Estimation of frontal alignment error of the extramedullary tibial guide on the bi-malleolar technique: A simulation study with magnetic resonance imaging

The bi-malleolar technique for the extramedullary tibial guide is a representative method for determining the ankle center in total knee arthroplasty (TKA). The purpose of this study is to estimate three-dimensionally the lateral errors (difference between the real ankle center and the bi-malleolar center) and the varus angular errors of this technique under the condition that the malleolar prominences were correctly identified.

Magnetic resonance images of 51 lower limbs from 51 healthy volunteers were analyzed. The lateral errors were measured, including or excluding the subcutaneous thickness, along the line perpendicular to the transmalleolar axis (TMA) or along the tibial anteroposterior (AP) axis. Furthermore, we evaluated the effects of the tibial torsion and the difference between the subcutaneous thicknesses on the malleoli on the lateral error.

When including the skin, the mean lateral errors of the ankle center observed along the line perpendicular to the TMA and along the tibial AP axis were 3.7 ± 1.4 mm and 1.2 ± 1.5 mm, respectively. The mean angular errors were 0.6 ± 0.2° and 0.2 ± 0.3°, respectively. A significant correlation between the tibial torsion and the lateral error was noted when observed along the tibial AP axis. The difference between the subcutaneous thicknesses on the malleoli affected the lateral error.

The errors were small enough to determine the mechanical axis of the tibia if the tibial guide could catch the bi-malleolar prominences of the ankle accurately and align along the tibial AP axis.