RES E A R C H Open Access
Three-dimensional analysis of the tibial
resection plane relative to the arthritic
tibial plateau in total knee arthroplasty
J. Michael Johnson
, Mohamed R. Mahfouz
, Mehmet Rüştü Midillioğlu
, Alexander J. Nedopil
and Stephen M. Howell
Background: Kinematically aligned total knee arthroplasty strives to correct the arthritic deformity by restoring the
native tibial joint line. However, the precision of such surgical correction needs to be quantified in order to reduce
recuts of the resection and to design assisting instrumentation. This study describes a method for novel three-
dimensional analysis of tibial resection parameters in total knee arthroplasty. Pre-operative versus post-operative
differences in the slopes of the varus-valgus and flexion-extension planes and the proximal-distal level between the
tibia resection and the arthritic tibial joint line can reliably be measured using the three-dimensional models of the
tibia and fibula. This work uses the proposed comparison method to determine the parameters for resecting the
tibia in kinematically aligned total knee arthroplasty.
Methods: Three-dimensional shape registration was performed between arthritic surface models segmented from pre-
operative magnetic resonance imaging scans and resected surface models segmented from post-operative computed
tomography scans. Mean, standard deviation and 95% confidence intervals were determined for all measurements.
Results: Results indicate that kinematically aligned total knee arthroplasty consistently corrects the varus deformity and
restores the slope of the flexion-extension plane and the proximal-distal level of the arthritic tibial joint line. The slope of
the varus-valgus plane is most precisely associated with the overall arthritic slope after approximately 3° of correction and
the posterior slope is biased towards the overall arthritic plateau, though less precisely than the varus correlation.
Conclusions: Use of this analysis on a larger population can quantify the effectiveness of the tibial resection for correcting
pathologies, potentially reduce imprecisions in the surgical technique, and enable development of instrumentation that
reduces the risk of resection recuts. The kinematic alignment technique consistently corrects varus deformities.
Keywords: Total knee arthroplasty, Arthritic tibia, Kinematics, Tibial resection, Three-dimensional surgical planning,
Tibial plateau, Tibial joint line, Kinematic Alignment
Varus alignment of the tibial component is associated
with tibial loosening in total knee arthroplasty (TKA)
(Jeffery et al. 1991; Windsor et al. 1989). Kinematically
aligned (KA) TKA strives to correct the arthritic
deformity and restore the native varus-valgus (V-V) and
flexion-extension (F-E) planes and the proximal-distal
(P-D) level of the tibial joint line. Despite work assessing
the promising post-operative outcomes of KA TKA
(Dossett et al. 2012; Howell et al. 2013a), a straightforward
femoral resection technique (Howell et al. 2017), and post-
operative limb alignment (Dossett et al. 2014; Ji et al.
2016), there remain uncertainties regarding the precision
for placing the tibial component. This aim of this study is
to better understand the three-dimensional orientation of
the tibial resection to allow surgeons to achieve reprodu-
cible outcomes. Providing quantification of the resection
may also provide an avenue to reduce recuts of the resec-
tion and design assisting instrumentation.
* Correspondence: email@example.com
Department of Mechanical, Aerospace and Biomedical Engineering, The
University of Tennessee, 307 Perkins Hall, 1506 Middle Drive, Knoxville, TN
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Johnson et al. Journal of Experimental Orthopaedics (2017) 4:27