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Changes in coronal knee-alignment parameters during the osteoarthritis process in the varus knee

Open AccessPublished:January 13, 2023DOI:https://doi.org/10.1016/j.jisako.2022.12.002

      Abstract

      Objectives

      The idea to aim for an ‘individualized’ alignment, whereby the constitutional alignment is restored, has gained much interest among knee surgeons. This requires insight into the pre-diseased, natural alignment of our patients’knees.The aim of this study is (1) to determine how the Hip-Knee-Ankle (HKA) angle is influenced during the arthritic process and (2) to investigate the correlation between joint line changes and the progression of osteoarthritis (OA). It is our hypothesis that the most pronounced coronal parameter changes appear at the proximal tibia and at the joint line.

      Methods

      One hundred sequential full-length X-rays with a minimum follow-up of 1 year were retrospectively reviewed from a radiographic joint database. Patients had to be at least 50 years of age needed to have an HKA-angle of more than 1,3° varus to be included. Patients with ipsilateral total hip arthroplasty, femoral or tibial fracture, osteotomy or ligamentous repair were excluded.15 alignment parameters were investigated on the sequential full-length X-rays. Moreover, the relationship between the alignment parameters and the Kellgren-Lawrence grade (KL-grade) was determined by using linear mixed models.

      Results

      A progressive KL-grade is associated with an increase of the HKA (p < 0.001). Mostly, HKA differs due to decrease of the medial tibial plateau (MPTA)-angle (0,93°) and an increase of the joint line angle (JLCA)(0,86°). The mLDFA demonstrated the most pronounced changes in the beginning of OA (KL-grade 1-2)(p=0.049). In particular, the MPTA becomes considerably smaller (p = 0.004) in the later stage of OA(KL-grade 3). Also, a progressive increase of the JLCA (p < 0.001) is observed upward of KL grade 3.

      Conclusion

      By comparing consecutive full-length x-rays in the same patients, it is possible to define the coronal alignment changes during the arthritic process. The HKA-angle increases according the arthritic progression, whereby the most pronounced changes appear at the proximal tibia (MPTA) and at the joint line (JLCA).The alignment changes in varus OA knees can be divided in 3 stadia: (1) erosion of the distal medial femoral condyle, (2) erosion of the medial tibial plateau and (3) a progressive increase of the joint line angle.

      Level of Evidence

      Therapeutic Study, Level III.

      Keywords

      Compliance with ethical standards

      Conflict of interest

      None to declare.

      Funding

      This study is part of Limburg Clinical Research Center supported by Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital.

      Ethical approval

      Not applicable.

      Informed consent

      Not applicable.

      Authors’ contributions

      WC: Designed the study, Performed the radiographic measurements, analyzed and inter-preted the data, prepared the manuscript.LB: performed the statistical analysis, analyzed and interpreted the data LS: analyzed and interpreted the data, reviewed the manuscript.
      JT: analyzed and interpreted the data, reviewed the manuscript KS: designed the study, analyzed and interpreted the data, reviewed the manuscript JB: designed the study, analyzed and interpreted the data, reviewed the manuscript.

      What are the new findings

      This is the first article whereby sequential X-rays of patients were used. Therefore, it was possible to clarify the radiographic changes during the arthritic process of the knee.
      We found that the first alterations towards increasing varus occurs at the femoral site, whereby an erosion of the medial femoral condyle appears. Secondly, an erosion of proximal medial tibial plateau occurs and finally a lateral ligamentous laxity causes an increased lateral joint opening.

      Introduction

      Restoring the alignment to neutral in total knee arthroplasty (TKA) could be perceived as unnatural for a substantial fraction of the population
      • Bellemans J.
      • Colyn W.
      • Vandenneucker H.
      • Victor J.
      The Chitranjan Rananat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus.
      . Further research has indeed shown that a mild undercorrection of the varus deformity during TKA was associated with better clinical and functional outcome scores
      • Beckers L.
      • Colyn W.
      • Bellemans J.
      • Victor J.
      • Vandekerckhove P.-J.
      The contralateral limb is no reliable reference to restore coronal alignment in.
      . A study by Parratte suggests a patient-specific ideal target for postoperative alignment which does not necessarily lie within 0° ± 3°
      • Parratte S.
      • Pagnano M.W.
      • Trousdale R.T.
      • Berry 282 D.J.
      Effect of mechanical axis alignment on fifteen-year survival of modern, cemented total knee replacement.
      . This supports Howell’s idea to aim for an ‘individualized’ alignment, whereby the pre-arthritic or native limb alignment is restored
      • Vanlommel L.
      • Vanlommel J.
      • Claes S.
      • Bellemans J.
      Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees.
      ,
      • Kellgren J.H.
      • Lawrence J.S.
      Radiological assessment of osteo-arthrosis.
      . However, restoring the natural, subject-specific alignment, requires insight in the original, pre-diseased natural alignment of the patient.
      Previous studies have suggested using the unaffected contralateral limb as a template for the arthritic limb but have failed to prove sufficient reliability
      • Vandekerckhove P.-J.T.K.
      • Matlovich N.
      • Teeter M.G.
      • MacDonald S.J.
      • Howard J.L.
      • Lanting B.A.
      The relationship between constitutional alignment and varus osteoarthritis of the.
      . Hence, the use of the contralateral limb to reconstruct the pre-diseased alignment is not encouraged
      • Beckers L.
      • Colyn W.
      • Bellemans J.
      • Victor J.
      • Vandekerckhove P.-J.
      The contralateral limb is no reliable reference to restore coronal alignment in.
      . Therefore, if it is only reliable to use the affected limb, the changes on the overall knee alignment through the arthritic process have to be understood to determine the pre-diseased alignment.
      Through the process of osteoarthritis, the cartilage thickness reduces, and erosion of the subchondral bone increases. As a consequence, leg alignment will change over time. A previous study by Thienpont et al. already mentioned the correlation between the varus alignment and MPTA, as well as the JLCA
      • Eckstein F.
      • Wirth W.
      • Huldelmaier M.
      • Stein V.
      • Lengfelder V.
      • Cahue S.
      • Marshall M.
      • Prasad P.
      • Sharma L.
      Patterns of Femorotibial Cartilage Loss in Knees With Neutral, Varus, and Valgus Alignment.
      . Other studies have also confirmed the strong correlation between the MPTA and the HKA
      • Bellemans J.
      • Colyn W.
      • Vandenneucker H.
      • Victor J.
      The Chitranjan Rananat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus.
      ,
      • Thienpont E.
      • Schwab P.E.
      • Cornu O.
      • Bellemans J.
      • Victor J.
      Bone morphotypes of the varus and valgus knee.
      ,
      • Shetty G.M.
      • Mullaji A.
      • Bhayde S.
      • Wook Nha K.
      • Keun Oh H.
      Factors contributing to. inherent varus alignment of lower limb in normal Asian adults.
      . Also, some studies have suggested that varus deformity increases as a result of distal femoral wear. Victor et al. have noted that progressive varus OA is also associated with changes in the tibial joint line angle. However, none of these studies could rely on longitudinal assessments within patients as cross-sectional comparisons were only made
      between different patients at different arthritic stages. By using such study design within subject evolutions cannot be fully elucidated. Moreover, all these studies relied on X-ray assessments without correcting for potential rotational errors, which is a well-known limitation of two-dimensional full-length X-rays
      • Beckers L.
      • Colyn W.
      • Bellemans J.
      • Victor J.
      • Vandekerckhove P.-J.
      The contralateral limb is no reliable reference to restore coronal alignment in.
      ,
      • Maderbacher G.
      • Baier C.
      • Benditz A.
      • Wagner F.
      • Greimel F.
      • Grifka J.
      Presence of.rotational errors in long leg radiographs after total knee arthroplasty and impact on measured lower limb and component alignment.
      ,
      • Nam D.
      • Shah R.R.
      • Nunley R.M.
      • Barrack R.L.
      Evaluation of the 3-dimensional, weight307 bearing orientation of the normal adult knee.
      .
      The aim of this study was: (1) to longitudinally investigate the changes in Hip Knee Ankle (HKA)-angle throughout the different arthritic stadia at mid-term follow up, and (2) to investigate the correlation between joint line changes and progression of OA. It was our hypothesis that the most pronounced coronal parameter changes appear at the proximal tibia and at the joint line.

      Patients and Methods

      Patient selection

      Using the (A) radiographic joint database, all full-length X-rays between 2014 and 2019 were
      retrospectively reviewed. The study was admitted by the Ethics Committee of (A) (internal ref
      nr 18/0088R). Inclusion required sequential full-length X-rays with a minimum follow-up of 1 year, patients were at least 50 years of age and had an HKA-angle of more than 1.3° varus at the time of the first available X ray as 1.3° was determined as the mean HKA-angle in a young healthy population in earlier research
      • Bellemans J.
      • Colyn W.
      • Vandenneucker H.
      • Victor J.
      The Chitranjan Rananat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus.
      . Full-leg radiographs had to be obtained while the patellae were facing forward
      • Bellemans J.
      • Colyn W.
      • Vandenneucker H.
      • Victor J.
      The Chitranjan Rananat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus.
      ,
      • Moreland J.R.
      • Basset L.W.
      • Hanke G.J.
      Radiographic analysis of the axial alignment of the lower extremity.
      ,

      Paley D. Principles of Deformity Correction. Heidelberg, Germany: Springer-Verlag; 2003:1–60.

      . Patients presenting with an ipsilateral total hip arthroplasty (THA), preoperative femoral or tibial fracture, osteotomy or ligamentous repair were excluded.
      From the 948 patients extracted from the database, 341 were excluded for insufficient varus, 36 for age, 268 for inadequate follow-up, 93 for extreme mispositioning, 76 for ipsilateral THP and 34 for fracture or ligamentous repair. 100 patients were included for measurement analysis. Information from two X-rays was available for every patient. Of these, 31 were excluded because of less than 0.5° difference between the measurements, which can be explained by rotational or measurement errors. Finally, 69 patients were included for statistical analysis.

      Radiographic measurements

      All radiographic measurements were performed by the same person (B) using the AGFA PACS software package (Agfa-Gevaert), with a documented measurement accuracy up to 0,1°
      • Beckers L.
      • Colyn W.
      • Bellemans J.
      • Victor J.
      • Vandekerckhove P.-J.
      The contralateral limb is no reliable reference to restore coronal alignment in.
      . In total, 14 alignment parameters were measured using previously described techniques. (1) The HKA angle was formed by the mechanical femoral axis and the mechanical tibial axis. (2) The Mechanical axis deviation (MAD) was measured as the distance between the mechanical axis line and the center of the knee. (3) The mechanical lateral distal femoral angle was defined as the lateral angle formed between the mechanical femoral axis and the knee joint line of the distal femur. (4) The medial angle formed between the mechanical tibial axis and the knee joint line of the proximal tibia was defined as the medial proximal tibial angle (MPTA). (5) The joint line convergence angle (JLCA) is the angle between the knee joint lines of the distal femur and the proximal tibia. (6) The angle between the parallel of the floor and the joint line of the distal femur was defined as the femoral joint line angle (FJLA).(7) The tibial joint line angle(TJLA) was formed between the proximal tibial joint line and the parallel of the floor
      • Victor J.M.K.
      • Bassens D.
      • Bellemans J.
      • Gürsu S.
      • Dhollander A.A.M.
      • Verdonk P.
      Constitutional varus does not affect joint line orientation in the coronal plane.
      . (8)A lateral open angle was expressed by a positive value and a medial open angle by a negative value. (9)The medial opening was measured as the distance between the medial tibial plateau and the surface of the medial femoral condyle. (10) This distance at the lateral side was determined as the lateral opening. (11) The medial neck-shaft angle (MNSA) was formed by the anatomic axis of the femur and the bisector of the femoral neck. (12) The angle formed by the mechanical and anatomic axis of the femur was called the knee valgus proximal angle (KVPA). (13) The angle between the line connecting the tip of the greater trochanter with the center of the femoral head and the mechanical femoral axis was defined as the lateral proximal femoral angle (LPFA). (14) The lateral angle angle formed by the mechanical axis of the tibia and the joint line of the proximal talus was defined as the lateral distal tibial angle (LDTA). (15) The distance measured between both medial malleoli was defined as the inter-malleolar distance (IM-distance).
      The degree of osteoarthritis was determined based on the Kellgren-Lawrence scale (KL-scale)
      • Kellgren J.H.
      • Lawrence J.S.
      Radiological assessment of osteo-arthrosis.
      . The formula of Maderbacher was used to correct possible rotational errors due to the use of two-dimensional full-length X-rays
      • Maderbacher G.
      • Baier C.
      • Benditz A.
      • Wagner F.
      • Greimel F.
      • Grifka J.
      Presence of.rotational errors in long leg radiographs after total knee arthroplasty and impact on measured lower limb and component alignment.
      . Therefore, some additional measurements were performed: the assessment of the lower limb rotation was based on the proximal fibular width (C), the distance between the lateral fibular cortex and the lateral tibial cortex (visible part of the fibula (E)), the distance between the tip of the fibula and the lateral tibal cortex (overlapped part of the fibular tip (B)) and the distance between the lateral fibular cortex and the fibular tip (B+E). The rotation was calculated using following formula
      • Maderbacher G.
      • Baier C.
      • Benditz A.
      • Wagner F.
      • Greimel F.
      • Grifka J.
      Presence of.rotational errors in long leg radiographs after total knee arthroplasty and impact on measured lower limb and component alignment.
      : rotation = −14.20 − 0.17 ∗ 100 ∗EC+ 0.35 ∗ 100 ∗BC+ 0.31 ∗ 100 ∗(B+E)C. For each increase with one degree of rotation, measured femoral parameters (mLDFA,KVPA,MNSA,LPFA and FJLA) increased by a factor of 0.0824, tibial measurements (MPTA,LDTA and TJLA) by a factor of 0.0504 and JLCA by a factor of 0.0664. The HKA was corrected by the rotation multiplied by 0.0697 in fully extended knees. Only patients with an increase of > 0.5° in HKA between two measurements were included for statistical analysis.

      Statistical methods

      Linear mixed models were used to investigate the association between (1) HKA or IM distance and the other angles and (2) the angles and the Kellgren-Lawrence scale

      Verbeke, G. and Molenberghs, G. Linear Mixed Models for Longitudinal Data . Springer-Verlag New York. 2000.

      . More specifically the following models were fitted. Models with either HKA or IM distance as dependent variable and one of the other alignment parameters as independent variable (predictor). Models with one of the angles as dependent variable and KL-grade as a categorical predictor, allowing for non-linear associations between the alignment parameters and degree of arthrosis. Every patient contributes data for both knees. This correlation between these two measurements needs to be taken into account in the statistical model. Therefore, a random patient effect was included in the linear mixed models (Verbeke & Molenberghs, 2000). The alignment parameters corrected for rotation were used in these models. And only those patients with an increase of > 0.5° in (for rotation corrected) HKA between the two measurements were included in the statistical analysis.

      Results

      In total fifty five patients equalling 110 knees were finally included. Of those knees, 14 had a KL-grade of I, 31 were a KL-grade II, 41 a KL grade III and 24 knees were rated as KL grade IV.
      The mean follow-up between two sequential X-rays was 2 years (1.0 yrs. – 4.5 yrs.). The mean change Δ in HKA in this period was 1.69° (SD, 1.20°). For mLDFA, MPTA, JLCA and LDTA is the mean change Δ was 0.27°(SD, 1.19°), -0.46°(SD, 1.09°), 0,96°(SD,1.26°) and -1.32° (SD,3.44°) respectively. An increase in KL-grade lead to an increase in HKA-angle (p < 0.001), JLCA (p < 0.001) and FJLA (p = 0.001) and lateral opening (p < 0,001). In contrast, the MPTA (p = 0.004), LDTA (p = 0.012) and the medial opening (p < 0,001) all decreased when the KL-grade increased (fig 1). The associations between KL-grade and mLDFA, KVPA and TJLA were not statistically significant,unless a linear trend is assumed (mLDFA (p=0.049), KVPA (p=0.021) and TJLA (p = 0.038)). mLDFA and TJLA showed the most pronounced changes between KL-grade I to KL-grade II. The opposite was observed for MPTA and FJLA, whereby the greatest decrease occurred between KL-grade II to IV (fig. 2). There was no association between MNSA (p = 0.258) or LPFA (0.292) and a more advanced KL-grade.
      Fig. 1
      Fig. 1Association between all significant alignment parameters and Kellgren-Lawrence scale. A progression of arthrosis will strongly influence the medial tibial plateau (MPTA) (p = 0.004), lateral distal tibial angle (LDTA) (p = 0.011), lateral opening (lat_op)(p < 0.001), medial opening (med_op)(p < 0.001) and the joint line ((FJLA (p = 0.001) and (JLCA) (p < 0.001)) The overall HKA-angle is correlated to the KL-grade (p<0.001).
      Fig. 2
      Fig. 2An illustration of the changes of mLDFA,TJLA,MPTA and FJLA correlated with the progression of KL-grade. mLDFA and TJLA changes in the beginning of the curve, in contrast of MPTA and FJLA who changes at the end of the curve
      The most pronounced changes in JLCA-angle were also observed between KL-grade 2 to 4 (fig 3). Changes in the medial opening were most consistently seen in KL-grades 2 to 3. The lateral opening began to increase progressively from KL-grade 1 onwards. In comparison, there was a decrease in the medial opening (slope = -0.3347; p = 0.257) and a sharper increase in the lateral opening (slope = 0.6308, p = 0.007)where the KL grade was above 3. The IM-distance was only associated with FJLA (p < 0.001; rsquare = 12.) and TJLA (p < 0.001; rsquare = 18.2). IM-distance and HKA-angle shower no association with eachother. The association between the HKA-angle and the other alignment parameters was described by means of linear mixed models (fig. 4). There was a positive association between HKA and FJLA (p < 0.001; rsquare = 9.1), mLDFA (p < 0.0001; rsquare = 11.4) and JLCA (p < 0.001; rsquare = 29.6). Conversely, a negative association was found between the HKA-angle and MPTA (p < 0.001; rsquare = 37.6).
      Fig. 3
      Fig. 3An illustration of the joint line changes correlated with the progression of KL-grade. The steepest slope of the curve is observed between KL-grade 2 and 4 for JLCA and the medial opening. The lateral opening increases progressively.
      Fig. 4
      Fig. 4An increase of 1 degree in MPTA decreased the HKA by 0.93°. An increase of 1 degree in FJLA, mLDFA and JLCA was associated with an increase of the HKA of respectively 0.45° , 0.61° and 0.86°.
      An increase of 1 degree in MPTA resulted in a decrease in the HKA by 0.93°. An increase of 1 degree in FJLA,mLDFA and JLCA was associated with an increase in the HKA of 0.45°, 0.61° and 0.86° respectively.

      Discussion

      The main objective of this study was to better understand the radiographic changes of a varus knee during arthritic evolution. In the mild arthritic stage, the knee alignment changes due to an erosion of the distal medial femoral condyle. In a more progressive arthritic stage, erosions of the medial tibial plateau will progressively change the knee alignment. The Joint line angle becomes progressively higher during the arthritic process: the lateral opening, a radiographic sign of the ligamentous laxity, progressively rises during the arthritic process. The change in the overall knee alignment of varus OA knees was mostly determined by a decrease of the medial tibial plateau angle and an increasing joint line convergence angle.
      These findings confirm earlier conclusions made by Thienpont et al
      • Thienpont E.
      • Schwab P.E.
      • Cornu O.
      • Bellemans J.
      • Victor J.
      Bone morphotypes of the varus and valgus knee.
      . They included 96 patients with a pre-op OA knee on one side and a non-arthritic knee on the contralateral side. Other studies also confirmed the strong correlation between the MPTA and the HKA
      • Bellemans J.
      • Colyn W.
      • Vandenneucker H.
      • Victor J.
      The Chitranjan Rananat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus.
      ,
      • Thienpont E.
      • Schwab P.E.
      • Cornu O.
      • Bellemans J.
      • Victor J.
      Bone morphotypes of the varus and valgus knee.
      ,
      • Shetty G.M.
      • Mullaji A.
      • Bhayde S.
      • Wook Nha K.
      • Keun Oh H.
      Factors contributing to. inherent varus alignment of lower limb in normal Asian adults.
      . Although, none of them used sequential X-rays, whereby reliable alignment changes could not be investigated. By using several radiographs at a different stage of the arthritic process, it was possible to investigate the influence of arthrosis on the overall knee alignment. A previous study on the patterns of the femoral cartilage loss had already concluded that the correlations between cartilage thickness changes and the HKA-angle were stronger for the tibia than for the femur in varus knees
      • Eckstein F.
      • Wirth W.
      • Huldelmaier M.
      • Stein V.
      • Lengfelder V.
      • Cahue S.
      • Marshall M.
      • Prasad P.
      • Sharma L.
      Patterns of Femorotibial Cartilage Loss in Knees With Neutral, Varus, and Valgus Alignment.
      . These findings support our findings of higher estimated changes in MPTA in comparison with the mLDFA.
      Based on our findings, the change of alignment during the arthritic process can radiographically be divided into three stages: First, an increase of mLDFA and TJLA occurs. Second, the MPTA becomes smaller and the FJLA increases. Thirdly, JLCA increases importantly. This means that the first alterations towards increasing varus occurs at the femoral site, whereby an erosion of the medial femoral condyle appears. Secondly, an erosion of proximal medial tibial plateau occurs and finally a lateral ligamentous laxity causes an increased lateral joint opening.
      Based on the findings of Cooke, Victor et al already suggested that 220 bone loss occurred at the level of the distal femur
      • Victor J.M.K.
      • Bassens D.
      • Bellemans J.
      • Gürsu S.
      • Dhollander A.A.M.
      • Verdonk P.
      Constitutional varus does not affect joint line orientation in the coronal plane.
      . We only observed this phenomenon in the earlier first stadium of arthrosis. When OA proceeds to KL grade III-IV the femoral changes become less important. On the contrary, the changes at the tibial side becomes more determinant. Victor also described that the resulting varus deformity would push the knee outward.
      Thereby, the position of the tibial mechanical axis will change with respect to the floor, which explains the changes of the TJLA
      • Victor J.M.K.
      • Bassens D.
      • Bellemans J.
      • Gürsu S.
      • Dhollander A.A.M.
      • Verdonk P.
      Constitutional varus does not affect joint line orientation in the coronal plane.
      . Previous research mentioned a progressive insufficiency of the lateral ligamentous complex appears to be associated with the end stage of varus OA knees
      • Thienpont E.
      • Schwab P.E.
      • Cornu O.
      • Bellemans J.
      • Victor J.
      Bone morphotypes of the varus and valgus knee.
      ,
      • Eckstein F.
      • Wirth W.
      • Huldelmaier M.
      • Stein V.
      • Lengfelder V.
      • Cahue S.
      • Marshall M.
      • Prasad P.
      • Sharma L.
      Patterns of Femorotibial Cartilage Loss in Knees With Neutral, Varus, and Valgus Alignment.
      ,
      • Victor J.M.K.
      • Bassens D.
      • Bellemans J.
      • Gürsu S.
      • Dhollander A.A.M.
      • Verdonk P.
      Constitutional varus does not affect joint line orientation in the coronal plane.
      ,
      • Cooke T.D.V.
      • Scudamore A.
      • Greer W.
      Varus knee osteoarthritis: whence the varus?.
      . We found that the lateral opening of the joint increases progressively from the beginning of the arthritic process.
      At the end of this process, changes of the lateral opening are more prominent than the decrease in the medial opening. The decrease in medial opening is caused by the loss of medial cartilage. Due to the Kellgren-Lawrence classification, the medial opening will diminish since a KL-grade I is classified by a doubtful narrowing of the joint space and a KL grade IV for means that there is a severe narrowing of the joint space. So, the gradual decrease in medial opening mentioned that the KL-scale was used adequately. The increase of the lateral opening can only be declared by the progressive laxity of the lateral ligamentous complex.
      The most important clinical relevance of this study lies in the possibility to determine the prediseased knee phenotype. This is increasingly recognized as the most relevant feature to restore the constitutional alignment and to develop customized knee components.
      This study has several limitations. First, weight-bearing full-leg radiographs were used. The three-dimensional geometry of the limb is projected in two dimensions, whereby the rotational position of the lower extremities may influence the outcome of the measurement. Especially when comparing consecutive X-rays of one patient, the consequences of rotation on the alignment has to be known. A perceived varus could in fact be a more external rotation of the limb. To tackle this issue, rotational corrections were calculated based on the formula of Maderbacher et al
      • Maderbacher G.
      • Baier C.
      • Benditz A.
      • Wagner F.
      • Greimel F.
      • Grifka J.
      Presence of.rotational errors in long leg radiographs after total knee arthroplasty and impact on measured lower limb and component alignment.
      . Second, all the measurements were observed by one single investigator. The results could be influenced by the accuracy of the investigator. However, a single observer assures consistency. Third, the time interval between the sequential radiographs is relatively short (maximum 4.5 years). The reason for this is that older radiographs were performed by different digital radiography systems and so had to be excluded to ensure the accuracy of the X-ray images.
      By using sequential X-rays of the patients, it was possible to investigate the effect of the inter malleolar distance on the HKA-angle as well as the joint line. Only positive correlations were found between the IM-distance and the TJLA as well as the FJLA. There is no association between the HKA-angle and the IM-distance, although clinicians perceived a more varus alignment when patients were standing with both feet together. This can be explained by the fact that the HKA and other alignment parameters such as mLDFA, MPTA, MNSA and KVPA represent the intrinsic geometry of the bone relative to a mechanical axis. We observed that only the relative orientation of the joint line to the floor is influenced by the IM-distance.

      Conclusion

      A clarification of the radiographic changes was given by using consecutive X-rays during different arthritic stadia of our patients. The alignment changes in varus OA knees can be divided in 3 stadia: (1) erosion of the distal medial femoral condyle, (2) erosion of the medial tibial plateau (3) a progressive increase of the joint line angle whereby at the end of the arthritic process, changes of the lateral opening become more prominent.

      Conflict of Interest and Authorship Conformation Form

      Please check the following as appropriate:
      x All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.
      x This manuscript has not been submitted to, nor is under review at, another journal or other publishing venue
      x The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript
      x No author have affiliations with organizations with direct or indirect financial interest in the subject matter discussed in the manuscript.

      Acknowledgements

      We wish to acknowledge Dr. Elizabeth Flesher for her help in reviewing and revising the manuscript for grammar and syntax.

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