Purpose The sulcus line (SL) is a three-dimensional curve produced from multiple points along the trochlear groove. Whiteside’s Line, also known as the anteroposterior axis (APA), is derived from single anterior and posterior points. The purposes of the two studies presented in this paper are to (1) assess the results from the clinical use of the SL in a large clinical series, (2) measure the SL and the APA on three-dimensional CT reconstructions, (3) demonstrate the effect of parallax error on the use of the APA and (4) determine the accuracy of an axis derived by combining the SL and the posterior condylar axis (PCA).MethodsIn the first study, we assessed the SL using a large, single surgeon series of consecutive patients undergoing primary total knee arthroplasties. The post-operative CT scans of patients (n = 200) were examined to determine the final rotational alignment of the femoral component. In the second study, measurements were taken in a series of 3DCT reconstructions of osteoarthritic knees (n = 44).Results The mean position of the femoral component in the clinical series was 0.6° externally rotated to the surgical epicondylar axis, with a standard deviation of 2.9° (ranges from −7.2° to 6.7°). On the 3DCT reconstructions, the APA (88.2° ± 4.2°) had significantly higher variance than the SL (90.3° ± 2.7°) (F = 5.82 and p = 0.017). An axis derived by averaging the SL and the PCA+3° produced a significant decrease in both the number of outliers (p = 0.03 vs. PCA and p = 0.007 vs. SL) and the variance (F = 6.15 and p = 0.015 vs. SL). The coronal alignment of the SL varied widely relative to the mechanical axis (0.4° ± 3.8°) and the distal condylar surface (2.6° ± 4.3°).ConclusionsThe multiple points used to determine the SL confer anatomical and geometrical advantages, and therefore, it should be considered a separate rotational landmark to the APA. These findings may explain the high degree of variability in the measurement of the APA which is documented in the literature. Combining a geometrically correct SL and the PCA is likely to further improve accuracy.

BackgroundFemoral component malrotation is a common cause of patient dissatisfaction after total knee arthroplasty. The sulcus line (SL) is more accurate than Whiteside’s line as it corrects for variation in the coronal orientation of the groove. The hypothesis is that averaging the SL and posterior condylar axis (PCA) will reduce femoral malrotation.MethodsThe component was inserted at a position between the SL and PCA in 91 patients. An intraoperative photograph was taken showing the landmarks. These were compared to the component position achieved relative to the surgical epicondylar axis (SEA) on a postoperative CT scan. The component position was compared to the position achieved using the individual landmarks.ResultsRelative to the SEA, the final component position was 0.6° (SD 1.4°, range −3.8° to +4.0°), the coronally corrected SL position was −0.7° (SD 2.3°, −5.5° to +4.6°), the PCA position was 0.9° (SD 1.9°, −6.1° to +5.0°). Averaging the landmarks significantly decreased the variance of the component position compared to using the SL and PCA individually. The number of outliers (>3° from SEA) was also significantly less (p < 0.05) for the average position (2/84) when each was compared to the SL (16/84) and PCA (14/84) individually. In 21/84 (25%) of cases, there was more than 4° of divergence between the SL and PCA.ConclusionsAveraging the SL and the PCA decreases femoral component malrotation. Femora are frequently asymmetrical in the axial plane. Referencing posterior condyles alone to set rotation is likely to cause high rates of patellofemoral malalignment.

Purpose Firstly, to assess and compare the accuracy and reproducibility of the sulcus line compared to Whiteside’s line. Secondly, to assess the accuracy of intraoperative techniques for using the rotational alignment of the trochlear groove to set femoral rotation. Thirdly, to assess the reproducibility of a trochlear alignment guide which removes parallax errors that occur when projecting the sulcus line onto the surface of the femur. Finally, to measure the result of combining the geometrically accurate sulcus line and the posterior condylar axis. Methods Three surgeons measured eight rotational angles on ten cadaveric femora. This included Whiteside’s line, the sulcus line and the techniques in which they can be referenced during surgery.ResultsRelative to the anatomical epicondylar axis, the sulcus line (mean −2.8°, SD 2.0°, range −5.4° to 0.8°) had significantly lower variance (F = 5.16, p = 0.036) than Whiteside’s line (mean −2.0°, SD 3.7°, range −6.0° to 3.4°). The trochlear alignment guide produced the best results of the intraoperative techniques by maintaining the accuracy of the sulcus line and projecting it onto the distal cut surface of the femur without change in rotational angle.ConclusionThe sulcus line is more accurate and reproducible than Whiteside’s line. Removing parallax errors during surgery improves femoral component rotation. The trochlear alignment guide produced accurate results suggesting that it may be beneficial in a clinical setting. Averaging the sulcus line and posterior condylar axis on the cut surface of the femur improved accuracy over the individual landmarks. Femoral component malrotation is a common cause of patient dissatisfaction and revision surgery. By isolating the rotational alignment of the trochlear groove using the sulcus line, and maintaining its accuracy with an intraoperative guide, we can decrease the risk of femoral component malrotation and improve patient outcomes.