Total Knee Replacement

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Malaysian Orthopaedic Journal 2009 Vol 3 No 1

http://dx.doi.org/10.5704/MOJ.0905.016
R Yoga, et al
Posterior Slope of the Tibia Plateau in Malaysian Patients

Undergoing Total Knee Replacement
R Yoga, MS Ortho, N Sivapathasundaram*, MS Ortho, C Suresh**, MS Ortho
Department of Orthopaedics , Sultanah Aminah Hospital, Johor Bahru, Malaysia
*Department of Orthopaedics, Malacca Hospital, Malacca, Malaysia
**Department of Orthopaedics, Alor Star Hospital, Alor Star, Malaysia
ABSTRACT
The posterior slope of the tibial plateau is an important
feature to preserve during knee replacement. The correct
slope aids in the amount of flexion and determines if the
knee will be loose on flexion. This is a study on the posterior
tibial plateau slope based on preoperative and postoperative
radiographs of 100 consecutive patients who had total knee
replacements. The average posterior slope of the tibia plateau
was 10.1 degrees. There is a tendency for patients with
higher pre-operative posterior tibial plateau slope to have
higher post-operative posterior tibial plate slope.
Key Words:
Tibial plateau, Osteoarthritis, Arthroplasty, Posterior Slope,
Knee Arthroplasty, Range of Motion
INTRODUCTION
One of the factors determining the outcome of total knee
replacement (TKR) is proper placement of the prosthesis 1; in
fact, it is well known that there is a significant correlation
between good clinical results and a well-positioned
prosthesis 2. The tibial component performs best when
positioned horizontally in the lateral view 3. This position
however, does not correspond to the normal tibial anatomic
slope. Whiteside 4 suggested that the tibial cut should made at
a 0 to 3 posterior slope, and some degree of posterior slope
is now recommended when cutting the tibial plateau with
most modern TKA designs.
We elected to study the posterior tibial plateau slope in
Malaysian patients undergoing TKR and examine if there are
any differences among the 3 major races of the Malaysian
population. In addition, we wanted to know review the
alignment of tibia plates following TKR in these patients.
MATERIALS AND METHODS

One hundred consecutive patients who underwent knee
replacements were initially included for this study. These
patients were treated in 2 major public hospitals, Sultanah
Aminah Hospital (50 patients) and Alor Star Hospital (50

patients). Patients who had large bone cysts, severe
osteoporosis or marked deformity from rheumatoid arthritis
were subsequently excluded from the study. Patients who did
not have a true anterior-posterior and lateral postoperative
radiographs were also excluded from this study. There were
3 different types of implants used : Apollo (Centerpulse),
Nex Gen (Zimmer), Scorpio (Stryker).
The pre-operative and post-operative knee flexion and
extension were recorded for each patient. Preoperative and
immediate postoperative radiographs of all patients were
reviewed. Firstly, a line was drawn parallel to the tibial
plateau. A second line was then drawn centring on the middle
of the tibia (anatomical axis) and intersecting the first line,
simulating the intramedullary rod for the tibial cutting jig.
The posterior slope calculated was 90 minus the angle
formed between the first line and the second line. In the
immediate postoperative radiographs, a line was drawn
parallel to the base of the tibial plate. The second line was
then drawn centring on the tibial anatomical axis. Similar
measurements were then taken. Horizontal or slight posterior
slope of the tibia plate is desirable (3,4). We identify patients
with post-operative posterior tibial plateau slope (posterior
slope of base plate) greater than 7 degrees for analysis.
The measurements were analysed using a statistical package
(SPSS for Windows, Version 9.0). Significance was defined
as a p < 0.05.
RESULTS
Nine patients were excluded for the study based on our
selection criteria. Among the remaining 91 patients, there
were 17 males and 74 females. The mean age of these
patients was 62 years (range, 43 80 years). Of these
patients, 34% were Malays, 56 % were Chinese and 10%
were Indians. Fifty-six of the cases involved surgery on left
knees and 44% on right knees.
The mean posterior tibial plateau slope of all the patients
was10.1 degrees (range 4- 21 degrees; SD = 3.9 degrees).
Corresponding Author: Yoga Raj, Department of Orthopaedic Surgery, Sultanah Aminah Hopsital, 80100 Johor Bahru, Johor, Malaysia
Email : [email protected]
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Posterior Slope of the Tibia Plateau in Malaysian Patients Undergoing Total Knee Replacement
Table I: The posterior tibial plateau slope distribution among the three different races
Race
Malay
Chinese
Indian
Mean Posterior Tibial Plateau Slope (degrees)

10.0
9.9
8.8
Range of knee motion (degrees) Standard Deviation

4 - 21
3.8
4 - 20
4.2
4 - 21
3.7
Table II: : Comparison between patients with higher or lower post-operative posterior tibial slope
Number (percentage)
Pre Operative Slope
Post Operative Slope
Post operative posterior tibial slope

More than 7 degrees
7 degrees or less
15 (16.5%)
76 (83.5%)
12.5 degrees
9.6 degrees
9.2 degrees
2.8 degrees
There was no significant difference in the posterior tibial

plateau slope in the three races studied (Table I). There was
also no statistically significant difference in the angle of the
slope between the males and the females.
The mean post-operative tibial base plate slope was 3.8
degrees (range, 0-14 degrees; SD=3.3 degrees) (Table II).
The mean reduction in the postoperative slope was 6.6
degrees. (SD = 4.5 degrees). There were four cases in which
the slope increased by an average of 1.2 degrees. In patients
for whom the posterior tibial plateau slope was reduced after
surgery, the mean pre-operative fixed flexion deformity was
2.9 degrees (SD = 6.7 degrees), and the mean range of knee
motion was 105.9 degrees (SD = 15.7 degrees). In
comparison, those who had an increased posterior tibial
plateau slope after surgery, they had a mean pre-operative
fixed flexion deformity of 7.8 degrees (SD = 9.7 degrees)
and mean range of knee motion of 97.5 degrees (SD = 15
degrees). Fifteen of the patients had a post-operative tibial
baseplate slope of more than seven degrees, which was
considered to be not ideal.
The left knee was more likely to be involved in fixed flexion
deformity than the right knee (P < 0.05), and patients
undergoing left knee surgery also had a higher pre-operative
tibial plateau slope.
DISCUSSION
The normal values for the posterior tibial plateau slope are
not well defined. Studies note that the normal tibial plateau
is inclined posteriorly between zero and 15 degrees 5, 6. A
value of five to ten degrees is generally considered to be
normal normal. There is a three degree variation between the
medial and lateral tibial plateau slope 7. It is however more
useful to have the values of the posterior tibial plateau slope
in the degenerated knees. In this study, the mean preoperative posterior tibial plateau slope was 10.0 degrees.
Chiu 7 noted that the average posterior plateau slope in
Chinese patients was 11.5 degrees, a result comparable to the
10.1 degrees noted for Chinese patients in this study. He also
concluded that osteoarthritis increases the slope by two to
three degrees 7. Although there are slight differences in mean
pre-operative posterior tibial plateau slope between the 3
races, they are not statistically significant. It is likely that the

study population was not big enough to elucidate the
findings.
This study also noted that patients with higher pre-operative
posterior tibial plateau slope are more likely to have higher
post operative posterior tibial slope 4. It is likely that knees
with a higher pre-operative posterior tibial slope usually have
fixed flexion deformity and reduced range of knee motion. In
a study by Hoffman10, it was found that tibiae cut parallel to
the surface exhibited 40% greater load carrying capacity and
70% greater stiffness than paired tibiae cut perpendicular to
the long axis. Therefore, an increased tibial slope is not
desirable although it improves the maximum flexion
achieved 11. Additional proximal tibia bone cut during surgery
to achieve a lower posterior base plate slope may help to
achieve full extension and better range of knee motion after
surgery.
However, it has its own limitations. For example, if the
posterior tibial slope is 15 degrees, and the anterior-posterior
diameter of the proximal tibia is 50 cm wide, a zero degree
tibia cutting guide will require the resection of 12 mm of
bone from the anterior tibia. This removal exposes the
weaker bone and predisposes the fixation to loosening.
Observations by Bartel et al 8 suggested that when the
stiffest and strongest cortical bone is removed, the remaining
weaker and less stiff cancellous bone stock often is
inadequate to support the physiologic loads of the knee. On
the other hand, anteriorly sloped tibial components led to a
tendency to posterior micromotion and thus more wear 3.
Inaccurate flexion extension gap also contributes to stiffness
of the knee after TKA 9.
CONCLUSION
The mean slope of the posterior tibia plateau in our pateints
was 10.1 degrees and the values were not significantly
different between the 3 major races in this country. Patients
with higher pre-operative posterior tibial plateau slope are
more likely to have higher post operative posterior tibial
slope, which may adversely influence the knee extension and
total range of knee motion.
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R Yoga, et al
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1.
Lotke PA, Ecker ML. Influence of positioning of prosthesis in total knee replacement. J Bone Joint Surg 1977; 59-A(1): 77-9.
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Bai B, Baez J, Testa N, Kummer FJ. Effect of posterior cut angle on tibial component loading. J Arthroplasty 2000; 15(7): 916-20.
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Whiteside, LA, Amador DD. The effect of posterior tibial slope on knee stability after Ortholoc total knee arthroplasty. J
Arthroplasty 1988; 3 Suppl: S51-7.
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Jiang CC, Yip, Liu TK. Posterior slope angle of the medial tibial plateau. J Formos Med Assoc 1994; 93(6): 509-12.
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Matsuda S, Miura H, Nagamine R, Urabe K, Ikenoue T, Okazaki K, et al. Posterior tibial slope in the normal and varus knee. Am
J Knee Surg 1999; 12(3): 165-8.
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Chiu KY, Zhang SD, Zhang GH. Posterior slope of tibial plateau in Chinese. J Arthroplasty 2000; 15(2): 224-7.
Bartel DL, Burstein AH, Santavicca EA, Insall JN. Performance of the tibial component in total knee replacement. J Bone Joint
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Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg 2004; 12(3): 164-71.
10. Hofmann AA, Bachus KN, Wyatt RW. Effect of the tibial cut on subsidence following total knee arthroplasty. Clin Orthop Relat
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000158 NV-OR15 78-80.

Malaysian Orthopaedic Journal 2009 Vol 3 No 1

Posterior Slope of the Tibia Plateau in Malaysian Patients

MATERIALS AND METHODS

Aminah Hospital (50 patients) and Alor Star Hospital (50

000158 NV-OR15 78-80.qxd

Mean Posterior Tibial Plateau Slope (degrees)

Range of knee motion (degrees) Standard Deviation

Post operative posterior tibial slope

There was no significant difference in the posterior tibial

races, they are not statistically significant. It is likely that the

000158 NV-OR15 78-80.qxd

Malaysian Orthopaedic Journal 2009 Vol 3 No 1

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