What should be considered in using standard knee radiographs to estimate mechanical alignment of the knee?

We found that the differences between mechanical and anatomical TFAs depend on gender and the presence of advanced OA, but not on a history of TKA. These findings indicate that prediction of mechanical TFA based on anatomical TFA is dependent on study population characteristics. This study also shows that the presence of lateral bowing of the femur is a major cause of mechanical TFA to anatomical TFA variations associated with gender and advanced OA. To reduce the adverse effects of anatomical variations on estimations of mechanical TFA based on an anatomical TFA method, more distant proximal and distal reference points are recommended to determine anatomical TFA value on standard knee radiographs.