n Case Report

Calculating the Position of the Joint Line of

the Knee Using Anatomical Landmarks
Gavin C. Pereira, MBBS, FRCS (Tr & Orth); Ericka von Kaeppler, BS; Michael J. Alaia, MD;
Kenneth Montini, MD; Matthew J. Lopez, MD; Paul E. Di Cesare, MD; Derek F. Amanatullah, MD, PhD

abstract breadths from the tibial tubercle,” to ab-

solute distances, including “10 mm from
the fibular styloid,” have been described
Restoration of the joint line of the knee during primary and revision total knee for joint line restoration, yet a lack of con-
arthroplasty is a step that directly influences patient outcomes. In revision total sensus remains.1,6,7 Alternatively, the joint
knee arthroplasty, necessary bony landmarks may be missing or obscured, so line of the knee can be estimated on a
there remains a lack of consensus on how to accurately identify and restore the preoperative radiograph by measuring the
joint line of the knee. In this study, 50 magnetic resonance images of normal distance from the joint line of the knee to
knees were analyzed to determine a quantitative relationship between the joint either the medial epicondyle, fibular head,
line of the knee and 6 bony landmarks: medial and lateral femoral epicondyles, or tibial tubercle.1,8 These methods cannot
medial and lateral femoral metaphyseal flares, tibial tubercle, and proximal tib-
io-fibular joint. Wide variability was found in the absolute distance from each The authors are from the Department of Or-
landmark to the joint line of the knee, including significant differences between thopaedic Surgery (GCP, MJL), University of Cal-
the sexes. Normalization of the absolute distances to femoral or tibial diameters ifornia, Davis Medical Center, Sacramento, and
the Department of Orthopaedic Surgery (EvK,
revealed reliable spatial relationships to the joint line of the knee. The joint line DFA), Stanford Hospital and Clinics, Palo Alto,
was found to be equidistant from the lateral femoral epicondyle and the proxi- California; the Department of Orthopaedic Sur-
mal tibio-fibular joint, representing a reproducible point of reference for joint gery (MJA), New York University—Hospital for
line restoration. The authors propose a simple 3-step algorithm that can be used Joint Disease, New York, New York; the Depart-
ment of Radiology (KM), The Mayo Clinic, Scott-
with magnetic resonance imaging, computed tomography, or radiography to sdale, Arizona; and the Department of Orthopae-
reliably determine the anatomical location of the joint line of the knee relative dic Surgery (PED), New York Hospital Queens,
to the surrounding bony anatomy. [Orthopedics. 2016; 39(6):381-386.] Queens, New York.
Ms von Kaeppler, Dr Alaia, Dr Montini, Dr
Lopez, and Dr Di Cesare have no relevant fi-

O
f the commonly accepted techni-
cal goals of a total knee arthro-
plasty (TKA), restoration of the
joint line of the knee is important. Failure
to restore the joint line of the knee to ana-
tomical position can lead to mid-flexion
instability, a reduction in range of motion,
impingement of the patellar tendon against
the tibial tray, and gap imbalance.1-5 Unfor-
tunately, successful restoration of the joint
line relies heavily on the presence and in-
tegrity of bone and soft tissue landmarks.
Unlike in primary TKA, in revision TKA,
the necessary landmarks are often missing
or obscured, making restoration of the joint
line both difficult and unreliable.
Numerous methods, ranging from
relative references, including “2 finger
nancial relationships to disclose. Dr Pereira has
received research grants from Zimmer. Dr Ama-
natullah is a paid consultant for Sanofi and has
received research grants from Acumed.
Correspondence should be addressed to:
Derek F. Amanatullah, MD, PhD, Department of
Orthopaedic Surgery, Stanford Hospital and Clin-
ics, 450 Broadway St, Redwood City, CA 94063-
6342 (dfa@stanford.edu).
Received: January 5, 2016; Accepted: July 14,
2016,
doi: 10.3928/01477447-20160729-01

NOVEMBER/DECEMBER 2016 | Volume 39 • Number 6 381


Figure 1: Coronal (A) and sagittal (B) diagrams of anatomical landmarks. Arrows: LE, lateral epicondyle; LF,
lateral flare; ME, medial epicondyle; MF, medial flare; PTFJ, proximal tibio-fibular joint; TT, tibial tubercle.
Red line: CTD, coronal tibial diameter; IED, interepicondylar diameter; IMD, intermetaphyseal diameter; STD,
sagittal tibial diameter. The blue line represents the joint line of the knee in the coronal and sagittal planes.
be employed if there is no radiograph prior
to TKA or if there is previous ipsilateral
or contralateral tibial tubercle osteotomy.
In another method, the inferior pole of the
patella with the knee in 90° of flexion can
serve as a guide to joint line position.9 This
method, however, cannot be employed in
the setting of patellar baja, tibial tubercle
osteotomy, patellectomy, or prior TKA.
Anatomical studies have evaluated the
distances from the femoral epicondyles,
fibular head, and tibial tubercle to the joint
line of the knee, in addition to the ratios
of these absolute distances to femoral or
tibial widths, compensating for sex and
size differences.10,11 Although these previ-
ous studies yielded valuable anatomical
relationships, the absolute distances can be
variable. Also, during revision TKA, the
identification of the necessary anatomical
landmarks can be exceedingly difficult.
The purpose of this study was to determine
a reproducible, quantitative relationship
between the position of the joint line of
the knee and identifiable anatomical land-
marks about the knee.
382
A B
Materials and Methods
Following institutional review board
approval, 50 randomly selected magnetic
resonance images (MRIs) of normal adult
human knees, originally obtained to rule
out meniscal or cruciate ligament pathol-
ogy after low-energy trauma, were exam-
ined by 2 independent observers (M.J.A.,
K.M.). Joints reported by radiologists to
have ligamentous pathology, degenera-
tive articular cartilage, or osteochondral
defects were excluded. The experimental
group consisted of 50 adults between 24
and 49 years old, including 24 men be-
tween 24 and 46 years old and 26 women
between 24 and 49 years old. Each ana-
tomical landmark was marked using a
digital caliper, included as part of the MRI
software.
The following anatomical landmarks
were identified on MRI (Figure 1):
1. Joint line of the knee (JL): the line
through the most distal points of the medial
and lateral femoral condyles in the coronal
plane, or the line through the most distal
point of the femur perpendicular to the ana-
n Case Report
tomical axis of the tibial shaft in the sagittal
plane.
2. Medial epicondyle (ME): the
medial-most point on the femur from
which the medial collateral ligament orig-
inated; coronal section (ME to the joint
line of the knee: MEJL).
3. Lateral epicondyle (LE): the most
prominent bony point of the femur from
which the lateral collateral ligament origi-
nated; coronal section (LE to the joint line
of the knee: LEJL).
4. Medial flare (MF): the point at which
the medial femoral metaphyseal flare met
the medial condylar cortex and also where
the epiphyseal scar met the medial cortex;
coronal section (MF to the joint line of the
knee: MFJL).
5. Lateral flare (LF): the point at which
the lateral femoral metaphyseal flare met
the lateral condylar cortex and also where
the epiphyseal scar met the lateral cortex;
coronal section (LF to the joint line of the
knee: LFJL).
6. Tibial tubercle (TT): the proximal-
most corner of the junction between
the tuberosity and the anterior cortex of
the tibia8; sagittal section. If this corner
was not identifiable, the most proximal
point of the patellar tendon insertion was
chosen (TT to the joint line of the knee:
TTJL).
7. Proximal tibio-fibular joint (PTFJ):
the center of the horizontal portion of the
proximal tibio-fibular joint; coronal sec-
tion (PTFJ to the joint line of the knee:
PTFJJL) (Figure 2).
The absolute perpendicular distance
between the joint line and each anatomi-
cal landmark was measured and reported.
The following diameters were mea-
sured (Figure 1):
A. Interepicondylar diameter of the
femur (IED): the distance between the
ME and the LE in the coronal plane, also
known as the surgical transepicondylar
axis; coronal section.
B. Intermetaphyseal diameter of the fe-
mur (IMD): the distance between the MF
and the LF in the coronal plane.
Copyright © SLACK Incorporated
n Case Report

Table 1
Absolute Distance From Each Anatomical Landmark to the Joint
Line of the Knee
Mean±SD, mm
Current Study
Distance Overall Males Females Servien et al11 Mountney et al12
MEJL 27.6±3.2 29.1±3.2 26.2±2.6a 28.3±2.6 26.4±2.8
a
Figure 2: Coronal magnetic resonance image show- LEJL 23.6±2.3 25.1±2.0 22.4±1.8 23.6±2.3 25.8±3.5
ing the proximal tibio-fibular joint landmark. Abbrevi- MFJL 41.5±4.0 44.0±3.8 39.3±2.8a
ation: PTFJJL, proximal tibio-fibular joint to joint line. LFJL 35.1±3.8 38.0±3.0 32.6±2.4a
PTFJJL 22.2±3.2 23.5±3.1 21.1±2.9a
C. Coronal tibial diameter (CTD): the
TTJL 20.9±4.4 21.5±4.4 20.5±4.5 22.3±2.8
diameter of the tibia at the level of the
PTFJ in the coronal plane, perpendicular Abbreviations: LEJL, lateral epicondyle to joint line of the knee; LFJL, lateral flare to joint
line of the knee; MEJL, medial epicondyle to joint line of the knee; MFJL, medial flare to joint
to the tibial shaft. line of the knee; PTFJJL, proximal tibio-fibular joint to joint line of the knee; TTJL, tibial
D. Sagittal tibial diameter (STD): the tubercle to joint line of the knee.
a
Statistically different from males (P<.005).
diameter of the tibia at the level of the TT
in the sagittal plane, perpendicular to the
tibial shaft.
To control for variation due to differ-
Table 2
ences between the sexes, the absolute dis-
tances were normalized to their respective Absolute Femoral and Tibial Diameters
bony diameters by dividing the appropri- Mean±SD, mm
ate diameter by the corresponding abso- Diameter Overall Males Females
lute distance (eg, IED:MEJL).10,11 These IED 77.6±6.4 82.9±3.9 72.6±3.9a
were termed either “femoral ratios” or IMD 72.7±6.1 77.7±3.9 68.2±3.7a
“tibial ratios.” To quantify the overall spa-
CTD 67.0±6.0 71.7±4.2 62.7±4.0a
tial relationship of the femoral and tibial
STD 40.8±6.1 45.2±5.0 36.8±3.9a
landmarks about the joint line of the knee,
the ratios between absolute femoral and Abbreviations: CTD, coronal tibial diameter; IED, interepicondylar diameter; IMD,
intermetaphyseal diameter; STD, sagittal tibial diameter.
tibial distances were reported. These were a
Statistically different from males (P<.005).
termed “femoro-tibial ratios.”
All measurements were repeated twice
by each of the 2 observers. The mean of 1). The absolute femoral and tibial diame- between the sexes (P>.05; Table 3). The
the 4 measurements was reported and the ters are listed in Table 2. All of the absolute CTD:TTJL and the STD:PTFJJL ratios
error was reported as SD. Statistically diameters were also statistically different were not calculated because it is not pos-
relevant results were determined via a between the sexes (P<.005; Table 2). sible to measure these absolute distances in
2-tailed Student’s t test and the signifi- To negate the effect of the difference the same plane of an MRI.
cance level was chosen to be P<.005 after between the sexes, the absolute distances Finally, the overall spatial relationship
Bonferroni correction. between the anatomical landmarks and the of the femoral and tibial landmarks about
joint line of the knee were normalized to the joint line of the knee was determined
Results their respective femoral or tibial diameters. by calculating the ratios between absolute
The absolute distances between each of The LEJL was found to be one-third of the femoral distances and absolute tibial dis-
the anatomical landmarks and the joint line IED (IED:LEJL=3.2±0.2). The femoral tances. The LEJL was found to be equal
of the knee are presented in Table 1. With and tibial ratios for all of the landmarks are to the PFTJJL (LEJL:PTFJJL=1.0±0.1),
the exception of the TTJL, all of the mea- provided in Table 3. After normalization, suggesting these landmarks are equidistant
sured absolute distances were statistically no statistically significant differences in the from the joint line. The femoro-tibial ra-
different between the sexes (P<.005; Table femoral and tibial measurements remained tios for all of the landmarks are presented

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 n Case Report

Table 3
Femoral and Tibial Ratios
Current Study
Rajagopal and
Ratio Overall Males Females Nathwani10 Mountney et al12 Servien et al11
IED:MEJL 2.8±0.3 2.9±0.3 2.8±0.2 3.0±0.3 3.1±0.2
IED:LEJL 3.2±0.2 3.3±0.3 3.3±0.3 3.3±0.2 3.4±0.2 3.5±0.3
IMD:MFJL 1.7±0.2 1.8±0.2 1.7±0.1
IMD:LFJL 2.1±0.2 2.1±0.2 2.1±0.2
CTD:PTFJJL 3.3±0.5 3.1±0.5 3.0±0.5
STD:TTJL 1.9±0.6 2.2±0.6 1.9±0.6 2.0±0.1a
Abbreviations: CTD, coronal tibial diameter; IED, interepicondylar diameter; IMD, intermetaphyseal diameter; LEJL, lateral epicondyle to joint
line of the knee; LFJL, lateral flare to joint line of the knee; MEJL, medial epicondyle to joint line of the knee; MFJL, medial flare to joint line of
the knee; PTFJJL, proximal tibio-fibular joint to joint line of the knee; STD, sagittal tibial diameter; TTJL, tibial tubercle to joint line of the knee.
a
Originally reported as TTJL:STD=0.5±0.1.

lar head and the tibial plateau, but a con-

sensus point of reference on the fibular
Table 4
head from which to make observations
Femoro-Tibial Ratios is lacking.13,14 In addition, the fibular sty-
Ratio Overall Males Females loid is variable in morphology.11 Further,
MEJL:TTJL 1.4±0.3 1.4±0.3 1.3±0.3 the fibular styloid can be excised intraop-
LEJL:TTJL 1.2±0.2 1.2±0.3 1.1±0.3 eratively, during the proximal tibial cut,
MFJL:TTJL 2.0±0.4 2.1±0.5 2.0±0.5 and is not always available as a reference
during revision TKA. The fibular head is
LFJL:TTJL 1.7±0.3 1.8±0.4 1.7±0.4
highly variable and unreliable as an ana-
MEJL:PTFJJL 1.3±0.2 1.3±0.3 1.3±0.2
tomical landmark.11,13,14
LEJL:PTFJJL 1.0±0.1 1.1±0.2 1.1±0.2
Compared with the fibular head, the
MFJL:PTFJJL 1.9±0.3 1.9±0.3 1.9±0.3 PTFJ used in this study is a superior
LFJL:PTFJJL 1.6±0.3 1.6±0.3 1.6±0.3 anatomical landmark. Unlike the fibular
Abbreviations: LEJL, lateral epicondyle to joint line of the knee; LFJL, lateral flare to joint head, the PTFJ is a clearly defined ana-
line of the knee; MEJL, medial epicondyle to joint line of the knee; MFJL, medial flare to joint tomical landmark that can be seen on a
line of the knee; PTFJJL, proximal tibio-fibular joint to joint line of the knee; TTJL, tibial
tubercle to joint line of the knee. plain radiograph, making it a widely us-
able point of reference regardless of pre-
operative imaging modality. If it is not
in Table 4. None of the femoro-tibial ra- troduced the concept that the joint line is visible because of fibular rotation, the
tios showed statistically significant differ- at a constant ratio from both the femoral PTFJ can be found at the intersection of
ences between the sexes (P>.05; Table 4). and the tibial anatomical landmarks. the lateral prominence of the fibular head
Although the ratios using the TTJL require The authors confirmed the following and the fibular styloid.
measurements in 2 different planes of an absolute distances: MEJL (27.6±3.2 mm), The authors observed that the LEJL
MRI, the authors included the TTJL in LEJL (23.6±2.3 mm), PTFJJL (22.2±3.2 has the lowest SD (2.3 mm) compared
their femoro-tibial ratios because it is a po- mm), and TTJL (20.9±4.4 mm). These with the other landmarks (ie, MEJL,
tentially visible intraoperative landmark. data are comparable to those of previously MFJL, LFJL, PTFJJL, and TTJL). This
published anatomical studies as reported observation confirms previous reports
Discussion in Table 1 and Table 3.10-12 that, despite statistically significant inter-
This study has defined the position of Previous anatomical and radiographic and intraobserver variability, the mean
the joint line with respect to the anatomi- studies have attempted to establish a re- LEJL intraobserver deviation was the
cal landmarks about the knee and has in- producible relationship between the fibu- most precise at 1.7 mm.15-17 This precision

384 Copyright © SLACK Incorporated

n Case Report
is likely a direct result of the anatomy of
this structure. The LE is readily identified
as the most prominent point on the lateral
distal femur, whereas, in contrast, the ME,
for example, is actually a sulcus between
2 prominences on the medial distal femur.
As such, the LEJL is the most reliable of
the authors’ measured distances for accu-
rate joint line reconstruction.
Individual variation related to sex
renders absolute measurements of ana-
tomical landmarks irrelevant.10,11 With
the exception of the TTJL (P>.05), the
authors found that all of the absolute dis-
tances and diameters were significantly
different between the sexes (P<.005).
Normalization to diameter negates sta-
tistically significant differences between
the sexes, offering a more reliable metric
for localizing the joint line. In addition,
normalization eliminates susceptibility
to magnification or positional distortion,
which is present in all imaging formats.
Normalization allows the authors’ MRI-
based technique to be employed more
broadly with either plain radiographs or
computed tomography scans, as all of the
landmarks used in this study are visible
with these modalities as well.
The current authors’ data corroborate
published computed tomography and
MRI data (Table 3)10-12 that the LEJL was
one-third of the IED (IED:LEJL=3.2±0.2)
(Figure 3). This anatomical relationship
is thus a valid and useful ratio for joint
line determination. Further, the authors
independently verified previous reports
(Table 3)11 that the TTJL was one-half the
STD (STD:TTJL=1.9±0.6) (Figure 3).
Among the authors’ most function-
ally useful findings was the establish-
ment of a novel femoro-tibial ratio of
1.0 between the LEJL and the PTFJJL
(LEJL:PTFJJL=1.0±0.1). This suggests
that the joint line of the knee is halfway
between the LE and the PTFJ, 2 readily
identifiable landmarks (Figure 3). This is
the first description of an equidistant spa-
tial relationship of anatomical landmarks
around the joint line of the knee.
NOVEMBER/DECEMBER 2016 | Volume 39 • Number 6
Figure 3: Relevant anatomical relationships about the joint line. Ratio of lateral epicondyle to joint line dis-
tance (LEJL) to interepicondylar diameter (IED) (A). Ratio of tibial tubercle to joint line distance (TTJL) to sag-
ittal tibial diameter (STD) (B). Ratio of LEJL to proximal tibio-fibular joint to joint line distance (LEJL:PTFJJL)
(C). The blue line represents the joint line of the knee in the coronal and sagittal planes. Abbreviations: LE,
lateral epicondyle; ME, medial epicondyle; PTFJ, proximal tibio-fibular joint; TT, tibial tubercle.
Servien et al11 first introduced the idea line should be equidistant from the LE
that normalization of absolute distances and the PTFJ.
to femoral or tibial diameters can control Incorporation of this algorithm into
for the high individual variability observed computer-assisted orthopedic surgery,
in absolute measurements about the joint especially when a preoperative MRI has
line. They described the use of an epicon- been obtained (eg, patient-specific instru-
dylar to femoral width ratio to determine mentation), may prove more useful than
the relative location of the joint line of the gross estimation. Further, the same spatial
knee.11 On the basis of their own results, relationships used to calculate the position
the current authors propose the following of the joint line of the knee relative to ana-
modification to the Servien et al11 algo- tomical landmarks can be used in reverse
rithm for establishing the location of the to calculate the position of anatomical
joint line of the knee (Figure 4). landmarks relative to the joint line of the
First, if the epicondyles are visible, knee. This reversal may be useful in es-
determine the IED of the femur. The timating ligament insertion points during
femoral articular line is approximately reconstruction, especially when the iden-
one-third this distance from the LE. If tification of an anatomical landmark (eg,
the epicondyles are difficult to identify, ME and LE) is subject to high interob-
determine the IMD of the femur. The server and intraobserver variability.15-17
femoral articular line is one-half this dis-
tance from the LF. Second, if the TT is Conclusion
visible, determine the STD. The tibial ar- The purpose of this study was to deter-
ticular line is one-half this distance from mine a quantitative relationship between an-
the TT. If the TT is not visible, determine atomical landmarks about the knee and the
the CTD. The tibial articular line is ap- joint line of the knee. The authors have pre-
proximately one-third this distance from sented a modified algorithm for successful
the PTFJ. Finally, the location of the joint restoration of the joint line of the knee dur-
line of the knee can be reliably verified ing TKA using the novel LEJL to PTFJJL
using the authors’ novel reported LEJL to femoro-tibial ratio. In TKA, successful res-
PTFJJL femoro-tibial ratio, as the joint toration of the joint line can be verified by
385

Figure 4: Modified algorithm for determining the position of the joint line of the knee using femoral and tibial
landmarks. Abbreviations: LEJL, lateral epicondyle to joint line of the knee; LFJL, lateral flare to joint line of the
knee; PTFJJL, proximal tibio-fibular joint to joint line of the knee; TTJL, tibial tubercle to joint line of the knee.
ensuring the joint line lies equidistant from
the LE and the PTFJ. The relationships de-
fined in this article can be applied broadly to
a variety of perioperative imaging modali-
ties, including MRI, computed tomogra-
phy scans, and radiographs. Further studies
validating the authors’ observations in retro-
spective radiographic review of primary and
revision TKA will help to translate these
observations into clinical practice.
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