The flexion space is more reliably balanced when using the transepicondylar axis as compared to the posterior condylar line.

Purpose: The purpose of this study was to evaluate the differences in flexion space balance when the femoral component is implanted parallel to the surgical transepicondylar axis (TEA) or with 3° of external rotation from the posterior condylar line (PoCoLi). It was hypothesized that implantation parallel to the TEA will produce a more reliably balanced flexion space.
Methods: Forty-eight consecutive patients with a varus deformity were prospectively randomized to undergo total knee arthroplasty with a femoral component implanted parallel the TEA, or with 3° of external rotation from the PoCoLi. The posterior condylar angle (PCA) was measured. Intraoperative load measurements were taken at 10°, 45°, and 90° of flexion.
Results: The PCA was similar between groups (TEA group: 4.2° ± 1.5° and PoCoLi group: 4.0° ± 1.3°; n.s.). The mean difference in load values between the medial and lateral compartments was significantly lower in the TEA group than in the PoCoLi group at the 45 (0 ± 8 vs. 9 ± 13 lbs; respectively, p = 0.008) and 90° flexion angles (1 ± 9 vs. 10 ± 15 lbs; respectively, p = 0.01). The PoCoLi group had a linear increase in the difference of load values between the medial and lateral compartments with increasing magnitude of the posterior condylar angle (45°, p = 0.0013; 90°, p = 0.0006), but this was not observed in the TEA group.
Conclusion: Femoral component implantation parallel to the TEA resulted in a more balanced flexion gap as compared to implantation at 3° of external rotation from the PoCoLi. The intraoperative use of the TEA rather than the PoCoLi to set femoral component rotation may provide a more balanced flexion space and decrease the need for extensive soft tissue releases.
Level of Evidence: II.