Several reference axes have been used to establish femoral rotational alignment during total knee arthroplasty. The current study examined the configuration of the anterior surface of the femur immediately proximal to the trochlea as an alternative rotational landmark. An analysis of computed tomographic images of 150 knees with osteoarthritis indicated that the configuration of the surface is mostly flat or slightly depressed, and the line tangential to the surface (femoral anterior tangent line; FAT line) was consistently determined to be 12.2° ± 3.6° internally rotated to the transepicondylar axis. This value was relatively constant and as reliable as the femoral anteroposterior axis for determining rotational alignment. In addition, the FAT line was not affected by the degree of the varus-valgus deformity of the osteoarthritic knees.
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