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Background  Although several reference axes have been established for determining femoral rotational alignment during total knee arthroplasty (TKA), the most accurate axis is undetermined. This study determines the relationship between the posterior cortical axis (PCA) and the trochlear anterior line (TAL) of the femur in relation to the epicondylar axis.    Methods  A total of 341 patients who underwent TKA for osteoarthritis were enrolled. Patients who had undergone previous bony surgery or replacement that might have changed the femoral geometry were excluded. Finally, 336 patients (200 females and 136 males) were included in the study. The angles between the transepicondylar axis (TEA) and TAL and TEA and the femoral PCA (FPCA) were evaluated. We also assessed whether there was any significant differences in variance and gender in these two angles. Student’s  t  tests were used to determine the significance of coronal alignment and any gender-based differences. The variances between the TAL/TEA and FPCA/TEA angles were compared using  F  tests.    Results  The FPCA was externally rotated by 2.6° ± 3.6°, and the trochlear anterior line was internally rotated by 5.2° ± 5.5°, relative to the TEA. Gender-based differences were observed in the comparisons between anatomical references and TEA.    Conclusions  The FPCA is a more conservative landmark than the TAL for intraoperative or postoperative approximation of the TEA. When conventional reference axes, such as the posterior condylar axis and the anteroposterior axis, are inaccurate, surgeons can refer to this alternative reference. These findings demonstrate that the FPCA may be useful for determining the rotational alignment of the femoral component before and during TKA.

The posterior cortical axis as an alternative reference for femoral component placement in total knee arthroplasty