Does Postoperative Mechanical Axis Alignment Have an Effect on Clinical Outcome of Primary Total Knee Arthroplasty? A Retrospective Cohort Study

Mikhail Salzmann1, Peter Fennema2, Roland Becker1, Hagen Hommel3, 4, *
1 Hochschulklinikum der MHB Theodor Fontane, Städtisches Klinikum Brandenburg GmbH, Center of Orthopedics and Traumatology, Hochstraße 29, 14770 Brandenburg an der Havel, Germany
2 AMR Advanced Medical Research GmbH, Hofenstrasse 89b, 8708 Männedorf, Switzerland
3 KH-MOL GmBH Sonnenburger Weg 3, 16269 Wriezen, Germany
4 Medizinische Hochschule Brandenburg (MHB), Theodor Fontane, Fehrbelliner Straße 38, 16816 Neuruppin, Germany

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© 2017 Salzmann et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the KH-MOL GmbH, Sonnenburger Weg 3, 16269 Wriezen, Germany, Tel: +49 3345640401, Fax: +49 3345640402, Email:



There is an ongoing debate whether patients with constitutional varus should be restored to neutral mechanical alignment following total knee arthroplasty (TKA).


The aim of this retrospective cohort study is to determine whether mild unintentional postoperative varus alignment (3°–6°) influences TKA outcome in patients with and without preoperative varus alignment due to medial osteoarthritis of the knee.


We analyzed 172 consecutive TKA cases between April 2011 and May 2014. Patients were divided into four groups based on their preoperative and postoperative hip-knee-ankle angles (HKA): preoperative varus ≤ 3° with postoperative varus position ≤ 3° (Group 1, n = 47); preoperative varus >3° with postoperative varus ≤ 3° (Group 2, n = 104); preoperative varus ≤ 3° with postoperative varus malalignment > 3° (Group 3, n = 3); and preoperative varus > 3° with postoperative varus malalignment > 3° (Group 4, n = 18). Patients were followed up until 2 years postoperatively.


Knee Society Score and Western Ontario and McMaster University Osteoarthritis Index scores for all study groups increased following TKA, with no postoperative differences at any time point. Group 4 performed significantly better on the Forgotten Joint Score than Group 2 (p = 0.019). Group 4 performed significantly better on the High Flexion Knee Score than Group 2 (p = 0.004) and Group 1 (p = 0.019). All other between-group differences were not statistically significant.


Residual postoperative varus alignment of the lower limb does not appear to adversely affect clinical outcome following TKA for varus-type osteoarthritis.

Keywords: Osteoarthritis, knee, Total knee arthroplasty, Constitutional varus, Clinical outcome, Surgical accuracy, Retrospective cohort study.