Biomechanics

Anatomic axis of tibia and femur

Mechanical axis of tibia and femur
Mechanic axis of limb
Anatomic axis femur (AAF)
- a line that bisects the medullary canal of the femur
Mechanical axis femur
- defined by line connecting center of femoral head to point where anatomic axis meets
intercondylar notch
Anatomic axis of tibia (AAT)
- a line that bisects medullary canal
Mechanical axis of tibia
- line from center of proximal tibia to center of talus
- usually mechanical axis and anatomic axis of tibia are coincident
Angle A represents knee mechanical
physiologic valgus angle of 3°.

Angle B represents tibia shaft angle, that is in

3° of varus from knee transverse axis.

Angle C corresponds to angle between

femoral anatomic and mechanical axis (6° of
valgus).

Femoral anatomic axis could be easily

determined by two points located at the
centre of the shaft.
Mechanical axis of the lower limb passes
near or through knee center and lies from
femoral head center to ankle center.
The Mechanical Axis of the leg is a line
drawn from the center of the hip to the
center of the ankle.
This line should cross through the center
of the knee.
This means that the knee has neutral
alignment.
The Anatomic Axis is the center of the
bones making up the leg, and the anatomic
axis of the femur is 6° from the mechanical
axis while the anatomic axis of the tibia is
inline with the mechanical axis.
Therefore the Knee Angle (referring to the
Femoral-Tibial Angle: FTA) is 6° valgus
(relative to the mechanical axis).
We also need to consider the joint line itself. The joint line is variable person-to-person,
however, on average its in about 3° of varus (relative to the mechanical axis). On the tibial
side, it means the tibial articular surface is in 3° varus, while on the femoral side, the femoral
articular surface is in 3° of valgus. Now we need to combine everything together. On the
femoral side, the joint line is in 9° of valgus relative to the anatomic axis (thats 6° from the
femoral center to the mechanical axis and then 3° more from the mechanical axis to the line
across the distal femoral condyle). On the tibial side, the joint line is in 3° of varus relative to
the anatomic axis (thats 0° from the tibial center to the mechanical axis because these two
are parallel, and then 3° from the mechanical axis to the tibial joint line).
Fujisawa detemined a
point (arrow) located at
62% of the tibial plateau
width when measured
from the medial tibial
plateau.
 High tibial osteotomy (HTO)

- predominately done for varus deformities

- less common for valgus deformities

Indications
- young, active patient (<50 years) in whom an arthroplasty would fail due to excessive
wear
- healthy patient with good vascular status
- non-obese patients
- pain and disability interfering with daily life
- only one knee compartment is affected
- Stable knee
- compliant patient that will be able to follow postop protocol
General contraindications
- inflammatory arthritis
- obese patient BMI>35
- flexion contracture >15 degrees
- knee flexion <90 degrees
- procedure will need >20 degrees of correction
- patellofemoral arthritis
- ligament instability
- varus thrust during gait
 Varus – producing tibial osteotomy

Surgical goals
- unload the involved joint compartment by correcting tibial malalignment
- maintain the joint line perpendicular to mechanical axis of the leg

Indications
- can be done for valgus knee with lateral compartment degeneration
- deformity should be <12 degrees or else the joint line will become oblique

specific contraindications
- medial compartment arthritis
- loss of medial meniscus
- distal femoral osteotomy better if lateral femoral condyle hypoplasia present
 Valgus – producing tibial osteotomies

Goals
- unload the involved joint compartment by correcting tibial malalignment
- maintain the joint line perpendicular to mechanical axis of the leg

Indications
- can be done for varus knee with medial compartment degeneration (more
common)
- best results achieved by overcorrection of the anatomical axis to 8-10 degrees of
valgus

Specific contraindications
- narrow lateral compartment cartilage space with stress radiographs
- loss of lateral meniscus
- lateral tibial subluxation >1cm
- medial compartment bone loss >2-3mm
- varus deformity >10 degrees
Technique

Lateral closing wedge technique

- most common technique
- wedge of bone removed with tibia via an anterolateral approach
- ORIF of wedge

Advantages
- more inherent stability allows for faster rehab and weight bearing
- no required bone grafting
Technique

Medial opening wedge technique

- transverse bone cut made in proximal tibia, and wedged open on medial side
- ORIF of wedge

Advantages
- of maintaining posterior slope
- avoids proximal tibiofibular joint
- avoids peroneal nerve in anterior compartment
Complications

Recurrence of deformity
60% failure rate after 3 years when
- failure to overcorrect
- patients are overweight
Loss of posterior slope
Patella baja
- refers to a shortened patellar tendon which decreases the distance of the patellar
tendon from the inferior joint line

- can be caused by raising tibiofemoral joint line in opening wedge osteotomies

- can be caused by retropatellar scarring and tendon contracture
- can cause bony impingement of patella on tibia
Compartment syndrome
Peroneal nerve palsy
- more common in lateral opening wedge osteotomy and lateral closing wedge osteotomy
- minimal risk in medial opening wedge osteotomy
Malunion or nonunion
Angle of correction for a high tibial osteotomy, a . (A) To determine the angle of correction for an opening wedge
osteotomy, a line was first drawn from a point located at 62.5% of the width of the tibial plateau to the center of the
femoral head (line a 0 c ). A second line was drawn from this point to the center of the ankle. The angle formed by the
intersection of these line is the correction angle ( a ). An osteotomy line was then defined from 4 cm below the medial
joint line to the tip of the fibular head (line ab ). This line segment ( ab ) was then transferred to the rays of the angle a
to obtain a 0 b 0 and a 0 c , with the distance between (line b 0 c ) corre- sponding to the opening that should be
achieved medially at the osteotomy site. (B) Using the same principles in (A), the angle of correction a was measured.
In contrast to an opening wedge osteotomy, the osteotomy site and angle of correction were transferred to the
proximal tibia to form a triangle with a lateral base.
Distal Femoral Osteotomy

- goal of is to correct the angle between anatomic axis of femur & mechanical
axis of tibia to 0-3 degrees of valgus;
- this will unload lateral tibiofemoral joint compartment and will prevent
recurrence of deformity;
- while high tibial osteotomy has been successful in the treatment of genu
varum, it has little use in genu valgum because it would tend to cause an oblique
joint line;
- this tilting leads to shear force across knee & gradual tibial subluxation
laterally, while distal femur appears to fall off medial tibial plateau;
- for these reasons, distal femoral osteomy is a better choice;

- Indications for Osteotomy:

- distal femoral osteotomy is inidicated if angle between anatomic femoral axis &
tibial mechanical axis is > 12-15 degrees of valgus or if plane of joint deviates from
the horizontal by > 10 degrees;
- stable joint with no evidence of subluxation, ROM of at least 90 deg of flexion
flexion contracture of no more than 15 degrees;
Relative contraindications

- Ligamentous instability (need to be treated)

- High body mass index
- Moderate patellofemoral arthritis
- Nicotine use
- Osteoporosis

Absolute contraindications

- Tricompartmental osteoarthritis
- Severe articular disruption
- Arthritis or meniscal deficiency in medial compartment
- Inflammatory disease
- Fixed valgus deformity > 20°
- Flexion contracture >15°
- Knee flexion <90°
A – mechanical axis of limb
B – mechanical axis of
femur
C – mechanical axix of tibia

Alpha – osteotomy angle

Medial closing wedge distal femoral osteotomy

Lateral opening wedge distal femoral osteotomy