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Background  The anatomical axis of the femur is crucial for determining the correct alignment in corrective osteotomies of the knee, total knee arthroplasty (TKA), and retrograde and antegrade femoral intramedullary nailing (IMN). The aim of this study was to propose the concept of different anatomical axes for the proximal and distal parts of the femur; compare these axes in normally aligned subjects and also to propose the clinical application of these axes.    Methods  In this cross-sectional study, the horizontal distances between the anatomical axis of the proximal and distal halves of the femur and the center of the intercondylar notch were measured in 100 normally aligned femurs using standard full length alignment view X-rays.    Results  The average age was 34.44 ± 11.14 years. The average distance from the proximal anatomical axis to the center of the intercondylar notch was 6.68 ± 5.23 mm. The proximal anatomical axis of femur passed lateral to the center of the intercondylar notch in 12 cases (12%), medial in 84 cases (84%) and exactly central in 4 cases (4%). The average distance from the distal anatomical axis to the center of the intercondylar notch was 3.63 ± 2.09 mm. The distal anatomical axis of the femur passed medially to the center of the intercondylar notch in 82 cases (82%) and exactly central in 18 cases (18%). There was a significant difference between the anatomical axis of the proximal and distal parts of the femur in reference to the center of intercondylar notch ( P  value < 0.05), supporting the hypothesis that anatomical axes of the proximal and distal halves of the femur are different in the coronal plane.    Conclusions  While surgeons are aware that the anatomical axis of the distal part of the femur is different than the anatomical axis of the proximal part in patients with femoral deformities, we have shown that these axes are also different in the normally aligned healthy people due to the anatomy of the femur in coronal plane. Also the normal ranges provided here can be used as a reference for the alignment guide entry point in TKA and antegrade and retrograde intramedullary femoral nailing.

Anatomical axes of the proximal and distal halves of the femur in a normally aligned healthy population: implications for surgery