Lower limb alignment and laxity measures before, during and after total knee arthroplasty: A prospective cohort study


      • Knee alignment and laxity before, during and after knee arthroplasty were determined.
      • No difference in coronal alignment was evident.
      • Greater knee extension occurred intra-operatively than in the clinic.



      This study compared knee alignment and laxity in patients before, during and after total knee arthroplasty, using methodologically similar procedures, with an aim to help inform pre-operative planning.


      Eighteen male and 13 female patients were recruited, mean age 66 years (51–82) and mean body mass index of 33 (23–43). All were assessed pre- and postoperatively using a non-invasive infrared position capture system and all underwent total knee arthroplasty using a navigation system. Knee kinematic data were collected and comparisons made between preoperative clinical and intraoperative measurements for osteoarthritic knees, and between postoperative clinical and intraoperative measurements for prosthetic knees.


      There was no difference in unstressed coronal mechanical femoral-tibial angles for either osteoarthritic or prosthetic knees. However, for sagittal alignment the knees were in greater extension intraoperatively (osteoarthritic 5.2° p < 0.001, prosthetic 7.2° p < 0.001). For osteoarthritic knees, both varus and valgus stress manoeuvres had greater angular displacements intraoperatively by a mean value of 1.5° for varus (p = 0.002) and 1.6° for valgus (p < 0.001). For prosthetic knees, only valgus angular displacement was greater intraoperatively (0.9°, p = 0.002).


      Surgeons performing total knee arthroplasties should be aware of potential differences in alignment and laxity measured under different conditions to facilitate more accurate operative planning and follow-up.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abdel M.P.
        • Oussedik S.
        • Parratte S.
        • Lustig S.
        • Haddad F.S.
        Coronal alignment in total knee replacement: historical review, contemporary analysis, and future direction.
        Bone Joint J. 2014; 96-B: 857-862
        • Aderinto J.
        • Brenkel I.J.
        • Chan P.
        National history of fixed flexion deformity following total knee replacement.
        J. Bone Joint Surg. (Br.). 2005; 87-B: 934-936
        • Bade M.J.
        • Kittelson J.M.
        • Kohrt W.M.
        • Stevens-Lapsley J.E.
        Predicting functional performance and range of motion outcomes after total knee arthroplasty.
        Am. J. Phys. Med. Rehabil. 2014; 93: 579-585
        • Bargren J.H.
        • Blaha J.D.
        • Freeman M.A.R.
        Alignment in total knee arthroplasty: correlated biomechanical and clinical investigations.
        Clin Orthop. 1983; 173: 178-183
        • Bathis H.
        • Perlick L.
        • Tingart M.
        • Luring C.
        • Zurakowski D.
        • Grifka J.
        Alignment in total knee arthroplasty: comparison of computer-assisted surgery with the conventional technique.
        J. Bone Joint Surg. (Br.). 2004; 86-B: 682-687
        • Bellemans J.
        • Vandenneuker H.
        • Victor J.
        • Vanlauwe J.
        Flexion contracture in total knee arthroplasty.
        Clin. Orthop. Relat. Res. 2006; 452: 78-82
        • Bonner T.J.
        • Eardley W.G.
        • Patterson P.
        • Gregg P.J.
        The effect of post-operative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years.
        J. Bone Joint Surg. (Br.). 2011; 93: 1217-1222
        • Chauhan S.K.
        • Scott R.G.
        • Breidahl W.
        • Beaver R.J.
        Computer-assisted knee arthroplasty versus a conventional jig-based technique: a randomized, prospective trial.
        J. Bone Joint Surg. (Br.). 2004; 86-B: 372-377
        • Clarke J.V.
        • Riches P.E.
        • Picard F.
        • Deakin A.H.
        Non-invasive computer-assisted measurement of knee alignment.
        Comput. Aided Surg. 2012; 17: 29-39
        • Clarke J.V.
        • Wilson W.T.
        • Wearing S.C.
        • Picard F.
        • Riches P.E.
        • Deakin A.H.
        Standardising the clinical assessment of coronal knee laxity.
        J Engineering in Medicine (Proc. IMechE Part H). 2012; 226: 699-708
        • Edwards J.Z.
        • Greene K.A.
        • Davis R.S.
        • Kovacik M.W.
        • Noe D.A.
        • Askew M.J.
        Measuring flexion in knee arthroplasty patients.
        J. Arthroplast. 2004; 19: 369-372
        • Freeman M.A.R.
        • Samuelson K.M.
        • Levack B.
        • DeAlencar P.G.C.
        Knee arthroplasty at the London Hospital.
        Clin. Orthop. Relat. Res. 1986; 205: 12-20
        • Goudie S.T.
        • Deakin A.H.
        • Ahmad A.
        • Maheshwari R.
        • Picard F.
        Flexion contracture following primary total knee arthroplasty: risk factors and outcomes.
        Orthopedics. 2011; 34: 855-859
        • Haaker R.G.
        • Stockheim M.
        • Kamp M.
        • Proff G.
        • Breitenfelder J.
        • Ottersbach A.
        Computer-assisted navigation increases precision of component placement in total knee arthroplasty.
        Clin. Orthop. Relat. Res. 2005; 433: 152-159
        • Hakki S.
        • Coleman S.
        • Saleh K.
        • Bilota V.J.
        • Hakki A.
        Navigational predictors in determining the necessity for collateral ligament release in total knee replacement.
        J. Bone Joint Surg. (Br.). 2009; 91-B: 1178-1182
        • Hardy M.A.
        The biology of scar formation.
        Phys. Ther. 1989; 69: 1014-1024
        • Jeffrey R.S.
        • Morris R.W.
        • Denham R.A.
        Coronal alignment after total knee replacement.
        J. Bone Joint Surg. (Br.). 1991; 73: 709-714
        • Jenny J.Y.
        • Boeri C.
        • Picard F.
        • Leitner F.
        Reproducibility of intra-operative measurement of the mechanical axes of the lower limb during total knee replacement with a non-imaged based navigation system.
        Comput. Aided Surg. 2004; 9: 161-166
        • Krackow K.A.
        Varus deformity.
        in: The Technique of Total Knee Arthroplasty. CV Mosby, St Louis, MO1990: 317-340
        • Lam L.O.
        • Swift S.
        • Shakespeare D.
        Fixed flexion deformity and flexion after knee arthroplasty. What happens in the first 12 months after surgery and can a poor outcome be predicted?.
        Knee. 2003; 10: 181-185
        • LaPrade R.F.
        • Heikes C.
        • Bakker A.J.
        • Jakobsen R.B.
        The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries. An in vitro biomechanical study.
        J. Bone Joint Surg. Am. 2008; 90: 2069-2076
        • Lonner J.H.
        • Laird M.T.
        • Stuchin S.A.
        Effect of rotation and knee flexion on radiographic alignment in total knee arthroplasties.
        Clin. Orthop. Relat. Res. 1996; 331: 102-106
        • Lotke P.A.
        • Ecker M.L.
        Influence of positioning of prosthesis in total knee replacement.
        J. Bone Joint Surg. Am. 1977; 59-A: 77-79
        • Mihalko W.M.
        • Saleh K.J.
        • Krackow K.A.
        • Whiteside L.A.
        Soft-tissue balancing during total knee arthroplasty in the varus knee.
        J. Am. Acad. Orthop. Surg. 2009; 17: 766-774
        • Oswald M.H.
        • Jakob R.P.
        • Schneider E.
        • Hoogewoud H.M.
        Radiological analysis of normal axial alignment of femur and tibia in view of total knee arthroplasty.
        J. Arthroplast. 1993; 8: 419-426
        • Parratte S.
        • Pagnano M.W.
        • Trousdale R.T.
        • Berry D.J.
        Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements.
        J. Bone Joint Surg. Am. 2010; 92: 2143-2149
        • Picard F.
        • Deakin A.H.
        • Clarke J.V.
        • Dillon J.M.
        • Gregori A.
        Using navigation intraoperative measurements narrows range of outcomes in TKA.
        Clin. Orthop. Relat. Res. 2007; 463: 50-57
        • Ritter M.A.
        • Faris P.M.
        • Keating E.M.
        • Meding J.B.
        Post-operative alignment of total knee replacement: its effect on survival.
        Clin. Orthop. 1994; 299: 153-156
        • Ritter M.A.
        • Harty L.D.
        • Davis K.E.
        • Meding J.B.
        • Berend M.E.
        Predicting range of motion after total knee arthroplasty. Clustering, log-linear regression, and regression tree analysis.
        J. Bone Joint Surg. Am. 2003; 85-A: 1278-1285
        • Ritter M.A.
        • Lutgring J.D.
        • Davis K.E.
        • Berend M.E.
        • Pierson J.L.
        • Meneghini R.M.
        The role of flexion contracture on outcomes in primary total knee arthroplasty.
        J. Arthroplast. 2007; 22: 1092-1096
        • Russell D.
        • Deakin A.H.
        • Fogg Q.A.
        • Picard F.
        Non-invasive, non-radiological quantification of anteroposterior knee joint ligamentous laxity: a study in cadavers.
        Bone Joint Res. 2013; 2: 233-237
        • Russell D.
        • Deakin A.H.
        • Fogg Q.A.
        • Picard F.
        Non-invasive quantification of lower limb mechanical alignment in flexion.
        Computer Aided Surgery. 2014; 19: 64-70
        • Russell D.
        • Deakin A.H.
        • Fogg Q.A.
        • Picard F.
        Quantitative measurement of lower limb mechanical alignment and coronal knee laxity in early flexion.
        Knee. 2014; 21: 1063-1068
        • Russell D.
        • Deakin A.H.
        • Fogg Q.A.
        • Picard F.
        Repeatability and accuracy of a non-invasive method of measuring internal and external rotation of the tibia.
        Knee Surg. Sports Traumatol. Arthrosc. 2014; 22: 1771-1777
        • Saragaglia D.
        • Chaussard C.
        • Rubens-Duval B.
        Navigation as a predictor of tissue release during 90 cases of computer assisted total knee arthroplasty.
        Orthopaedics. 2006; 29: 137-139
        • Stockl B.
        • Nogler M.
        • Rosiek R.
        • Fischer M.
        • Krismer M.
        • Kessler O.
        Navigation improves accuracy of rotational alignment in total knee arthroplasty.
        Clin. Orthop. Relat. Res. 2004; 426: 180-186
        • Stulberg D.S.
        • Loan P.
        • Sarin V.
        Computer-assisted navigation in total knee replacement: results of an initial experience in thirty-five patients.
        J. Bone Joint Surg. Am. 2002; 84-A: 90-98
        • Swanson K.E.
        • Stocks G.W.
        • Warren P.D.
        • Hazel M.R.
        • Janssen H.F.
        Does axial limb rotation affect the alignment measurements in deformed limbs?.
        Clin. Orthop. Relat. Res. 2000; 371: 246-252
        • Unitt L.
        • Sambatakakis A.
        • Johnstone D.
        • Briggs T.W.R.
        Short-term outcome in total knee replacement after soft-tissue release and balancing.
        J. Bone Joint Surg. (Br.). 2008; 90-B: 159-165
        • Wasielewski R.C.
        • Galante J.O.
        • Leighty R.
        • Natarajan R.N.
        • Rosenberg A.G.
        Wear patterns on retrieved polyethylene tibial inserts and their relationship to technical considerations during total knee arthroplasty.
        Clin Orthop. 1994; 299: 31-43