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Highly variable proximal tibia anatomy causes controversies for proper tibial component rotational alignment in total knee arthroplasty: A current concept review

par Hofmann, Siegfried;Tecame, Andrea;Hirschmann, Michael Tobias;Lustig, Sebastian;Seitlinger, Gerd;Innocenti, Bernardo
Référence Knee surgery, sports traumatology, arthroscopy
Publication Publié, 2026-06-01

Article révisé par les pairs

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Abstract Purpose Rotational tibial component alignment represents a critical factor for proper patella tracking, optimal clinical outcome and preventing femorotibial mismatch. For osteoarthritic knees, substantial anatomical variability of tibia tubercle (TT) position exists. This common intraarticular tibial rotational deformity complicates decision‐making and often requires compromises, which have contributed to the lack of consensus for optimal tibial component positioning. Methods An intensive literature search has been performed in multiple databases to identify relevant laboratory studies, imaging, clinical trials, surgical techniques and current practice. The selected 95 key articles formed the basis to summarize the complex biomechanics of the patellofemoral joint, high anatomical variability of TT position and current clinical practice for tibial component rotational alignment in total knee arthroplasty (TKA). Results More than 20 reference lines and methods have been described for tibial component rotational alignment, which can be separated into three different philosophies (anatomical, functional and self‐rotational). Currently, there is no evidence that any approach yields superior patellar tracking, functional outcome and less anterior knee pain. In knees with normal TT positioning, most of these different techniques achieve satisfactory results. For TKA surgeons, it is important to identify the 30% of osteoarthritic knees with intraarticular tibial rotational deformities and correct them during surgery. Conclusion This narrative review summarizes the complex patellofemoral joint biomechanics, the high variability of intraarticular tibia axial plane deformities, and current surgical strategies for tibial component rotational alignment. It further describes methods to detect and correct intraarticular tibial rotational deformities in TKA. Level of Evidence Level V.