The Knee, ISSN: 1873-5800, Vol: 25, Issue: 1, Page: 15-24

Usefulness of the “grand-piano sign” for determining femoral rotational alignment in total knee arthroplasty

Ohmori, Takaaki; Kabata, Tamon; Kajino, Yoshitomo; Taga, Tadashi; Inoue, Daisuke; Yamamoto, Takashi; Takagi, Tomoharu; Yoshitani, Junya; Ueno, Takuro; Tsuchiya, Hiroyuki


The “grand-piano sign” is a well-known indicator of proper rotational femoral alignment. We investigated changes in the shape of the femoral anterior cutting plane by changing the rotational alignment, anterior portion depth, and cutting plane flexion angle.


We simulated various cutting planes after cutting the anterior portion of the femur next to the distal femoral osteotomy in 50 patients with varus knee and also a femoral anterior osteotomy with four degree (S group) and seven degree (T group) flexion angles regarding the mechanical axis. We defined the final cutting plane as the farthest position that we could reach without making a notch and the precutting plane as two millimeters anterior from the final cutting plane. The simulated resection plane was rotated to produce external and internal rotation angles of 0°, three degrees, and five degrees relative to the surgical transepicondylar axis (SEA). We investigated medial and lateral portions of the femoral anterior cutting plane length ratio (M/L).


When we cut parallel to SEA, M/L was 0.67 ± 0.09 and 0.62 ± 0.12 in the T and S groups, respectively. M/L was approximately 0.8 and 0.5 with five degree internal and external rotations, respectively (P < 0.01). On comparing final cutting and precutting planes, there were no significant differences in M/L without five degree external rotation in the T group and no significant difference in any case in the S group (P > 0.01).


The ideal M/L of the femoral anterior cutting plane was 0.62–0.67. M/L did not change with a precutting plane in almost all rotational patterns.

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