google Scholar 

  7. Beckmann J, Steinert AF, Huber B, et al. Customised bi-compartmental knee arthroplasty shows encouraging 3-year results: findings of a prospective, multicenter study. Knee Surg Sports Traumatol Arthrosc. 2020;28:1742–9.

    Article  CAS  PubMed  Google Scholar 

  8. Townley CO. Total knee arthroplasty. A personal retrospective and prospective review. Clin Orthop Relat Res. 1988;236:8–22.

    Article  Google Scholar 

  9. Andriacchi TP, Galante JO, Fermier RW. The influence of total knee-replacement design on walking and stair-climbing. J Bone Joint Surg Am. 1984;64:1328–35.

    Article  Google Scholar 

  10. Freeman MA, Insall JN, Besser W, Walker PS, Hallel T. Excision of the cruciate ligaments in total knee replacement. Clin Orthop Relat Res. 1977;126:209–12.

    Google Scholar 

  11. Baumann F, Bahadin Ö, Krutsch W, et al. Proprioception after bicruciate-retaining total knee arthroplasty is comparable to unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2017;25:1697–704.

    Article  PubMed  Google Scholar 

  12. Zumbrunn T, Varadarajan KM, Rubash HE, Malchau H, Li G, Muratoglu OK. Regaining native knee kinematics following joint arthroplasty: A novel biomimetic design with ACL and PCL preservation. J Arthroplasty. 2015;30:2143–8.

    Article  PubMed  Google Scholar 

  13. Pritchett JW. Patients prefer a bicruciate-retaining or the medial Pivot total knee prosthesis. J Arthroplasty. 2011;26:224–8.

    Article  PubMed  Google Scholar 

  14. Pritchett JW. Patient preferences in knee prostheses. J Bone Joint Surg Br. 2004;86:979–82.

    Article  CAS  PubMed  Google Scholar 

  15. Cherian JJ, Kapadia BH, Banerjee S, Jauregui JJ, Harwin SF, Mont MA. Bicruciate-retaining total knee arthroplasty: a review. J Knee Surg. 2014;27:199–205.

    Article  PubMed  Google Scholar 

  16. Baumann F, Krutsch W, Worlicek M, et al. Reduced joint-awareness in bicruciate-retaining total knee arthroplasty compared to cruciate-sacrificing total knee arthroplasty. Arch Orthop Trauma Surg. 2018;138:273–9.

    Article  PubMed  Google Scholar 

  17. Nicoll D, Rowley DI. Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Joint Surg Br. 2010;92:1238–44.

    Article  CAS  PubMed  Google Scholar 

  18. Bédard M, Vince KG, Redfern J, Collen SR. Internal rotation of the tibial component is frequent in stiff total knee arthroplasty. Clin Orthop Relat Res. 2011;469:2346–55.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Schiavone Panni A, Cerciello S, Vasso M, Tartarone M. Stiffness in total knee arthroplasty. J Orthop Traumatol. 2009;10:111–8.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Panni AS, Ascione F, Rossini M, et al. Tibial internal rotation negatively affects clinical outcomes in total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2018;26:1636–44.

    Article  PubMed  Google Scholar 

  21. Bell SW, Young P, Drury C, et al. Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee. 2014;21:272–7.

    Article  PubMed  Google Scholar 

  22. Verlinden C, Uvin P, Labey L, Luyckx JP, Bellemans J, Vandenneucker H. The influence of malrotation of the femoral component in total knee replacement on the mechanics of patellofemoral contact during gait: an in vitro Biomechanical study. J Bone Joint Surg Br. 2010;92:737–42.

    Article  CAS  PubMed  Google Scholar 

  23. Pietsch M, Hofmann S. Early revision for isolated internal malrotation of the femoral component in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2012;20:1057–63.

    Article  PubMed  Google Scholar 

  24. Sternheim A, Lochab J, Drexler M, et al. The benefit of revision knee arthroplasty for component malrotation after primary total knee replacement. Int Orthop. 2012;36:2473–8.

    Article  PubMed  PubMed Central  Google Scholar 

  25. World Medical Association. World medical association declaration of Helsinki: ethical principles for medical research involving. Hum Subj JAMA. 2013;310:2191–4.

    Google Scholar 

  26. Ueyama H, Minoda Y, Sugama R, et al. Malrotation of the fixed-bearing posterior stabilized total knee prosthesis causes a postoperative rotational mismatch between the femur and tibia. Knee Surg Sports Traumatol Arthrosc. 2020;28:3810–20.

    Article  PubMed  Google Scholar 

  27. Kawaguchi K, Inui H, Taketomi S, et al. Preoperative tibiofemoral rotational alignment is a risk factor for component rotational mismatch in total knee arthroplasty. Knee. 2021;29:448–56.

    Article  PubMed  Google Scholar 

  28. Miura M, Hagiwara S, Nakamura J, Wako Y, Kawarai Y, Ohtori S. Interobserver and intraobserver reliability of computed Tomography-Based Three-Dimensional preoperative planning for primary total knee arthroplasty. J Arthroplasty. 2018;33:1572–8.

    Article  PubMed  Google Scholar 

  29. Yoshino K, Hagiwara S, Nakamura J, Tsukeoka T, Tsuneizumi Y, Ohtori S. Intra- and interobserver reliability and agreement in three-dimensional computed tomography measurements of component positions after total knee arthroplasty. Knee. 2019;26:1102–10.

    Article  PubMed  Google Scholar 

  30. Noble PC, Scuderi GR, Brekke AC, et al. Development of a new knee society scoring system. Clin Orthop Relat Res. 2012;470:20–32.

    Article  PubMed  Google Scholar 

  31. Debette C, Parratte S, Maucort-Boulch D, et al. French adaptation of the new knee society scoring system for total knee arthroplasty. Orthop Traumatol Surg Res. 2014;100:531–4.

    Article  CAS  PubMed  Google Scholar 

  32. Kim SJ, Basur MS, Park CK, et al. Crosscultural adaptation and validation of the Korean version of the new knee society knee scoring system. Clin Orthop Relat Res. 2017;475:1629–39.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Kayaalp ME, Keller T, Fitz W, Scuderi GR, Becker R. Translation and validation of the German new knee society scoring system. Clin Orthop Relat Res. 2019;477(2):383–93.

    Article  PubMed  Google Scholar 

  34. Mirahmadi A, Hosseini-Monfared P, Amiri S, et al. Crosscultural adaptation and validation of the Persian version of the new knee society knee scoring system (KSS). J Orthop Surg Res. 2023;18:858.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new knee society knee scoring system. Clin Orthop Relat Res. 2012;470:3–19.

    Article  PubMed  Google Scholar 

  36. Hamamoto Y, Ito H, Furu M, et al. Cross-cultural adaptation and validation of the Japanese version of the new knee society scoring system for Osteoarthritic knee with total knee arthroplasty. J Orthop Sci. 2015;20:849–53.

    Article  PubMed  Google Scholar 

  37. Pritchett JW. Bicruciate-retaining total knee replacement provides satisfactory function and implant survivorship at 23 years. Clin Orthop Relat Res. 2015;473:2327–33.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Sabouret P, Lavoie F, Cloutier JM. Total knee replacement with retention of both cruciate ligaments: a 22-year follow-up study. Bone Joint J. 2013;95–B:917–22.

    Article  PubMed  Google Scholar 

  39. Confalonieri N, Manzotti A, Cerveri P, De Momi E. Bi-unicompartmental versus total knee arthroplasty: a matched paired study with early clinical results. Arch Orthop Trauma Surg. 2009;129:1157–63.

    Article  CAS  PubMed  Google Scholar 

  40. Kawahara S, Okazaki K, Matsuda S, Nakahara H, Okamoto S, Iwamoto Y. Internal rotation of femoral component affects functional activities after TKA–survey with the 2011 knee society score. J Arthroplasty. 2014;29:2319–23.

    Article  PubMed  Google Scholar 

  41. Thielemann FW, Konstantinids L, Herget GW, et al. Effect of rotational component alignment on clinical outcome 5 to 7 years after TKA with the Columbus knee system. Orthopedics. 2016;39:S50–55.

    Article  PubMed  Google Scholar 

  42. Nicoll D, Rowley DI. Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Joint Surg Br. 2010;929:1238–44.

    Article  Google Scholar 

  43. Lützner J, Kirschner S, Günther KP, Harman MK. Patients with no functional improvement after total knee arthroplasty show different kinematics. Int Orthop. 2012;36:1841–7.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Tone S, Hasegawa M, Naito Y, Wakabayashi H, Sudo A. Association between pre- and postoperative rotational mismatches of the femorotibial components and bones in bi-cruciate retaining and posterior stabilized total knee arthroplasty. Sci Rep. 2023;13:14902.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res. 1993;286:40–7.

    Article  Google Scholar 

  46. Insall JN, Scuderi GR, Komistek RD, Math K, Dennis DA, Anderson DT. Correlation between condylar lift-off and femoral component alignment. Clin Orthop Relat Res. 2002;403:143–52.

    Article  Google Scholar 

  47. Akagi M, Oh M, Nonaka T, Tsujimoto H, Asano T, Hamanishi C. An anteroposterior axis of the tibia for total knee arthroplasty. Clin Orthop Relat Res. 2004;420:213–9.

    Article  Google Scholar 

  48. Cobb JP, Dixon H, Dandachli W, Iranpour F. The anatomical tibial axis: reliable rotational orientation in knee replacement. J Bone Joint Surg Br. 2008;90:1032–8.

    Article  CAS  PubMed  Google Scholar 

  49. Benjamin J. Component alignment in total knee arthroplasty. Instr Course Lect. 2006;55:405–12.

    PubMed  Google Scholar 

  50. Ma Y, Mizu-Uchi H, Ushio T, et al. Bony landmarks with tibial cutting surface are useful to avoid rotational mismatch in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2019;27:1570–9.

    Article  PubMed  Google Scholar 

  51. Brenner DJ, Hall EJ. Computed tomography–an increasing source of radiation exposure. N Engl J Med. 2007;357:2277–84.

    Article  CAS  PubMed  Google Scholar 

  52. Dinjens RN, Senden R, Heyligers IC, Grimm B. Clinimetric quality of the new 2011 knee society score: high validity, low completion rate. Knee. 2014;21:647–54.

    Article  PubMed  Google Scholar 

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Acknowledgements

Not applicable.

Funding

This study was not supported by any funding.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Mie, Japan

    Shine Tone, Yohei Naito, Hiroki Wakabayashi, Akihiro Sudo & Masahiro Hasegawa

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  1. Shine Tone
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ST collected the data, performed the measurement and analysis, participated in the study design and drafted the manuscript. MH participated in the study design, supervised the analysis and helped to draft the manuscript. YN collected the data, performed the measurement, help to draft the manuscript. HW participated in the study design. AS participated in the study design and coordination, supervised the analysis. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Masahiro Hasegawa.

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This study was approved by Institutional Review Board at Mie University hospital. All patients provided their informed consent.

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Not applicable.

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The authors declare no competing interests.

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Tone, S., Naito, Y., Wakabayashi, H. et al. Association between femorotibial rotational mismatch and early clinical outcomes after bi-cruciate retaining total knee arthroplasty. BMC Musculoskelet Disord 26, 251 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08478-2

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08478-2

Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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