No Consensus on the Role of Component Rotation in Postoperative Outcomes After Total Knee Arthroplasty: A Systematic Review

Abstract

Up to 20% of patients report dissatisfaction after total knee arthroplasty (TKA), often due to unexplained long-term pain. Component malrotation has been proposed as a contributing factor. This systematic review aimed to evaluate the association between component malrotation and patient-reported outcome measures (PROMs). A systematic search was conducted in PubMed/Medline, Embase, and the Cochrane Library. Studies assessing the effect of femoral, tibial, combined rotation, or rotational mismatch on PROMs were included. Methodological quality was assessed using the Joanna Briggs Institute manual, and evidence levels were assigned based on the Oxford Levels of Evidence. A total of 22 studies involving 1,943 patients met the inclusion criteria. No consistent association was found between component rotation, whether femoral, tibial, combined, or mismatch, and PROMs. There is no clear consensus on the impact of component malrotation on PROMs. However, combined malrotation and rotational mismatch may influence outcomes more than isolated femoral or tibial rotation. Further, high-quality, Level 1 studies are needed to define optimal rotational alignment in TKA.

Keywords

total knee arthroplasty - component malrotation - patient-reported outcome measures - systematic review

Contributors' Statement

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by S.G. and H.P.J. The first draft of the manuscript was written by S.G. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics Approval

The protocol for this systematic review was registered with the Prospero database (registration number CRD42020188580).

Publication History

Received: 15 September 2025

Accepted: 24 January 2026

Accepted Manuscript online:
28 January 2026

Article published online:
12 February 2026

• References

• 1 Dailiana ZH, Papakostidou I, Varitimidis S. et al. Patient-reported quality of life after primary major joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord 2015; 16: 366
• 2 Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. National Joint Registry for England and Wales, Data from the National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. J Bone Joint Surg Br 2007; 89 (07) 893-900
• 3 Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2 (01) e000435
• 4 Park CN, White PB, Meftah M, Ranawat AS, Ranawat CS. Diagnostic algorithm for residual pain after total knee arthroplasty. Orthopedics 2016; 39 (02) e246-e252
• 5 Valkering KP, Breugem SJ, van den Bekerom MP, Tuinebreijer WE, van Geenen RC. Effect of rotational alignment on outcome of total knee arthroplasty. Acta Orthop 2015; 86 (04) 432-439
• 6 Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD. Early revision for component malrotation in total knee arthroplasty. Clin Orthop Relat Res 2007; 458 (458) 131-136
• 7 Lakstein D, Zarrabian M, Kosashvili Y, Safir O, Gross AE, Backstein D. Revision total knee arthroplasty for component malrotation is highly beneficial: a case control study. J Arthroplasty 2010; 25 (07) 1047-1052
• 8 Castelli CC, Falvo DA, Iapicca ML, Gotti V. Rotational alignment of the femoral component in total knee arthroplasty. Ann Transl Med 2016; 4 (01) 4
• 9 Barrack RL, Schrader T, Bertot AJ, Wolfe MW, Myers L. Component rotation and anterior knee pain after total knee arthroplasty. Clin Orthop Relat Res 2001; (392) 46-55
• 10 Bédard M, Vince KG, Redfern J, Collen SR. Internal rotation of the tibial component is frequent in stiff total knee arthroplasty. Clin Orthop Relat Res 2011; 469 (08) 2346-2355
• 11 Kim Y-H, Park J-W, Kim J-S, Park S-D. The relationship between the survival of total knee arthroplasty and postoperative coronal, sagittal and rotational alignment of knee prosthesis. Int Orthop 2014; 38 (02) 379-385
• 12 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
• 13 Aromataris E, Munn Z. JBI Manual for Evidence Synthesis. JBI, 2020 . Accessed at: https://synthesismanual.jbi.global:10.46658/JBIMES-20-01
• 14 OCEBM Levels of Evidence Working Group. The Oxford levels of evidence 2. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009
• 15 Aunan E, Østergaard D, Meland A, Dalheim K, Sandvik L. A simple method for accurate rotational positioning of the femoral component in total knee arthroplasty. Acta Orthop 2017; 88 (06) 657-663
• 16 Babazadeh S, Dowsey MM, Vasimalla MG, Stoney JD, Choong PFM. Knee arthroplasty component malrotation does not affect function or quality of life in the short to medium term. J Arthroplasty 2019; 34 (07) 1382-1386
• 17 Becker R, Bäker K, Hommel H, Bernard M, Kopf S. No correlation between rotation of femoral components in the transverse plane and clinical outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27 (05) 1456-1462
• 18 Bell SW, Young P, Drury C. et al. Component rotational alignment in unexplained painful primary total knee arthroplasty. Knee 2014; 21 (01) 272-277
• 19 Benazzo F, Rossi SMP, Danesino G, Klersy C, Perelli S, Ghiara M. Computed tomography evaluation of total knee arthroplasty implants position after two different surgical methods of implantation. Int Orthop 2019; 43 (01) 139-149
• 20 Bhattee G, Moonot P, Govindaswamy R, Pope A, Fiddian N, Harvey A. Does malrotation of components correlate with patient dissatisfaction following secondary patellar resurfacing?. Knee 2014; 21 (01) 247-251
• 21 Czurda T, Fennema P, Baumgartner M, Ritschl P. The association between component malalignment and post-operative pain following navigation-assisted total knee arthroplasty: results of a cohort/nested case-control study. Knee Surg Sports Traumatol Arthrosc 2010; 18 (07) 863-869
• 22 Grillo G, Pelfort X, Balaguer-Castro M. et al. Study of femoral component malrotation as a cause of pain after total knee arthroplasty. Rev Esp Cir Ortop Traumatol 2024; 68 (03) 231-238
• 23 Huijbregts HJ, Khan RJ, Fick DP, Jarrett OM, Haebich S. Prosthetic alignment after total knee replacement is not associated with dissatisfaction or change in Oxford Knee Score: a multivariable regression analysis. Knee 2016; 23 (03) 535-539
• 24 Jabłoński J, Sibiński M, Polguj M. et al. The influence of implant position on final clinical outcome and gait analysis after total knee arthroplasty. J Knee Surg 2019; 32 (09) 891-896
• 25 Kawahara S, Okazaki K, Matsuda S, Nakahara H, Okamoto S, Iwamoto Y. Internal rotation of femoral component affects functional activities after TKA–survey with the 2011 Knee Society Score. J Arthroplasty 2014; 29 (12) 2319-2323
• 26 Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R. Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplasty 2009; 24 (04) 570-578
• 27 Murakami AM, Hash TW, Hepinstall MS, Lyman S, Nestor BJ, Potter HG. MRI evaluation of rotational alignment and synovitis in patients with pain after total knee replacement. J Bone Joint Surg Br 2012; 94 (09) 1209-1215
• 28 Nedopil AJ, Howell SM, Hull ML. Does malrotation of the tibial and femoral components compromise function in kinematically aligned total knee arthroplasty?. Orthop Clin North Am 2016; 47 (01) 41-50
• 29 Nicoll D, Rowley DI. Internal rotational error of the tibial component is a major cause of pain after total knee replacement. J Bone Joint Surg Br 2010; 92 (09) 1238-1244
• 30 Romero J, Stähelin T, Binkert C, Pfirrmann C, Hodler J, Kessler O. The clinical consequences of flexion gap asymmetry in total knee arthroplasty. J Arthroplasty 2007; 22 (02) 235-240
• 31 Thielemann FW, Konstantinids L, Herget GW. et al. Effect of rotational component alignment on clinical outcome 5 to 7 years after TKA with the Columbus knee system. Orthopedics 2016; 39 (03) S50-S55
• 32 Tone S, Naito Y, Wakabayashi H, Sudo A, Hasegawa M. Association between femorotibial rotational mismatch and early clinical outcomes after bi-cruciate retaining total knee arthroplasty. BMC Musculoskelet Disord 2025; 26 (01) 251
• 33 Young SW, Saffi M, Spangehl MJ, Clarke HD. Unexplained pain following total knee arthroplasty: is rotational malalignment the problem?. Knee 2018; 25 (02) 329-334
• 34 Lützner J, Kirschner S, Günther KP, Harman MK. Patients with no functional improvement after total knee arthroplasty show different kinematics. Int Orthop 2012; 36 (09) 1841-1847
• 35 Ueyama H, Minoda Y, Sugama R. et al. Malrotation of the fixed-bearing posterior stabilized total knee prosthesis causes a postoperative rotational mismatch between the femur and tibia. Knee Surg Sports Traumatol Arthrosc 2020; 28 (12) 3810-3820
• 36 Corona K, Cerciello S, Vasso M. et al. Femoral component malrotation is not correlated with poor clinical outcomes after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28 (12) 3879-3887
• 37 Panni AS, Ascione F, Rossini M. et al. Tibial internal rotation negatively affects clinical outcomes in total knee arthroplasty: a systematic review. Knee Surg Sports Traumatol Arthrosc 2018; 26 (06) 1636-1644
• 38 Kazarian GS, Lieberman EG, Hansen EJ, Nunley RM, Barrack RL. Clinical impact of component placement in manually instrumented total knee arthroplasty : a systematic review. Bone Joint J 2021; 103-B [phone]
• 39 Berger RA, Crossett LS, Jacobs JJ, Rubash HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 1998; (356) 144-153
• 40 Yoshino N, Takai S, Ohtsuki Y, Hirasawa Y. Computed tomography measurement of the surgical and clinical transepicondylar axis of the distal femur in osteoarthritic knees. J Arthroplasty 2001; 16 (04) 493-497
• 41 Deckey DG, Rosenow CS, Verhey JT. et al. Robotic-assisted total knee arthroplasty improves accuracy and precision compared to conventional techniques. Bone Joint J 2021; 103-B (6, Supple A): 74-80