Effect of Postoperative Mechanical Axis Alignment on the Fifteen-Year Survival of Modern, Cemented Total Knee Replacements

Background: One long-held tenet of total knee arthroplasty is that implant durability is maximized when postoperative limb alignment is corrected to 0 degrees +/- 3 degrees relative to the mechanical axis. Recently, substantial health-care resources have been devoted to computer navigation systems that allow surgeons to more often achieve that alignment. We hypothesized that a postoperative mechanical axis of 0 degrees +/- 3 degrees would result in better long-term survival of total knee arthroplasty implants as compared with that in a group of outliers. Methods: Clinical and radiographic data were reviewed retrospectively to determine the fifteen-year Kaplan-Meier survival rate following 398 primary total knee arthroplasties performed with cement in 280 patients from 1985 to 1990. Preoperatively, most knees were in varus mechanical alignment (mean and standard deviation, 6 degrees +/- 8.8 degrees of varus [range, 30 degrees of varus to 22 degrees of valgus]), whereas postoperatively most knees were corrected to neutral (mean and standard deviation, 0 degrees +/- 2.8 degrees [range, 8 degrees of varus to 9 degrees of valgus]). Postoperatively, we defined a mechanically aligned group of 292 knees (with a mechanical axis of 0 degrees +/- 3 degrees) and an outlier group of 106 knees (with a mechanical axis of beyond 0 degrees +/- 3 degrees). Results: At the time of the latest follow-up, forty-five (15.4%) of the 292 implants in the mechanically aligned group had been revised for any reason, compared with fourteen (13%) of the 106 implants in the outlier group (p = 0.88); twentyseven (9.2%) of the 292 implants in the mechanically aligned group had been revised because of aseptic loosening, mechanical failure, wear, or patellar problems, compared with eight (7.5%) of the 106 implants in the outlier group (p = 0.88); and seventeen (5.8%) of the 292 implants in the mechanically aligned group had been revised because of aseptic loosening, mechanical failure, or wear, compared with four (3.8%) of the 106 implants in the outlier group (p = 0.49). Conclusions: A postoperative mechanical axis of 0 degrees +/- 3 degrees did not improve the fifteen-year implant survival rate following these 398 modern total knee arthroplasties. We believe that describing alignment as a dichotomous variable (aligned versus malaligned) on the basis of a mechanical axis goal of 0 degrees +/- 3 degrees is of little practical value for predicting the durability of modern total knee arthroplasty implants.