Femoral and tibial malrotation in total knee arthroplasty: Causes and cures

Prosthetic malrotation is an important surgical error that can lead to patellar subluxation, chronic ligamentous instability, and a painful outcome after total knee arthroplasty. Surgical technique must create a near normal anatomical condition that considers bone reconstruction and normal ligament balance. The classic anatomical methods will be historically reviewed assessing reasons for outliers and factors that may cause error. Newer methods will be considered such as computer navigation with ligament tensors, the kinematic method, and patient-specific cutting guides. Computer navigation will eventually rely on intra-operative digital imaging capabilities.