A Restriction Boundary-Based Coronal Plane Alignment of the Knee (CPAK) Classification for Restricted Kinematic Alignment Total Knee Arthroplasty

Abstract

Background Coronal plane alignment of the knee (CPAK) classification was proposed as a means of understanding the knee phenotype in leg alignment and joint line obliquity (JLO). However, when it is adapted to restricted kinematic alignment total knee arthroplasty (rKA-TKA), the boundaries of CPAK and those of rKA-TKA phenotype are different. We therefore reappraise the boundary between the CPAK classification and restriction protocol and propose a restriction boundary-based CPAK (Rb-CPAK). Methods Between May 2020 and March 2022, 143 knees in 95 patients underwent rKA at our institution and were included in this study. In Rb-CPAK, we set the following ranges: 6° varus to 3° valgus for arithmetic hip-knee-ankle angle (aHKA), 0° to 6° varus for the medial proximal tibial angle (MPTA), 0° to 5° valgus for the lateral distal femoral angle (LDFA), and 169° to 180° for JLO. The pre- and postoperative alignments were classified using the original CPAK and Rb-CPAK. Results There were significant differences in pre- and postoperative distributions between original CPAK and Rb-CPAK (p < 0.0001). Postoperative Rb-CPAK primarily led to neutral aHKA (116 of 143 knees), and decreased MPTA varus (pre: 83.9 ± 3.4, post: 87.0 ± 2.3, p < 0.0001) and stable LDFA values (pre: 88.7 ± 3.1, post: 88.5 ± 2.7, p = 0.4) were observed. Among cases with neutral JLO, 78 knees required MPTA or LDFA corrections. Postoperatively, 67 (64%) out of 119 knees categorized as neutral JLO fell within MPTA and LDFA ranges. Conclusion The Rb-CPAK modification more effectively outlined knees that required restriction, and the restriction was properly performed compared with the original CPAK. However, JLO does not effectively indicate if a knee requires restriction or not, and thus individual evaluation of LDFA and MPTA might be necessary.