Achieving ligament stability and correct rotational alignment of the femur in knee arthroplasty

In a series of 90 Medial Pivot arthroplasties rotational alignment of the femur was achieved by provisionally reconstructing the lateral side of the joint and tensioning the medial side with feeler gauges. Axial CT scans were employed to measure the rotational alignment relative to surgical epicondylar axis. In valgus knees the cutting block was externally rotated to adjust for posterolateral bone loss. The mean rotational alignment of the femur was 0.6° of external rotation (S.D. 1.3, range 3° of ER to 4° of IR). The mean laxity of the medial ligament was 1 mm in flexion (SD 1, range 0–5 mm) and 0.5 mm in flexion (S.D. 0.5, range 0–2 mm) In those knees in which the medial ligament had been released the CT alignment was perfect, but when internally rotated against the hip 3–4 mm of gapping was noted. In valgus knees the mean rotation of the femoral component was 0.8° of internal rotation (S.D. 1.5, range 1° of IR to 4° of ER). In spite of externally rotating the cutting block there was still a tendency to internally rotate the femur in some knees. This simple technique achieves the two goals of ligament stability and correct rotational alignment in a high proportion of cases. It may be applicable to any instrument system which employs posterior referencing.