J Med Assoc Thai 2008; 91 (7):1051

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The Comparison of Femoral Component Rotational Alignment with Transepicondylar Axis in Mobile Bearing TKA, CT-Scan Study
Polawat P Mail, Seubchompoo O

Objective: The tibial axis referencing method with a balanced tension flexion gap at 90° knee flexion provides
adequate femoral component rotation usually in external rotation, the trans-epicondylar line being parallel
to the proximal tibial cut. The LCS mobile bearing TKA uses this technique to automatically determine the
femoral component rotation with desired tension.
The determination of the epicondyles may lead to some confusion. On the lateral side, the prominence
of the lateral condyle makes it easy to define. However, on the medial side, some surgeons use the prominent
part of the medial epicondyle (well recognized on CT scan as the most proximal ridge that gives insertion to
the superficial collateral ligament) and use the anatomical transepicondylar axis (aTEA). Other surgeons use
the depression below called sulcus that defines the surgical transepicondylar axis (sTEA).

Material and Method: The authors evaluated 40 clinically successful mobile bearing TKA in 33 patients. All
the knees were performed by single surgeon and the rotational alignment of the femoral component was
applied with balanced flexion gap technique. Post-op CT-scans were done in all knees with 2-mm interval and
measurement of the different angles (between aTEA and the prosthetic posterior condylar line and between
the sTEA and the prosthetic posterior condylar line) with the UTHSCSA Imagetool (IT) version 3 from the
University of Texas Health Science Center at San Antonio.

Results: The authors found that the mean femoral implant angle was in 2.39° (SD = 2.80°) of internal rotation
with reference to the aTEA and in 1.34° (SD = 1.57°) of external rotation with reference to the sTEA when the
medial sulcus was perfectly detected (nine knees, 22.5%). The angle between the aTEA and the sTEA was
-3.98° (SD = 1.05°). No patella subluxation was identified. Nineteen or 47.5% of the femoral components were
in internal or external femoral rotation of more than 3° to the aTEA. When sTEA was detected, no knee was in
internal or external rotation more than 3° to sTEA.

Conclusion: The balanced flexion gap technique positions the femoral component in external rotation with
the LCS TKA. Within 3° to aTEA or sTEA, this technique produced femoral rotational angle closer to sTEA
when the sulcus was detected and produced a wide range of different angles when compared to aTEA. However,
sTEA is not the consistent bony landmark. This technique is a reliable method to determine femoral
rotational alignment.

Keywords: Arthritis, Balanced flexion gap technique, Total knee arthroplasty, Transepicondylar axis, Surgical
transepicondylar technique, Anatomical transepicondylar axis, Mobile bearing, Surgical technique, Computer

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