The influence of tibial slope on maximal flexion after total knee arthroplasty

Many surgeons believe that increasing the tibial slope in total knee arthroplasty (TKA) is beneficial with regard to maximal postoperative flexion. Review of the clinical literature, however, does not confirm this hypothesis, neither does it give an answer to the question of how much flexion gain can be expected per degree extra tibial slope. The purpose of this study was, therefore, to evaluate and quantify the influence of tibial slope on maximal postoperative flexion in contemporary posterior cruciate ligament (PCL)-retaining TKA. Twenty-one cadaver simulations of a standard PCL-retaining TKA were studied while reproducing identical deep flexion femorotibial kinematics as documented by three-dimensional computer-aided videofluoroscopy from patients with well-functioning TKAs of the same design. In each knee the tibial component was consecutively implanted with 0° posterior slope, 4° posterior slope, and 7° posterior slope. Maximal flexion was recorded for each configuration. Average maximal flexion at 0° tibial slope was 104°, and increased significantly to 112° when the same knees were implanted with 4° tibial slope. Increasing the slope further to 7° again significantly improved average maximal flexion to 120°. When postoperative radiographic tibial slope was compared to maximal flexion, an average gain of 1.7° flexion for every degree extra tibial slope was noted. Increasing the tibial slope in PCL-retaining TKA does indeed improve maximal flexion before tibial insert impingement occurs against the femoral bone. The surgeon can expect an average gain of 1.7° flexion for every degree extra tibial slope.