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Alternate Alignment Technique for Total Knee Replacement

Alternate alignment is gaining popularity amongst orthopaedic surgeons. The alternate alignment principal for total knee is based on the gap balancing principal, allowing the medial and lateral soft tissue envelope to remain at their native lengths.12

It is an anatomical tibia 1st technique with subsequent femoral cuts to balance the knee within its native soft tissue envelope, Compared to mechanical alignment, use of the alternate alignment technique results in the femoral component being slightly valgus and the tibial component slightly varus, in most cases without affecting mean HKA alignment and leading to improved early functional outcomes.13

Cadaveric studies have shown alternate alignment in TKA reduces tibial forces and contact, although these studies were only performed on native rather than osteoarthritis knees.14

Howell et al.15 followed a cohort of kinematically aligned postoperative neutral and varus/valgus outliers and found no incidence of failures for any category after 31 months, with comparable functional scores for the three alignment categories.

The utility of specific postoperative target alignment categories for TKA patients was recently questioned by Rames et al.16, who found no significant benefit to functional outcomes regardless of whether patients were corrected to neutral, mild varus, severe varus or valgus mMPTA postoperatively. The authors highlight the contribution of factors other than coronal alignment toward implant survivorship, including ligament balancing and component rotation.

Unlike mechanical alignment, alternate alignment does not target a specific postoperative alignment category, instead restoring the joint line to its native alignment.

However, there is concern that, particularly for patients with severe preoperative varus or valgus alignment, this technique may increase the risk of catastrophic failure of the implants.2,9 Stan et al.17 demonstrated using finite element analysis, that knee balancing significantly reduces the contact pressure on the tibial polyethylene insert and improves prosthesis survival. The authors however caution that increasing tibial varus tilt beyond 3° may have a detrimental effect on pressure distribution across the tibial component. Further studies are therefore warranted to determine the suitability of alternative alignment for patients with constitutional varus or valgus deformity and to better understand the effect this has on risk of catastrophic failure of the tibial component.

I’m sharing intra operative Navigated resection and alignment parameters of my first 50 Alternate Aligned Knees. It shows that the Alternate alignment resection is very similar to the preoperatively templated Resection angles.

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