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Purpose  In contemporary total knee arthroplasty (TKA), most often, the goal is to align the femoral component to the epicondylar axis (EA). The posterior condylar axis (PCA) is easier to define than the EA, and thus the relationship of PCA to the EA is then used instead to align the femoral component to the EA. However, the relationship of PCA to EA is not constant and has been reported to differ between varus and valgus knees and with increasing deformity. The aim of this large MRI-based study was to evaluate the relationship between PCA and EA with varying coronal deformity especially with increasing valgus deformity.    Methods  EA, PCA, AP (Whiteside’s line) and the mechanical axis were obtained from 474 magnetic resonance imaging (MRI) scans used to create patient-specific instrumentation (PSI) for the Biomet Signature (Warsaw, NJ) system.    Results  The relationship of EA relative to the PCA showed considerable heterogeneity in both varus and valgus groups. In the valgus group, there was statistically greater external rotation ( P  < 0.05) of the EA from the PCA with a mean of 2.52° (range − 1.9° to 6°) compared to the varus group with a mean of 2.03° (range − 3.9° to 6.9°). This relationship did not significantly change with increasing severity of coronal malalignment.  Externally rotating the femoral cutting guide by 3° from the PCA, 11% (42 of 382) of varus knees would lie outside of ± 3° from EA. In valgus knees, externally rotating the femoral cutting block by 3° or 5° from the PCA, 6.5% (6 of 92) and 33.7% (31 of 92) of knees, respectively, would lie outside of ± 3° from EA.    Conclusion  The relationship of PCA to EA is heterogeneous and is not altered significantly with increasing valgus coronal deformity. External rotation beyond 3° from PCA in valgus knees may lead to significant femoral component malrotation in a large proportion cases.

How coronal alignment affects distal femoral anatomy: an MRI-based comparison of varus and valgus knees