Distal femur rotational alignment and patellar subluxation: A CT scan in vivo assessment

Background: Patellofemoral instability following total knee arthroplasty is a very common complication which may result from a defective rotational positioning of the femoral component. However, rotational landmarks for optimal orientation are not unequivocal. Moreover, no proven correlation has yet been established between preexisting rotational malposition and patellofemoral instability occurrence. Hypothesis: Any preexisting distal femoral rotational misalignment is associated with a preoppatellofemoral instability in arthritic knees prior to undergoing arthroplasty. A prospective diagnostic study was conducted to test this hypothesis on the basis of morphometric data. Material and methods: One hundred and eighteen patients were prospectively enrolled in this study. Patellar lateralization was measured on 30 degrees flexion patellofemoral views. Three positionings were arbitrarily defined (less than 3mm of lateralization, between 3 and 5mm, over 5 mm). Three angles were preoperatively measured using CT scans: (1) the posterior condylar angle between posterior bicondylar axis and transepiphyseal axis, (2) the anterior trochlear angle between transepicondylar axis and trochlear opening plane, (3) the sum of anterior trochlear and posterior condylar angles finally formed the global trochlear opening angle. Results: The patella was centered in 86 cases and lateralized in 32 cases (less than 5mm in 25 cases and over 5mm in seven cases). Independently from the degree of patellar lateralization, the global trochlear opening angle was constant (p = 0,41). The value of the posterior condylar angle was statistically inferior when patella was centered (p = 0,01; r = 0,44). The value of the anterior trochlear angle varied opposite to the posterior condylar angle. Femoral anteversion, position of the anterior tibial tuberosity and tibiofemoral index could not be correlated with patellar positioning. No relationship could be established between patellar lateralization and overall torsional deformities of the lower extremity. Conclusion: The centering of the patella in arthritic knees depends on distal femoral osseous factors which determines the posterior condylar angle and anterior trochlear angle on either side of the transepicondylar axis. Since the trochlear opening angle is constant, the obliquity of the transepicondylar axis appears crucial in patellar lateralization. A better understanding of the influence of distal femoral morphology on patellar positioning will ensure improved positioning of femoral components in total knee arthroplasties or in isolated femoropatellar joint replacements. Level of Evidence III: Prospective diagnostic study. (C) 2009 Elsevier Masson SAS. All rights reserved.