Proximal Tibial Anthropometry in the Iranian Population and Its Implications for Custom Total Knee Prosthesis Design

Proximal Tibial Anthropometry in the Iranian Population and Its Implications for Custom Total Knee Prosthesis Design | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Proximal Tibial Anthropometry in the Iranian Population and Its Implications for Custom Total Knee Prosthesis Design Salman Ghaffari, Parna Hosseini, Mehran Razavipour, Faezeh Ghaffari, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5474087/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Apr, 2025 Read the published version in Scientific Reports → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction. Total knee arthroplasty is a spreading surgery, mainly indicated in severe osteoarthritis patients. The anthropometric features of the prosthesis are one of the main factors affecting the surgery outcome, which varies among different races and genders. Challenges arise when prostheses are poorly matched, leading to suboptimal results and increased revision rates. This study aims to quantify proximal tibial dimensions for ethnically tailored prosthesis design of the Iranian population. Materials and Methods. All adult candidates for total knee arthroplasty were enrolled in this study. A surgical blade of 38 mm in length is placed on the resected surface of the proximal tibia in all patients, acting as a scale. The trained operating room technician takes a high-quality picture of the area using a camera. Photographs of the proximal tibial cut, removed during the surgery, were analyzed to extract its anthropometric features. AutoCAD software measured the anteroposterior (AP) length, mediolateral (ML) length, and 18 lengths parallel to the AP length for a more precise representation of the proximal tibial morphology. Results. Overall, 110 patients were enrolled in this study with a mean age of 64.94 (± 7.57). The mean mediolateral (ML) and medial anteroposterior (AP) lengths were 71.03 (± 4.58) and 41.71 (± 4.48) mm, respectively. The mean AP length of women and men were 41.17 ± 4.03 mm (95% CI [40.39, 41.95]) and 48.48 ± 4.59 mm (95% CI [45.30, 51.66]), respectively. The AP length was also significantly different between the two limbs, but not the ML. Conclusions. This study provides baseline anthropometric data for the proximal tibia in the Iranian population, highlighting gender and limb asymmetry variations that significantly influence proximal tibial dimensions. These findings offer critical insights for developing ethnically tailored and gender-specific prostheses, potentially improving implant fit, reducing revision rates, and enhancing overall surgical outcomes. Health sciences/Anatomy Health sciences/Diseases/Rheumatic diseases Health sciences/Rheumatology/Musculoskeletal system Anthropometry Ethnic Variation Knee Prosthesis Proximal Tibia Total Knee Arthroplasty Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Osteoarthritis (OA), the most prevalent form of arthritis, affects over 520 million people globally. OA ranks as the 15th leading cause of years lived with disability (YLDs) worldwide, contributing 2.2% of the global burden. The main reason that those suffering from OA seek medical attention is the severe pain that affects the joints, and this, in turn, reduces physical activity and quality of life in general. [ 1 ]. While treatment options for OA include both pharmacological and surgical approaches, many patients with advanced disease ultimately require surgical intervention despite initial drug therapy[ 2 ]. Total knee arthroplasty (TKA) is the most widely accepted procedure for patients with advanced OA, focusing on minimal complications while achieving pain relief and functional improvement. Osteoarthritis is the most common chronic disease in the end stages of degenerative joint changes. It is designated as the primary TKA indication from 90–97%, followed by rheumatoid arthritis[ 3 ]. TKA is considered a highly successful procedure, with the ability to relieve pain, enhance quality of life, and improve function in patients with knee arthritis[ 4 ]. TKA is becoming one of the most commonly performed surgeries in healthcare systems. It is predicted that by 2030, the total number of primary TKAs in the United States will increase to 3.48 million surgeries annually[ 5 ]. TKA is a technique that requires very accurate bone resection, the right balance in the soft tissues involved, and a precise fit of prosthetic components to resected surfaces for desired outcomes. An inherent challenge posed by the Asian populations is that they have comparatively smaller bodies and bone structures than Western populations, and these groups present unique challenges for prosthetic sizes. Notably, the tibial component has a higher incidence of postoperative issues than the femoral component, which emphasizes the need for precise tibial prosthesis sizing to enhance the stability and longevity of the implant[ 6 ]. The tibia is one of the long bones of the lower limbs, which bears a significant portion of the body and plays a key role in movement. This bone also shows significant dimorphic properties, particularly its proximal end, which expands into a weight-bearing surface. This area transmits forces from the femur through the medial condyle, lateral condyle, intercondylar area, and tibial tuberosity. These morphologies of the proximal tibia are essential in assessing knee replacement procedures and other specialized treatments. The morphometric analysis is a reliable approach to measuring these tibial structures for medical purposes[ 7 ]. Postoperative complications of TKA, like subsidence and prosthetic loosening, mainly happen on the tibial side. Therefore, systemic measurement of the proximal tibia was one key issue in the tibial component design [ 8 ]. The stability and longevity of TKA are significantly predicated on choosing a tibial prosthesis that appropriately matches the resected proximal tibial surface[ 9 ]. The components' precise axial and rotational alignment significantly influences functional outcomes, particularly in fixed-bearing knees, ultimately creating a better long-term outcome in patients with lesser demands[ 10 ]. Prostheses mainly present in hospital settings are predominantly designed for European and American populations with a larger body size compared to Asian populations. Indeed, this shape mismatch between the prosthesis and the resected bone surface arises in TKA due to the size difference[ 11 ]. Studies have reported that 4.1% of Asian patients had revision surgery after primary TKA, while in the United States, it is only 2.6%. However, this discrepancy may be influenced by factors such as variations in healthcare systems, surgical techniques, follow-up durations, and patient demographics[ 8 ]. An anthropometric study of 86 knees (47 osteoarthritic Indians) found that most Indian men (86.8%) could be fitted with available femoral components. In contrast, a significant portion of women (60.4%) had smaller anteroposterior diameters than the smallest prosthetic option, with splaying observed in all groups, indicating the need for prosthetics tailored to smaller anthropometric measurements in the Asian-Pacific population[ 12 ]. Additionally, morphometric measurements of the Arab knee (includes those populations residing in the 23 Arab states of the Arab League), such as an average mediolateral (ML) dimension of 74.36 ± 6 mm and anteroposterior (AP) dimension of 48.94 ± 4.57 mm, demonstrate these Dimensions differ notably compared with Caucasian and Asian knees, which further points to the incongruity of the Arab knee anatomy with currently available TKA implants[ 13 ]. Anthropometric measurements of the Iranian population indicate that the average AP length of the proximal tibia is approximately 48.6 ± 4.5 mm, and the ML width is approximately 74.6 ± 5.9 mm. Notably, males tend to have larger tibial dimensions with AP and ML measurements of 51.0 ± 2.77 mm and 78.0 ± 3.81 mm, respectively, while the females have smaller AP measurements of 44.2 ± 3.51 mm and ML measurements of 68.5 ± 3.83 mm[ 14 ]. In addition, the mean proximal width of the tibia was 82.2 mm in males and 74.1 mm in females, while the distal widths were 54.0 mm and 50.6 mm, respectively[ 15 ]. Given the increasing prevalence of TKA in Iran[ 16 ], an anthropometric study was essential to ensure prosthetic components are tailored to the unique anatomical characteristics of the Iranian population, as currently, there is limited anthropometric data on the proximal tibia of patients with knee arthritis in Iran. To fill the gap noted in this study of prosthetic design for Iranians, the present study aims to evaluate the anthropometric data of proximal tibia in knee arthritis patients undergoing TKA surgery by photographic methods to generate more appropriate prostheses for the unique anatomical characteristics of the Iranian population. Methods This study was conducted at the Imam Khomeini Hospital and Shafa Hospital, Mazandaran, Iran. A total number of 110 patients were enrolled in this study, and the sampling technique was purposive. The purposive sampling technique was applied to ensure that participants with the characteristics of interest for this study were adequately represented. The inclusion criteria were Iranian patients older than 18 years old with severe knee arthritis that warrants TKA and no comorbidities that contraindicate TKA. The exclusion criteria were non-Iranian patients, patients who didn’t accept their enrollment or didn’t sign the written consent, had a history of intra-articular tibial fracture, tibial osteotomy, bone lesion, bone graft, proximal tibial osteomyelitis, or rheumatoid arthritis, and patients with poor quality tibial pictures excluded from the study. This study was approved by the local ethics committee, with the ethical number IR.MAZUMS.IMAMHOSPITAL.REC.1399.090, at the Research Ethics Committees of Imam Hospital—Mazandaran University of Medical Sciences. Written informed consent was collected from each patient. The data-capturing master sheet was maintained throughout the study. At patient enrollment, demographic and baseline characteristics were recorded. During TKA, after the final cut of the proximal tibia, the thickness of the resected tibial bone is measured in millimeters using calipers, taken from that surface which has been minimally worn (lateral in genu varum and medial in genu valgum). A high-quality picture is taken of the area using an Apple iPhone 13 Pro Max (which was the newest iPhone available at the time) by the trained operating room technician from a distance of 30 cm, ensuring that the camera was held parallel to the resected tibial surface. To minimize glare and enhance clarity, overhead surgical lights (ceiling-mounted scialytic lights) were turned off while non-scialytic lighting remained on. Images were taken under controlled conditions to minimize potential variability in measurement. The technician was comprehensively trained in consistency for both quality and alignment of images. A surgical blade of 38 mm in length is placed on the resected surface of the proximal tibia in all patients, acting as a scale for when measurements are taken. Parallel to the AP line, 5% increment lines are drawn medially (9 lines from M5 to M45) and laterally (9 lines from L5 to L45) to obtain a more detailed and accurate representation of the proximal tibial surface, as shown in Fig. 1 . The exact lengths of these 20 lines were measured automatically for all specimens using AutoCAD 2014 software, ensuring precision and minimizing intra-observer variability with a predefined script that generated parallel lines at 5% increments along the ML axis. Finally, an average shape of the proximal tibia derived from the collected measurements is obtained. The first author and the corresponding author collaborated to define critical landmarks and place key reference points before measurements were conducted to enhance accuracy further. The dimensions of the proximal tibia will be evaluated based on gender, height, and weight. The tibial cut thickness was determined based on the extent of the medial tibial defect and the placement of the thinnest possible polyethylene insert rather than a fixed depth[ 17 ]. The surgical epicondylar axis of the femur was designated as the X-axis, determined by the line connecting the lateral epicondylar prominence to the medial sulcus of the medial epicondyle. The ML dimension was defined as the maximum mediolateral length of the resected surface, aligned parallel to the X-axis. The AP dimension was established perpendicular to the ML dimension, intersecting at its midpoint[ 11 ]. In the present study, photographic analysis was used because this method allows measuring the exact surface of the cut during surgery, providing precise dimensions of the tibia relevant to prosthetic design. In this way, the approach remains cost-effective and aligned with routine clinical practice, thus posing no extra load on the patients without compromising the reliability of the data obtained. The intent and purpose of the study, as well as its procedures, risks, and benefits, were explained in an easy-to-understand local language. The patients then gave oral and written consent. All information and records are guaranteed to be treated confidentially. Statistical analysis was conducted using linear regression, and the student’s t-test was used to compare means with normal distribution and Pearson's correlation coefficient through SPSS for Windows version 24.0 (IBM SPSS, US). A p-value less than 0.05 (P < 0.05) was considered statistically significant. Assumptions for the parametric tests were tested. The normality of the data was assessed using the Kolmogorov–Smirnov test before applying parametric tests such as the t-test and linear regression. All variables met the assumption of normality (p > 0.05). Missing data were minimal and included two measurements for lateral lengths (L) and one measurement for medial lengths (M), which were excluded during calculations to ensure accuracy. Power analysis was used to justify the sample size, considering the study's unequal group allocation. Based on the large effect size (Cohen's d = 1.80) of gender difference in AP length that was seen, the adjusted effective sample size was calculated, and a statistical power of 89% at a significance level of 0.05 was obtained. While the sample size is sufficient, the limited number of men limits the statistical power of gender comparisons, which must be interpreted cautiously. Results A total of 110 patients who underwent TKA participated in this study at Imam Khomeini Hospital and Shafa Hospital, Mazandaran. Among them, 53 (48.1%) had right TKA, and 57 (51.9%) had left TKA. The study population comprised 102 (92.7%) females and 8 (7.3%) males. The mean tibial cut thickness, representing the bone resection thickness at the medial tibial plateau, along with other demographic and morphological characteristics, is summarized in Table 1 . Notably, the proximal tibia exhibited a wider mediolateral dimension than the anteroposterior dimension, suggesting a potential mismatch with standard implant designs. Table 1 Demographic Characteristics and Tibial Dimensions of Patients. Parameter Value (mean ± SD) Age (year) 64.94 ± 7.57 Height (cm) 161.44 ± 7.39 Weight (kg) 79.36 ± 9.43 BMI (kg/m 2 ) 30.54 ± 4.26 Tibial cut thickness (mm) 6.18 ± 1.64 Average AP dimension (mm) 71.03 ± 4.59 Average ML dimension (mm) 41.71 ± 4.48 Figure 2 shows an example of axial length measurements in millimeters from a cross-sectional cut of the proximal tibia. A 38 mm scalpel blade is used as a standard reference, positioned at the center of the proximal tibial surface to ensure consistency in comparing anatomical dimensions. The ML and AP dimensions were estimated and analyzed to assess the size of the removed bony surface. In the present study, males consistently proved larger than females in ML and AP dimensions, affirming the demonstrated sexual dimorphism in these measures. Figures 3 and 4 show the average shape of the proximal tibial surface in Iranian men and women. Nine lateral lines (L5 to L45) and nine medial lines (M5 to M45) parallel to the AP line were measured, highlighting the precise morphometric analysis summarized in Table 2 . The proximal tibia's mean medial AP length was 41.71 ± 4.48 mm (95% CI: 40.86–42.56 mm). The mean AP lengths of the right and left tibia were 42.78 ± 4.25 mm (95% CI [41.64, 43.92]) and 40.73 ± 4.50 mm (95% CI [39.56, 41.90]), respectively, with a statistically significant difference (p = 0.016). The mean AP length of women and men were 41.18 ± 4.03 mm (95% CI [40.39, 41.95]) and 48.49 ± 4.59 mm (95% CI [45.30, 51.66]), respectively. The difference between genders showed a significant effect size (Cohen's d = 1.80d). Table 2 The average length of the axial lines of the proximal tibial cuts measured in millimeters (mm). Medial Lateral Axial plane Mean length (± SD) Axial plane Mean length (± SD ) M5 25.25 (± 3.91) L5 21.99 (± 3.28) M10 34.35 (± 4.07) L10 29.48 (± 3.77) M15 40.15 (± 4.11) L15 34.17 (± 4.13) M20 44.08 (± 4.14) L20 37.26 (± 4.40) M25 46.61 (± 4.37) L25 39.26 (± 4.70) M30 47.78 (± 4.63) L30 40.61 (± 5.00) M35 47.60 (± 5.08) L35 41.55 (± 5.18) M40 45.91 (± 5.53) L40 41.72 (± 5.40) M45 46.99 (± 3.69) L45 41.38 (± 5.17) Measurements at M40 and M45 revealed significant differences between the right and left knees (p = 0.040, p = 0.032, respectively). However, no statistically significant differences were observed in the other medial (M5–M35) and lateral (L5–L45) regions (p-values ranging from 0.163 to 0.899), supporting approximate symmetry in these areas (Table 3 ) between the right and left knees. The correlation between height and anthropometric parameters of the knee was examined. According to the Pearson test, no significant correlation (p-value = 0.881) was found between height and proximal tibia dimensions. However, a significant correlation was observed when analyzing the correlation between weight and anthropometric knee parameters. This relationship held markedly for the medial (M20: r = 0.202, p = 0.043; M25: r = 0.218, p = 0.029) and lateral (L20: r = 0.203, p = 0.041; L25: r = 0.196, p = 0.049) knee measurements. Table 3 The average length and p-values for the medial (M5–M45) and lateral (L5–L45) measurements in millimeters (mm) of the right and left tibia. Region Right tibia (mean ± SD) Left tibia (mean ± SD) p-value Medial (M5–M45) M5 24.88 ± 3.43 25.61 ± 4.32 0.333 M10 34.26 ± 3.92 34.36 ± 4.27 0.899 M15 40.00 ± 4.01 40.20 ± 4.24 0.797 M20 43.95 ± 4.05 44.10 ± 4.23 0.846 M25 46.61 ± 4.35 46.48 ± 4.35 0.877 M30 47.94 ± 4.73 47.49 ± 4.46 0.614 M35 48.13 ± 5.15 46.94 ± 4.83 0.225 M40 47.05 ± 5.53 44.87 ± 5.37 0.040 M45 44.56 ± 5.06 42.47 ± 4.99 0.032 Lateral (L5–L45) L5 22.16 ± 3.11 21.75 ± 3.41 0.522 L10 29.80 ± 3.44 29.11 ± 4.03 0.341 L15 34.42 ± 3.69 33.84 ± 4.45 0.459 L20 37.50 ± 3.95 36.91 ± 4.72 0.486 L25 39.47 ± 4.26 38.92 ± 4.97 0.536 L30 40.88 ± 4.53 40.21 ± 5.29 0.478 L35 41.89 ± 4.77 41.06 ± 5.42 0.403 L40 42.27 ± 4.87 41.08 ± 5.70 0.249 L45 42.07 ± 4.66 40.69 ± 5.58 0.163 Discussion For successful TKA, the prosthesis must correctly align and firmly position itself on the resected bony surface since the anatomical dimensions are almost certainly not the same for each ethnic group[ 11 ]. The present study is the first to use an intraoperative photographic study measuring the exact surface of the tibial cut during surgery in the Iranian race. This could help refine the design of tibial implants for better compatibility and better outcomes for Iranian patients. Anthropological studies are crucial for optimizing TKA outcomes. Close morphometric measurements of the proximal tibia at the resection plane must be analyzed to ensure the tibial component's optimal development while acknowledging some anatomical variations among specific populations. The present study examined the anthropometric characteristics of the proximal tibia in the Iranian population, focusing on gender and asymmetry of limbs. The findings indicate that men have larger mediolateral (ML) dimensions than women, and significant disparities were observed between some axial lines of the anteroposterior (AP) lengths of the right and left tibia. Such disparities necessitate population-based and potentially gender-based prosthetic design to facilitate improved success for TKA. Karimi et al. [ 18 ] and the present study both examine the proximal tibial measurements in the Iranian population but with notable differences in methodology and patient populations. The prior research utilized photographic measurements from a younger cohort (mean age 38.26 ± 11.45 years) with a mean ML size of 73.36 ± 6.86 mm and AP size of 46.53 ± 4.05 mm and aspect ratio of 1.58 ± 0.11, suggesting tibial asymmetry. For comparison, the current study was directed towards a slightly older population of TKA and determined a slightly smaller size of 71.03 ± 4.59 mm for ML and 41.71 ± 4.48 mm for AP. Both studies have similar trends in the morphology of the tibia. Although both studies show similar trends in tibial morphology, the observed discrepancies in AP sizes can be due to several reasons, such as age-related changes, methodological differences, and osteoarthritis (OA) severity. Since the present study population was significantly older than Karimi et al., bone remodeling secondary to age can be one reason. Nevertheless, differences in OA severity, sampling, and measurements can also be reasons. Further research with grading of OA severity and a wider range of age groups can strengthen these associations and enhance the comprehension of tibial morphology for prosthesis design. In contrast to Karimi et al., who used photographic measurements, direct intraoperative measurement was utilized in the present study more precisely to prevent any possible distortion secondary to image scaling, angulation, or interference from soft tissues. The intraoperative method is real-time surgeon-validated anatomic information with a more realistic representation of actual bone size applicable to prosthetic fitting. Moreover, while providing more accuracy, the present technique is still cost-effective, in contrast to the high-cost imaging modalities such as CT or MRI. The average anteroposterior AP and ML lengths of the proximal tibia differ across populations. The average AP length in the Thai population was 46.36 mm, while the ML width measured 72.52 mm[ 4 ]. Research on a Kenyan population revealed an average AP diameter of 49.38 mm and an ML width of 69.38 mm[ 19 ]. The average AP length of the proximal tibia in the Japanese population is 50.3 ± 3.6mm, while the ML length is 71.4 ± 5.0 mm[ 20 ]. In the Indian population, the average AP length of the proximal tibia is approximately 47.8 mm in men and 43.4 mm in women. In comparison, the ML length is about 70.1 mm in men and 65.4 mm in women[ 12 ]. The average ML and AP dimensions for Caucasian males by 3D MRI are 79.4 ± 4.3 mm and 49.5 ± 2.9 mm, respectively, while for Caucasian females, the corresponding dimensions are 70.2 ± 2.7 mm and 45.2 ± 2.3 mm[ 21 ]. In the present study, the average ML measurement for the Iranian population was 71.03 ± 4.59 mm, and the AP dimension was 41.71 ± 4.48 mm. This further confirms the discrepancy between the proximal tibia's average AP and ML dimensions among different populations. Along with ML and medial AP dimensions, the present study employed 18 parallel segmental measurements (M5–M45 medially and L5–L45 laterally) to gain an even better understanding of tibial morphology. The measurements give a clearer understanding of tibial shape by capturing deviations within the width of the resection plane that ML and medial AP dimensions cannot fully explain. The segmental analysis also demonstrates subtle but significant differences in the medial and lateral compartments of the tibial plateau. Although most lateral measurements failed to achieve statistical significance, examining the full spectrum of segmental widths remains beneficial in ascertaining general trends in tibial contouring. The results highlight the value of creating tibial implants that respect both global and regional morphological variation to achieve an improved fit and minimize the risk of overhang or poor coverage. By including these 18 parallel measurements in prosthetic design, this research offers a more inclusive plan for designing tibial components with closer adaptation to patient-specific anatomy. This extensive strategy validates our hypothesis that implant design changes must address not just ML and medial AP measurements but also variability in shapes between different areas of the tibia. It is commonly assumed that contralateral bones exhibit negligible bilateral differences, but this may not be entirely accurate. The geometrical asymmetries in human tibiae were evaluated using advanced 3D modeling techniques based on CT scans of paired tibiae as current methodologies. The findings indicated that while most 2D measurements and some specific surface areas (like the lateral plateau and distal subchondral bone surfaces) showed no significant differences, other anatomical surfaces did present substantial asymmetries. The subchondral discrepancies were minor, resting between less than 0.3 mm; this could be for potential surgical applications involving articular reconstructions, given the reliability with which the contralateral tibia can serve as a reference[ 22 ]. Computerized axial tomography scans (< 1.0 mm slices) from both lower limbs of 361 subjects show that, although angular features, such as those seen in the femur and tibia, are essentially symmetric from left to right, the rotational features show notable asymmetries. The tibial version ranges, on average, from 3, with extremes of 0 and 8 degrees. Therefore, recognizing and understanding the bilateral differences in rotational alignment become paramount when evaluating knee function and treatment planning for surgical interferences like TKA[ 23 ]. The present study supports this conclusion by demonstrating significant differences in anteroposterior (AP) length between the right and left tibia, emphasizing the need for prosthetic designs that account for such asymmetry. The findings indicate notable limb-specific variation in proximal tibial size. The AP size differed between the right and left tibia by 2.05 mm, which was statistically significant (p = 0.016). While some degree of asymmetry can be expected in human anatomy, its clinical relevance pertains to alignment tolerances in knee arthroplasty. As noted earlier, a previous study suggested that a limit of 0.3 mm in subchondral asymmetries is acceptable as a guideline for articular reconstructions. Compared to this limit, the 2.05 mm asymmetry found in this study is significantly higher, indicating that tibial asymmetry should not be overlooked in implant design. The current research demonstrates the mean proximal tibial anatomy through axial measurements of length (Figs. 3 and 4 ). Although the figures do not directly depict the aspect ratio (ML/AP) or contour range, these factors are essential for prosthetic fit and alignment. The discrepancy between prosthetic components and the tibial plateau aspect ratio can result in implant overhang or under-coverage, leading to soft tissue irritation or instability. Similarly, variations in the medial-lateral tibial plateau contour affect rotational stability and implant placement [ 24 ]. While not explicitly examined in this study, aspect ratio and contour variation remain important considerations for future research and refining prosthetic design. Gender-specific differences in tibial morphology have been widely documented. The Evaluation of MRI in 700 patients with osteoarthritis demonstrated that all mediolateral, medial anteroposterior, lateral anteroposterior, and mediolateral-to-lateral anteroposterior ratios are significantly smaller in women. The results indicated that an asymmetric gender-specific tibial component may be necessary in improving outcome achievement in total knee arthroplasty [ 9 ]. A CT-scan-based anthropometry study on 130 patients with osteoarthritis (65 males and 65 women) showed that men with similar AP lengths to women have a larger ML/AP ratio[ 24 ]. Asymmetrical tibial components, particularly concerning gender-specific configurations, could address anatomical differences between males and females, consequently contributing to the improvement in tibial coverage and rotational alignment performance features of TKA[ 25 ]. Given that 92.7% of patients in the present study were female, these comparisons should be interpreted cautiously. However, similar trends were observed across all 20 measured tibial dimensions. Gender-specific implants could help reduce overhang, improve prosthetic fit, and minimize complications such as soft tissue irritation and misalignment. Some studies have shown that tibial anthropometric variation is primarily related to various sizes of the tibia, irrespective of race or gender. Such shape differences between populations exist, albeit minor, but their clinical significance is less than size variation. Differences in the tibia size have a more substantial bearing on implant design as they directly affect prosthetic alignment, fit, and long-term outcomes of surgery. Surgeons and designers of prosthetics balance such size differences to eliminate conditions such as implant overhang, which postoperatively may cause soft tissue irritation, knee pain, and inadequate load distribution[ 26 ]. The results of this present study validate the necessity of incorporating size as well as asymmetry in designing customized implants for the Iranian population, thus increasing TKA success rates. This study highlights significant gender- and limb-specific variations in proximal tibial anatomy in the Iranian population, with bearing on custom implant design. Smaller female sizes of tibiae necessitate narrower gender-specific implants to reduce overhang and enhance fit, and right-left asymmetry of tibiae suggests the necessity for limb-specific designs to strengthen alignment and stability. Customization of implants can enhance implant longevity, reduce complications, and optimize surgical outcomes. Nevertheless, there are several limitations regarding the results obtained in this study. The number of subjects in the trial was small, containing only eight males, thus potentially limiting the extent to which findings generalize to a broader population. Future research should include multi-center studies across Iran to validate these results and larger male cohorts for better gender comparisons. Conclusion The morphology of the proximal tibia in the Iranian population features distinct characteristics that are essential for designing effective orthopedic implants, such as total knee arthroplasty. This study indicates that males generally display larger ML dimensions than females, and a significant difference in AP lengths has been observed. Additionally, distinct limb-specific variations in proximal tibial measurements, particularly in AP length, suggest a correlation between these anthropometric measures and the current sizes of tibial implants. Furthermore, this implies that the design of implants may need modifications to align with the anatomical features of the Iranian population. This underscores the importance of considering population-specific data in orthopedic surgery to enhance surgical outcomes and patient satisfaction. By utilizing these anthropometric data, manufacturers will be able to create gender- and population-specific, customized implants that will optimize TKA success and patient satisfaction. Future research with a larger, more diverse populations will be needed to further elucidate these findings and further customize prosthetic compatibility for varied populations. Declarations Ethics approval All procedures adhered to the guidelines approved by the Research Ethics Committee of Mazandaran University of Medical Sciences, Iran (IR.MAZUMS.IMAMHOSPITAL.REC.1399.090). Funding The authors did not receive support from any organization for the submitted work. Author Contribution G.S: Conceptualization and Methodology of study and final approval of the version to be published;H.P: Design of study, data curation, and interpretation of data;R.M: Conceptualization and interpretation of data;A.H: Writing – original draft and Formal analysis;G.F: Writing – review and editing;S.A: Formal analysis and investigation;All authors reviewed the manuscript. Data Availability All the data are available in the main text. All the data generated in this study can be obtained from the corresponding authors upon reasonable request. References Zhai, G. and J. Huang, Genetics of osteoarthritis. Best Practice & Research Clinical Rheumatology, 2024: p. 101972 DOI: https://doi.org/10.1016/j.berh.2024.101972. Zhang, A.-R., et al., Meta-analysis of outcomes after total knee arthroplasty in patients with rheumatoid arthritis and osteoarthritis. Asian Journal of Surgery, 2024. 47 (1): p. 43-54 DOI: https://doi.org/10.1016/j.asjsur.2023.09.015. Chung, H.-K., et al., Acute surgical site infection after total knee arthroplasty in patients with rheumatoid arthritis versus osteoarthritis. Scientific Reports, 2021. 11 (1): p. 22704 DOI: https://doi.org/10.1038/s41598-021-02153-x. Phombut, C., S. Rooppakhun, and B. Sindhupakorn, Morphometric measurement of the proximal tibia to design the tibial component of total knee arthroplasty for the Thai population. Journal of Experimental Orthopaedics, 2021. 8 : p. 1-12 DOI: https://doi.org/10.1186%2Fs40634-021-00429-9. Maman, D., et al., Trends and epidemiology in robotic‐assisted total knee arthroplasty: reduced complications and shorter hospital stays. Knee Surgery, Sports Traumatology, Arthroscopy, 2024 DOI: https://doi.org/10.1002/ksa.12353. Surendran, S., et al., Morphometry of the proximal tibia to design the tibial component of total knee arthroplasty for the Korean population. The Knee, 2007. 14 (4): p. 295-300 DOI: https://doi.org/10.1016/j.knee.2007.05.004. Lucena dos Santos, E.R.S., et al., Determination of sex based on the morphometric evaluation of the proximal tibia. Int. j. morphol, 2018. 36 (1): p. 104-8 DOI: https://doi.org/10.4067/S0717-95022018000100104. Zhang, K., et al., Measurement of proximal tibial morphology in northeast Chinese population based on three-dimensional reconstruction computer tomography. Medicine, 2019. 98 (45): p. e17508 DOI: https://doi.org/10.1097%2FMD.0000000000017508. Kang, K.-T., et al., Effects of measurement methods for tibial rotation axis on the morphometry in Korean populations by gender. The Knee, 2017. 24 (1): p. 23-30 DOI: https://doi.org/10.1016/j.knee.2016.09.012. Chaudhary, C., et al., Functional and Clinical Outcomes of Total Knee Arthroplasty: A Prospective Study. Cureus, 2024. 16 (1) DOI: https://doi.org/10.7759%2Fcureus.52415. Liu, Z., et al., Anthropometry of the proximal tibia of patients with knee arthritis in Shanghai. The Journal of Arthroplasty, 2013. 28 (5): p. 778-783 DOI: https://doi.org/10.1016/j.arth.2012.12.006. Vaidya, S.V., et al., Anthropometric measurements to design total knee prostheses for the Indian population. The Journal of arthroplasty, 2000. 15 (1): p. 79-85 DOI: https://doi.org/10.1016/S0883-5403(00)91285-3. Hafez, M.A., S.M. Sheikhedrees, and E.S. Saweeres, Anthropometry of Arabian arthritic knees: comparison to other ethnic groups and implant dimensions. The Journal of arthroplasty, 2016. 31 (5): p. 1109-1116 DOI: https://doi.org/10.1016/j.arth.2015.11.017. Moghtadaei, M., et al., Morphology of proximal tibia in Iranian population and its correlation with available prostheses. Medical journal of the Islamic Republic of Iran, 2015. 29 : p. 225. Akhlaghi, M., et al., The value of the anthropometric parameters of the tibia in the forensic identification of the Iranian population over the age of 20. Journal of Forensic and Legal Medicine, 2011. 18 (6): p. 257-263 DOI: https://doi.org/10.1016/j.jflm.2011.05.001. Alinia, C., et al., Physician induced demand for knee replacement surgery in Iran. BMC health services research, 2021. 21 : p. 1-8 DOI: https://doi.org/10.1186/s12913-021-06697-6. Schnurr, C., et al., How much tibial resection is required in total knee arthroplasty? International orthopaedics, 2011. 35 : p. 989-994 DOI: https://doi.org/10.1007/s00264-010-1025-5. Karimi, E., et al., Correlation of anthropometric measurements of proximal tibia in iranian knees with size of current tibial implants. Archives of Bone and Joint Surgery, 2019. 7 (4): p. 339. Lakati, K. and B. Ndeleva, Anthropometry of the proximal tibia in a Kenyan population and its correlation with total knee replacement implants. East African Orthopaedic Journal, 2018. 12 (1): p. 3-8. Uehara, K., et al., Anthropometry of the proximal tibia to design a total knee prosthesis for the Japanese population. The Journal of arthroplasty, 2002. 17 (8): p. 1028-1032 DOI: http://dx.doi.org/10.1054/arth.2002.35790. Li, P., et al., Morphological measurement of the knee: race and sex effects. Acta Orthop Belg, 2014. 80 (2): p. 260-268. Radzi, S., et al., Assessing the bilateral geometrical differences of the tibia–are they the same? Medical Engineering & Physics, 2014. 36 (12): p. 1618-1625 DOI: https://doi.org/10.1016/j.medengphy.2014.09.007. Eckhoff, D.G., et al., Bilateral symmetrical comparison of femoral and tibial anatomic features. The Journal of Arthroplasty, 2016. 31 (5): p. 1083-1090 DOI: https://doi.org/10.1016/j.arth.2015.11.021. Yang, B., et al., Computed tomography morphometric study of gender differences in osteoarthritis proximal tibias. The Journal of Arthroplasty, 2013. 28 (7): p. 1117-1120 DOI: https://doi.org/10.1016/j.arth.2012.07.036. Zhang, Z., et al., Comparison of the coverage and rotation of asymmetrical and symmetrical tibial components: a systematic review and meta-analysis. BMC Musculoskeletal Disorders, 2024. 25 (1): p. 336 DOI: https://doi.org/10.5792/ksrr.2015.27.1.17. Dai, Y. and J.E. Bischoff, Comprehensive assessment of tibial plateau morphology in total knee arthroplasty: influence of shape and size on anthropometric variability. Journal of orthopaedic research, 2013. 31 (10): p. 1643-1652 DOI: https://doi.org/10.1002/jor.22410. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Apr, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Accepted 08 Apr, 2025 Reviewers invited by journal 31 Mar, 2025 Submission checks completed at journal 25 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5474087","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":436341659,"identity":"80c6cf28-0efd-41ef-97c7-3c00f5406ae1","order_by":0,"name":"Salman Ghaffari","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Salman","middleName":"","lastName":"Ghaffari","suffix":""},{"id":436341661,"identity":"2fd6a8b1-4481-4d6d-ad88-a1279cbafe82","order_by":1,"name":"Parna Hosseini","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYJACZhh5+A+PDZDF2HiAaC0HeGTSQFoaiNQCAjw2h8E0Xi3m7GcfMBdU1Nnzs/MePCCRc95ubfthoC01NtG4tFj2pBswzzhzOHFmM1/CAYMzt5O3nUkEajmWltuAQ4vBgTQGZt62AwkGh3kMDiT23E42OwDUwthwGLeW889AWurs7UFaDv47l2x2/iEBLTfAtjAzbmDmMTjYwHPAzuwGAVssZzxjOMwD9MsMoC2HGXiSE8xuAG1JwOMXc/40xsc8oBDrP2P8mYHHzt7sfPrDBx9qbHA7jAEtFhLBKhNwKIdpQQH2eBSPglEwCkbBCAUA60xfjFU4f0kAAAAASUVORK5CYII=","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Parna","middleName":"","lastName":"Hosseini","suffix":""},{"id":436341662,"identity":"9772d84b-ce92-473b-8ece-a5fe0eb4a35c","order_by":2,"name":"Mehran Razavipour","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehran","middleName":"","lastName":"Razavipour","suffix":""},{"id":436341663,"identity":"27100765-8b76-4c9a-b353-bbf315fc4e3d","order_by":3,"name":"Faezeh Ghaffari","email":"","orcid":"","institution":"Islamic Azad University Sari Branch","correspondingAuthor":false,"prefix":"","firstName":"Faezeh","middleName":"","lastName":"Ghaffari","suffix":""},{"id":436341665,"identity":"3e3ca52a-0831-4094-a2a6-4fce5580813f","order_by":4,"name":"Hesamoddin Arabnozari","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hesamoddin","middleName":"","lastName":"Arabnozari","suffix":""},{"id":436341667,"identity":"94167acd-f9f3-46d2-92bf-7d01216bf11b","order_by":5,"name":"Seyyed Afshin Shorofi","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyyed","middleName":"Afshin","lastName":"Shorofi","suffix":""}],"badges":[],"createdAt":"2024-11-18 08:24:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5474087/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5474087/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-98013-z","type":"published","date":"2025-04-13T16:05:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79745554,"identity":"8b6de77b-5be2-456b-8fd1-ca6d10bf3eef","added_by":"auto","created_at":"2025-04-02 08:44:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84728,"visible":true,"origin":"","legend":"\u003cp\u003eThe axial lines (AP, ML, M5- M45 and L5- L45) of the proximal plateau of the tibia\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5474087/v1/b149dd99b575c8342e760bf9.png"},{"id":79745553,"identity":"937d9afe-0fcc-4b02-b0f0-516886f19ed1","added_by":"auto","created_at":"2025-04-02 08:44:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":576836,"visible":true,"origin":"","legend":"\u003cp\u003eA sample of the measurements in a cut of the proximal tibial surface. The 38mm surgical blade was placed in the middle of all cuts as an index. All dimensions are measured in millimeters (mm).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5474087/v1/aeda5db14b611e94fb397f5c.png"},{"id":79745557,"identity":"86bfe480-ca54-4ba3-94ac-c7af57d8a788","added_by":"auto","created_at":"2025-04-02 08:44:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":109675,"visible":true,"origin":"","legend":"\u003cp\u003eThe average length of the axial lines of the proximal plateau of the tibia in Iranian women, measured in millimeters (mm).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5474087/v1/5a96ac0731ace83ec1772251.png"},{"id":79746154,"identity":"58e4b429-0aa0-49cf-9c85-3231bbe92af6","added_by":"auto","created_at":"2025-04-02 08:52:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":98367,"visible":true,"origin":"","legend":"\u003cp\u003eThe average length of the axial lines of the proximal plateau of the tibia in Iranian men, measured in millimeters (mm).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5474087/v1/c64c14a78719f0dc8df152f0.png"},{"id":80559007,"identity":"49890057-b58f-4d5f-8921-d5ee2299753e","added_by":"auto","created_at":"2025-04-14 16:17:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1615462,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5474087/v1/7c7bee19-c3b0-4161-85be-b8649c05ceaf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Proximal Tibial Anthropometry in the Iranian Population and Its Implications for Custom Total Knee Prosthesis Design","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteoarthritis (OA), the most prevalent form of arthritis, affects over 520\u0026nbsp;million people globally. OA ranks as the 15th leading cause of years lived with disability (YLDs) worldwide, contributing 2.2% of the global burden. The main reason that those suffering from OA seek medical attention is the severe pain that affects the joints, and this, in turn, reduces physical activity and quality of life in general. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While treatment options for OA include both pharmacological and surgical approaches, many patients with advanced disease ultimately require surgical intervention despite initial drug therapy[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTotal knee arthroplasty (TKA) is the most widely accepted procedure for patients with advanced OA, focusing on minimal complications while achieving pain relief and functional improvement. Osteoarthritis is the most common chronic disease in the end stages of degenerative joint changes. It is designated as the primary TKA indication from 90\u0026ndash;97%, followed by rheumatoid arthritis[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. TKA is considered a highly successful procedure, with the ability to relieve pain, enhance quality of life, and improve function in patients with knee arthritis[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. TKA is becoming one of the most commonly performed surgeries in healthcare systems. It is predicted that by 2030, the total number of primary TKAs in the United States will increase to 3.48\u0026nbsp;million surgeries annually[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTKA is a technique that requires very accurate bone resection, the right balance in the soft tissues involved, and a precise fit of prosthetic components to resected surfaces for desired outcomes. An inherent challenge posed by the Asian populations is that they have comparatively smaller bodies and bone structures than Western populations, and these groups present unique challenges for prosthetic sizes. Notably, the tibial component has a higher incidence of postoperative issues than the femoral component, which emphasizes the need for precise tibial prosthesis sizing to enhance the stability and longevity of the implant[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe tibia is one of the long bones of the lower limbs, which bears a significant portion of the body and plays a key role in movement. This bone also shows significant dimorphic properties, particularly its proximal end, which expands into a weight-bearing surface. This area transmits forces from the femur through the medial condyle, lateral condyle, intercondylar area, and tibial tuberosity. These morphologies of the proximal tibia are essential in assessing knee replacement procedures and other specialized treatments. The morphometric analysis is a reliable approach to measuring these tibial structures for medical purposes[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Postoperative complications of TKA, like subsidence and prosthetic loosening, mainly happen on the tibial side. Therefore, systemic measurement of the proximal tibia was one key issue in the tibial component design [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The stability and longevity of TKA are significantly predicated on choosing a tibial prosthesis that appropriately matches the resected proximal tibial surface[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The components' precise axial and rotational alignment significantly influences functional outcomes, particularly in fixed-bearing knees, ultimately creating a better long-term outcome in patients with lesser demands[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProstheses mainly present in hospital settings are predominantly designed for European and American populations with a larger body size compared to Asian populations. Indeed, this shape mismatch between the prosthesis and the resected bone surface arises in TKA due to the size difference[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies have reported that 4.1% of Asian patients had revision surgery after primary TKA, while in the United States, it is only 2.6%. However, this discrepancy may be influenced by factors such as variations in healthcare systems, surgical techniques, follow-up durations, and patient demographics[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. An anthropometric study of 86 knees (47 osteoarthritic Indians) found that most Indian men (86.8%) could be fitted with available femoral components. In contrast, a significant portion of women (60.4%) had smaller anteroposterior diameters than the smallest prosthetic option, with splaying observed in all groups, indicating the need for prosthetics tailored to smaller anthropometric measurements in the Asian-Pacific population[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, morphometric measurements of the Arab knee (includes those populations residing in the 23 Arab states of the Arab League), such as an average mediolateral (ML) dimension of 74.36\u0026thinsp;\u0026plusmn;\u0026thinsp;6 mm and anteroposterior (AP) dimension of 48.94\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57 mm, demonstrate these Dimensions differ notably compared with Caucasian and Asian knees, which further points to the incongruity of the Arab knee anatomy with currently available TKA implants[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Anthropometric measurements of the Iranian population indicate that the average AP length of the proximal tibia is approximately 48.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 mm, and the ML width is approximately 74.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 mm. Notably, males tend to have larger tibial dimensions with AP and ML measurements of 51.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77 mm and 78.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.81 mm, respectively, while the females have smaller AP measurements of 44.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.51 mm and ML measurements of 68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.83 mm[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, the mean proximal width of the tibia was 82.2 mm in males and 74.1 mm in females, while the distal widths were 54.0 mm and 50.6 mm, respectively[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the increasing prevalence of TKA in Iran[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], an anthropometric study was essential to ensure prosthetic components are tailored to the unique anatomical characteristics of the Iranian population, as currently, there is limited anthropometric data on the proximal tibia of patients with knee arthritis in Iran. To fill the gap noted in this study of prosthetic design for Iranians, the present study aims to evaluate the anthropometric data of proximal tibia in knee arthritis patients undergoing TKA surgery by photographic methods to generate more appropriate prostheses for the unique anatomical characteristics of the Iranian population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was conducted at the Imam Khomeini Hospital and Shafa Hospital, Mazandaran, Iran. A total number of 110 patients were enrolled in this study, and the sampling technique was purposive. The purposive sampling technique was applied to ensure that participants with the characteristics of interest for this study were adequately represented. The inclusion criteria were Iranian patients older than 18 years old with severe knee arthritis that warrants TKA and no comorbidities that contraindicate TKA. The exclusion criteria were non-Iranian patients, patients who didn\u0026rsquo;t accept their enrollment or didn\u0026rsquo;t sign the written consent, had a history of intra-articular tibial fracture, tibial osteotomy, bone lesion, bone graft, proximal tibial osteomyelitis, or rheumatoid arthritis, and patients with poor quality tibial pictures excluded from the study.\u003c/p\u003e \u003cp\u003e This study was approved by the local ethics committee, with the ethical number IR.MAZUMS.IMAMHOSPITAL.REC.1399.090, at the Research Ethics Committees of Imam Hospital\u0026mdash;Mazandaran University of Medical Sciences. Written informed consent was collected from each patient. The data-capturing master sheet was maintained throughout the study. At patient enrollment, demographic and baseline characteristics were recorded.\u003c/p\u003e \u003cp\u003eDuring TKA, after the final cut of the proximal tibia, the thickness of the resected tibial bone is measured in millimeters using calipers, taken from that surface which has been minimally worn (lateral in genu varum and medial in genu valgum). A high-quality picture is taken of the area using an Apple iPhone 13 Pro Max (which was the newest iPhone available at the time) by the trained operating room technician from a distance of 30 cm, ensuring that the camera was held parallel to the resected tibial surface. To minimize glare and enhance clarity, overhead surgical lights (ceiling-mounted scialytic lights) were turned off while non-scialytic lighting remained on. Images were taken under controlled conditions to minimize potential variability in measurement. The technician was comprehensively trained in consistency for both quality and alignment of images. A surgical blade of 38 mm in length is placed on the resected surface of the proximal tibia in all patients, acting as a scale for when measurements are taken. Parallel to the AP line, 5% increment lines are drawn medially (9 lines from M5 to M45) and laterally (9 lines from L5 to L45) to obtain a more detailed and accurate representation of the proximal tibial surface, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe exact lengths of these 20 lines were measured automatically for all specimens using AutoCAD 2014 software, ensuring precision and minimizing intra-observer variability with a predefined script that generated parallel lines at 5% increments along the ML axis. Finally, an average shape of the proximal tibia derived from the collected measurements is obtained. The first author and the corresponding author collaborated to define critical landmarks and place key reference points before measurements were conducted to enhance accuracy further. The dimensions of the proximal tibia will be evaluated based on gender, height, and weight.\u003c/p\u003e \u003cp\u003eThe tibial cut thickness was determined based on the extent of the medial tibial defect and the placement of the thinnest possible polyethylene insert rather than a fixed depth[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The surgical epicondylar axis of the femur was designated as the X-axis, determined by the line connecting the lateral epicondylar prominence to the medial sulcus of the medial epicondyle. The ML dimension was defined as the maximum mediolateral length of the resected surface, aligned parallel to the X-axis. The AP dimension was established perpendicular to the ML dimension, intersecting at its midpoint[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, photographic analysis was used because this method allows measuring the exact surface of the cut during surgery, providing precise dimensions of the tibia relevant to prosthetic design. In this way, the approach remains cost-effective and aligned with routine clinical practice, thus posing no extra load on the patients without compromising the reliability of the data obtained.\u003c/p\u003e \u003cp\u003eThe intent and purpose of the study, as well as its procedures, risks, and benefits, were explained in an easy-to-understand local language. The patients then gave oral and written consent. All information and records are guaranteed to be treated confidentially.\u003c/p\u003e \u003cp\u003eStatistical analysis was conducted using linear regression, and the student\u0026rsquo;s t-test was used to compare means with normal distribution and Pearson's correlation coefficient through SPSS for Windows version 24.0 (IBM SPSS, US). A p-value less than 0.05 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) was considered statistically significant. Assumptions for the parametric tests were tested. The normality of the data was assessed using the Kolmogorov\u0026ndash;Smirnov test before applying parametric tests such as the t-test and linear regression. All variables met the assumption of normality (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Missing data were minimal and included two measurements for lateral lengths (L) and one measurement for medial lengths (M), which were excluded during calculations to ensure accuracy.\u003c/p\u003e \u003cp\u003ePower analysis was used to justify the sample size, considering the study's unequal group allocation. Based on the large effect size (Cohen's d\u0026thinsp;=\u0026thinsp;1.80) of gender difference in AP length that was seen, the adjusted effective sample size was calculated, and a statistical power of 89% at a significance level of 0.05 was obtained. While the sample size is sufficient, the limited number of men limits the statistical power of gender comparisons, which must be interpreted cautiously.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e A total of 110 patients who underwent TKA participated in this study at Imam Khomeini Hospital and Shafa Hospital, Mazandaran. Among them, 53 (48.1%) had right TKA, and 57 (51.9%) had left TKA. The study population comprised 102 (92.7%) females and 8 (7.3%) males. The mean tibial cut thickness, representing the bone resection thickness at the medial tibial plateau, along with other demographic and morphological characteristics, is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Notably, the proximal tibia exhibited a wider mediolateral dimension than the anteroposterior dimension, suggesting a potential mismatch with standard implant designs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics and Tibial Dimensions of Patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e64.94\u0026thinsp;\u0026plusmn;\u0026thinsp;7.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e161.44\u0026thinsp;\u0026plusmn;\u0026thinsp;7.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e79.36\u0026thinsp;\u0026plusmn;\u0026thinsp;9.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.54\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTibial cut thickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage AP dimension (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e71.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage ML dimension (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e41.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows an example of axial length measurements in millimeters from a cross-sectional cut of the proximal tibia. A 38 mm scalpel blade is used as a standard reference, positioned at the center of the proximal tibial surface to ensure consistency in comparing anatomical dimensions. The ML and AP dimensions were estimated and analyzed to assess the size of the removed bony surface.\u003c/p\u003e \u003cp\u003eIn the present study, males consistently proved larger than females in ML and AP dimensions, affirming the demonstrated sexual dimorphism in these measures. Figures\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e show the average shape of the proximal tibial surface in Iranian men and women.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNine lateral lines (L5 to L45) and nine medial lines (M5 to M45) parallel to the AP line were measured, highlighting the precise morphometric analysis summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The proximal tibia's mean medial AP length was 41.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48 mm (95% CI: 40.86\u0026ndash;42.56 mm). The mean AP lengths of the right and left tibia were 42.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.25 mm (95% CI [41.64, 43.92]) and 40.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.50 mm (95% CI [39.56, 41.90]), respectively, with a statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.016).\u003c/p\u003e \u003cp\u003eThe mean AP length of women and men were 41.18\u0026thinsp;\u0026plusmn;\u0026thinsp;4.03 mm (95% CI [40.39, 41.95]) and 48.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59 mm (95% CI [45.30, 51.66]), respectively. The difference between genders showed a significant effect size (Cohen's d\u0026thinsp;=\u0026thinsp;1.80d).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe average length of the axial lines of the proximal tibial cuts measured in millimeters (mm).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMedial\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxial plane\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean length (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAxial plane\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean length (\u0026plusmn;\u0026thinsp;SD )\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e25.25 (\u0026plusmn;\u0026thinsp;3.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e21.99 (\u0026plusmn;\u0026thinsp;3.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.35 (\u0026plusmn;\u0026thinsp;4.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e29.48 (\u0026plusmn;\u0026thinsp;3.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.15 (\u0026plusmn;\u0026thinsp;4.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e34.17 (\u0026plusmn;\u0026thinsp;4.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e44.08 (\u0026plusmn;\u0026thinsp;4.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e37.26 (\u0026plusmn;\u0026thinsp;4.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e46.61 (\u0026plusmn;\u0026thinsp;4.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e39.26 (\u0026plusmn;\u0026thinsp;4.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.78 (\u0026plusmn;\u0026thinsp;4.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e40.61 (\u0026plusmn;\u0026thinsp;5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.60 (\u0026plusmn;\u0026thinsp;5.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e41.55 (\u0026plusmn;\u0026thinsp;5.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e45.91 (\u0026plusmn;\u0026thinsp;5.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e41.72 (\u0026plusmn;\u0026thinsp;5.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e46.99 (\u0026plusmn;\u0026thinsp;3.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e41.38 (\u0026plusmn;\u0026thinsp;5.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMeasurements at M40 and M45 revealed significant differences between the right and left knees (p\u0026thinsp;=\u0026thinsp;0.040, p\u0026thinsp;=\u0026thinsp;0.032, respectively). However, no statistically significant differences were observed in the other medial (M5\u0026ndash;M35) and lateral (L5\u0026ndash;L45) regions (p-values ranging from 0.163 to 0.899), supporting approximate symmetry in these areas (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) between the right and left knees.\u003c/p\u003e \u003cp\u003eThe correlation between height and anthropometric parameters of the knee was examined. According to the Pearson test, no significant correlation (p-value\u0026thinsp;=\u0026thinsp;0.881) was found between height and proximal tibia dimensions. However, a significant correlation was observed when analyzing the correlation between weight and anthropometric knee parameters. This relationship held markedly for the medial (M20: r\u0026thinsp;=\u0026thinsp;0.202, p\u0026thinsp;=\u0026thinsp;0.043; M25: r\u0026thinsp;=\u0026thinsp;0.218, p\u0026thinsp;=\u0026thinsp;0.029) and lateral (L20: r\u0026thinsp;=\u0026thinsp;0.203, p\u0026thinsp;=\u0026thinsp;0.041; L25: r\u0026thinsp;=\u0026thinsp;0.196, p\u0026thinsp;=\u0026thinsp;0.049) knee measurements.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe average length and p-values for the medial (M5\u0026ndash;M45) and lateral (L5\u0026ndash;L45) measurements in millimeters (mm) of the right and left tibia.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight tibia (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft tibia (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedial (M5\u0026ndash;M45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e24.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e25.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.333\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e34.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.20\u0026thinsp;\u0026plusmn;\u0026thinsp;4.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.797\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e43.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.10\u0026thinsp;\u0026plusmn;\u0026thinsp;4.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e46.61\u0026thinsp;\u0026plusmn;\u0026thinsp;4.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e46.48\u0026thinsp;\u0026plusmn;\u0026thinsp;4.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.877\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.94\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e47.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e48.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e46.94\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e47.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e44.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e44.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e42.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLateral (L5\u0026ndash;L45)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e22.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e29.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e29.11\u0026thinsp;\u0026plusmn;\u0026thinsp;4.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.42\u0026thinsp;\u0026plusmn;\u0026thinsp;3.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e33.84\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e37.50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e36.91\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e39.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e38.92\u0026thinsp;\u0026plusmn;\u0026thinsp;4.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.536\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.478\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e41.89\u0026thinsp;\u0026plusmn;\u0026thinsp;4.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e41.06\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e41.08\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e40.69\u0026thinsp;\u0026plusmn;\u0026thinsp;5.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor successful TKA, the prosthesis must correctly align and firmly position itself on the resected bony surface since the anatomical dimensions are almost certainly not the same for each ethnic group[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The present study is the first to use an intraoperative photographic study measuring the exact surface of the tibial cut during surgery in the Iranian race. This could help refine the design of tibial implants for better compatibility and better outcomes for Iranian patients.\u003c/p\u003e \u003cp\u003eAnthropological studies are crucial for optimizing TKA outcomes. Close morphometric measurements of the proximal tibia at the resection plane must be analyzed to ensure the tibial component's optimal development while acknowledging some anatomical variations among specific populations. The present study examined the anthropometric characteristics of the proximal tibia in the Iranian population, focusing on gender and asymmetry of limbs. The findings indicate that men have larger mediolateral (ML) dimensions than women, and significant disparities were observed between some axial lines of the anteroposterior (AP) lengths of the right and left tibia. Such disparities necessitate population-based and potentially gender-based prosthetic design to facilitate improved success for TKA.\u003c/p\u003e \u003cp\u003eKarimi et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and the present study both examine the proximal tibial measurements in the Iranian population but with notable differences in methodology and patient populations. The prior research utilized photographic measurements from a younger cohort (mean age 38.26\u0026thinsp;\u0026plusmn;\u0026thinsp;11.45 years) with a mean ML size of 73.36\u0026thinsp;\u0026plusmn;\u0026thinsp;6.86 mm and AP size of 46.53\u0026thinsp;\u0026plusmn;\u0026thinsp;4.05 mm and aspect ratio of 1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11, suggesting tibial asymmetry. For comparison, the current study was directed towards a slightly older population of TKA and determined a slightly smaller size of 71.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59 mm for ML and 41.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48 mm for AP. Both studies have similar trends in the morphology of the tibia. Although both studies show similar trends in tibial morphology, the observed discrepancies in AP sizes can be due to several reasons, such as age-related changes, methodological differences, and osteoarthritis (OA) severity. Since the present study population was significantly older than Karimi et al., bone remodeling secondary to age can be one reason. Nevertheless, differences in OA severity, sampling, and measurements can also be reasons. Further research with grading of OA severity and a wider range of age groups can strengthen these associations and enhance the comprehension of tibial morphology for prosthesis design. In contrast to Karimi et al., who used photographic measurements, direct intraoperative measurement was utilized in the present study more precisely to prevent any possible distortion secondary to image scaling, angulation, or interference from soft tissues. The intraoperative method is real-time surgeon-validated anatomic information with a more realistic representation of actual bone size applicable to prosthetic fitting. Moreover, while providing more accuracy, the present technique is still cost-effective, in contrast to the high-cost imaging modalities such as CT or MRI.\u003c/p\u003e \u003cp\u003eThe average anteroposterior AP and ML lengths of the proximal tibia differ across populations. The average AP length in the Thai population was 46.36 mm, while the ML width measured 72.52 mm[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Research on a Kenyan population revealed an average AP diameter of 49.38 mm and an ML width of 69.38 mm[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The average AP length of the proximal tibia in the Japanese population is 50.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6mm, while the ML length is 71.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 mm[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the Indian population, the average AP length of the proximal tibia is approximately 47.8 mm in men and 43.4 mm in women. In comparison, the ML length is about 70.1 mm in men and 65.4 mm in women[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The average ML and AP dimensions for Caucasian males by 3D MRI are 79.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 mm and 49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 mm, respectively, while for Caucasian females, the corresponding dimensions are 70.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 mm and 45.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 mm[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the present study, the average ML measurement for the Iranian population was 71.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59 mm, and the AP dimension was 41.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48 mm. This further confirms the discrepancy between the proximal tibia's average AP and ML dimensions among different populations.\u003c/p\u003e \u003cp\u003eAlong with ML and medial AP dimensions, the present study employed 18 parallel segmental measurements (M5\u0026ndash;M45 medially and L5\u0026ndash;L45 laterally) to gain an even better understanding of tibial morphology. The measurements give a clearer understanding of tibial shape by capturing deviations within the width of the resection plane that ML and medial AP dimensions cannot fully explain. The segmental analysis also demonstrates subtle but significant differences in the medial and lateral compartments of the tibial plateau. Although most lateral measurements failed to achieve statistical significance, examining the full spectrum of segmental widths remains beneficial in ascertaining general trends in tibial contouring. The results highlight the value of creating tibial implants that respect both global and regional morphological variation to achieve an improved fit and minimize the risk of overhang or poor coverage. By including these 18 parallel measurements in prosthetic design, this research offers a more inclusive plan for designing tibial components with closer adaptation to patient-specific anatomy. This extensive strategy validates our hypothesis that implant design changes must address not just ML and medial AP measurements but also variability in shapes between different areas of the tibia.\u003c/p\u003e \u003cp\u003eIt is commonly assumed that contralateral bones exhibit negligible bilateral differences, but this may not be entirely accurate. The geometrical asymmetries in human tibiae were evaluated using advanced 3D modeling techniques based on CT scans of paired tibiae as current methodologies. The findings indicated that while most 2D measurements and some specific surface areas (like the lateral plateau and distal subchondral bone surfaces) showed no significant differences, other anatomical surfaces did present substantial asymmetries. The subchondral discrepancies were minor, resting between less than 0.3 mm; this could be for potential surgical applications involving articular reconstructions, given the reliability with which the contralateral tibia can serve as a reference[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Computerized axial tomography scans (\u0026lt;\u0026thinsp;1.0 mm slices) from both lower limbs of 361 subjects show that, although angular features, such as those seen in the femur and tibia, are essentially symmetric from left to right, the rotational features show notable asymmetries. The tibial version ranges, on average, from 3, with extremes of 0 and 8 degrees. Therefore, recognizing and understanding the bilateral differences in rotational alignment become paramount when evaluating knee function and treatment planning for surgical interferences like TKA[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The present study supports this conclusion by demonstrating significant differences in anteroposterior (AP) length between the right and left tibia, emphasizing the need for prosthetic designs that account for such asymmetry. The findings indicate notable limb-specific variation in proximal tibial size. The AP size differed between the right and left tibia by 2.05 mm, which was statistically significant (p\u0026thinsp;=\u0026thinsp;0.016). While some degree of asymmetry can be expected in human anatomy, its clinical relevance pertains to alignment tolerances in knee arthroplasty. As noted earlier, a previous study suggested that a limit of 0.3 mm in subchondral asymmetries is acceptable as a guideline for articular reconstructions. Compared to this limit, the 2.05 mm asymmetry found in this study is significantly higher, indicating that tibial asymmetry should not be overlooked in implant design.\u003c/p\u003e \u003cp\u003eThe current research demonstrates the mean proximal tibial anatomy through axial measurements of length (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Although the figures do not directly depict the aspect ratio (ML/AP) or contour range, these factors are essential for prosthetic fit and alignment. The discrepancy between prosthetic components and the tibial plateau aspect ratio can result in implant overhang or under-coverage, leading to soft tissue irritation or instability. Similarly, variations in the medial-lateral tibial plateau contour affect rotational stability and implant placement [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. While not explicitly examined in this study, aspect ratio and contour variation remain important considerations for future research and refining prosthetic design.\u003c/p\u003e \u003cp\u003eGender-specific differences in tibial morphology have been widely documented. The Evaluation of MRI in 700 patients with osteoarthritis demonstrated that all mediolateral, medial anteroposterior, lateral anteroposterior, and mediolateral-to-lateral anteroposterior ratios are significantly smaller in women. The results indicated that an asymmetric gender-specific tibial component may be necessary in improving outcome achievement in total knee arthroplasty [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A CT-scan-based anthropometry study on 130 patients with osteoarthritis (65 males and 65 women) showed that men with similar AP lengths to women have a larger ML/AP ratio[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Asymmetrical tibial components, particularly concerning gender-specific configurations, could address anatomical differences between males and females, consequently contributing to the improvement in tibial coverage and rotational alignment performance features of TKA[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Given that 92.7% of patients in the present study were female, these comparisons should be interpreted cautiously. However, similar trends were observed across all 20 measured tibial dimensions. Gender-specific implants could help reduce overhang, improve prosthetic fit, and minimize complications such as soft tissue irritation and misalignment.\u003c/p\u003e \u003cp\u003eSome studies have shown that tibial anthropometric variation is primarily related to various sizes of the tibia, irrespective of race or gender. Such shape differences between populations exist, albeit minor, but their clinical significance is less than size variation. Differences in the tibia size have a more substantial bearing on implant design as they directly affect prosthetic alignment, fit, and long-term outcomes of surgery. Surgeons and designers of prosthetics balance such size differences to eliminate conditions such as implant overhang, which postoperatively may cause soft tissue irritation, knee pain, and inadequate load distribution[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The results of this present study validate the necessity of incorporating size as well as asymmetry in designing customized implants for the Iranian population, thus increasing TKA success rates.\u003c/p\u003e \u003cp\u003eThis study highlights significant gender- and limb-specific variations in proximal tibial anatomy in the Iranian population, with bearing on custom implant design. Smaller female sizes of tibiae necessitate narrower gender-specific implants to reduce overhang and enhance fit, and right-left asymmetry of tibiae suggests the necessity for limb-specific designs to strengthen alignment and stability. Customization of implants can enhance implant longevity, reduce complications, and optimize surgical outcomes.\u003c/p\u003e \u003cp\u003eNevertheless, there are several limitations regarding the results obtained in this study. The number of subjects in the trial was small, containing only eight males, thus potentially limiting the extent to which findings generalize to a broader population. Future research should include multi-center studies across Iran to validate these results and larger male cohorts for better gender comparisons.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe morphology of the proximal tibia in the Iranian population features distinct characteristics that are essential for designing effective orthopedic implants, such as total knee arthroplasty. This study indicates that males generally display larger ML dimensions than females, and a significant difference in AP lengths has been observed. Additionally, distinct limb-specific variations in proximal tibial measurements, particularly in AP length, suggest a correlation between these anthropometric measures and the current sizes of tibial implants. Furthermore, this implies that the design of implants may need modifications to align with the anatomical features of the Iranian population. This underscores the importance of considering population-specific data in orthopedic surgery to enhance surgical outcomes and patient satisfaction. By utilizing these anthropometric data, manufacturers will be able to create gender- and population-specific, customized implants that will optimize TKA success and patient satisfaction. Future research with a larger, more diverse populations will be needed to further elucidate these findings and further customize prosthetic compatibility for varied populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e All procedures adhered to the guidelines approved by the Research Ethics Committee of Mazandaran University of Medical Sciences, Iran (IR.MAZUMS.IMAMHOSPITAL.REC.1399.090).\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eG.S: Conceptualization and Methodology of study and final approval of the version to be published;H.P: Design of study, data curation, and interpretation of data;R.M: Conceptualization and interpretation of data;A.H: Writing \u0026ndash; original draft and Formal analysis;G.F: Writing \u0026ndash; review and editing;S.A: Formal analysis and investigation;All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll the data are available in the main text. All the data generated in this study can be obtained from the corresponding authors upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhai, G. and J. Huang, \u003cem\u003eGenetics of osteoarthritis.\u003c/em\u003e Best Practice \u0026amp; Research Clinical Rheumatology, 2024: p. 101972 DOI: https://doi.org/10.1016/j.berh.2024.101972.\u003c/li\u003e\n\u003cli\u003eZhang, A.-R., et al., \u003cem\u003eMeta-analysis of outcomes after total knee arthroplasty in patients with rheumatoid arthritis and osteoarthritis.\u003c/em\u003e Asian Journal of Surgery, 2024. \u003cstrong\u003e47\u003c/strong\u003e(1): p. 43-54 DOI: https://doi.org/10.1016/j.asjsur.2023.09.015.\u003c/li\u003e\n\u003cli\u003eChung, H.-K., et al., \u003cem\u003eAcute surgical site infection after total knee arthroplasty in patients with rheumatoid arthritis versus osteoarthritis.\u003c/em\u003e Scientific Reports, 2021. \u003cstrong\u003e11\u003c/strong\u003e(1): p. 22704 DOI: https://doi.org/10.1038/s41598-021-02153-x.\u003c/li\u003e\n\u003cli\u003ePhombut, C., S. Rooppakhun, and B. Sindhupakorn, \u003cem\u003eMorphometric measurement of the proximal tibia to design the tibial component of total knee arthroplasty for the Thai population.\u003c/em\u003e Journal of Experimental Orthopaedics, 2021. \u003cstrong\u003e8\u003c/strong\u003e: p. 1-12 DOI: https://doi.org/10.1186%2Fs40634-021-00429-9.\u003c/li\u003e\n\u003cli\u003eMaman, D., et al., \u003cem\u003eTrends and epidemiology in robotic‐assisted total knee arthroplasty: reduced complications and shorter hospital stays.\u003c/em\u003e Knee Surgery, Sports Traumatology, Arthroscopy, 2024 DOI: https://doi.org/10.1002/ksa.12353.\u003c/li\u003e\n\u003cli\u003eSurendran, S., et al., \u003cem\u003eMorphometry of the proximal tibia to design the tibial component of total knee arthroplasty for the Korean population.\u003c/em\u003e The Knee, 2007. \u003cstrong\u003e14\u003c/strong\u003e(4): p. 295-300 DOI: https://doi.org/10.1016/j.knee.2007.05.004.\u003c/li\u003e\n\u003cli\u003eLucena dos Santos, E.R.S., et al., \u003cem\u003eDetermination of sex based on the morphometric evaluation of the proximal tibia.\u003c/em\u003e Int. j. morphol, 2018. \u003cstrong\u003e36\u003c/strong\u003e(1): p. 104-8 DOI: https://doi.org/10.4067/S0717-95022018000100104.\u003c/li\u003e\n\u003cli\u003eZhang, K., et al., \u003cem\u003eMeasurement of proximal tibial morphology in northeast Chinese population based on three-dimensional reconstruction computer tomography.\u003c/em\u003e Medicine, 2019. \u003cstrong\u003e98\u003c/strong\u003e(45): p. e17508 DOI: https://doi.org/10.1097%2FMD.0000000000017508.\u003c/li\u003e\n\u003cli\u003eKang, K.-T., et al., \u003cem\u003eEffects of measurement methods for tibial rotation axis on the morphometry in Korean populations by gender.\u003c/em\u003e The Knee, 2017. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 23-30 DOI: https://doi.org/10.1016/j.knee.2016.09.012.\u003c/li\u003e\n\u003cli\u003eChaudhary, C., et al., \u003cem\u003eFunctional and Clinical Outcomes of Total Knee Arthroplasty: A Prospective Study.\u003c/em\u003e Cureus, 2024. \u003cstrong\u003e16\u003c/strong\u003e(1) DOI: https://doi.org/10.7759%2Fcureus.52415.\u003c/li\u003e\n\u003cli\u003eLiu, Z., et al., \u003cem\u003eAnthropometry of the proximal tibia of patients with knee arthritis in Shanghai.\u003c/em\u003e The Journal of Arthroplasty, 2013. \u003cstrong\u003e28\u003c/strong\u003e(5): p. 778-783 DOI: https://doi.org/10.1016/j.arth.2012.12.006.\u003c/li\u003e\n\u003cli\u003eVaidya, S.V., et al., \u003cem\u003eAnthropometric measurements to design total knee prostheses for the Indian population.\u003c/em\u003e The Journal of arthroplasty, 2000. \u003cstrong\u003e15\u003c/strong\u003e(1): p. 79-85 DOI: https://doi.org/10.1016/S0883-5403(00)91285-3.\u003c/li\u003e\n\u003cli\u003eHafez, M.A., S.M. Sheikhedrees, and E.S. Saweeres, \u003cem\u003eAnthropometry of Arabian arthritic knees: comparison to other ethnic groups and implant dimensions.\u003c/em\u003e The Journal of arthroplasty, 2016. \u003cstrong\u003e31\u003c/strong\u003e(5): p. 1109-1116 DOI: https://doi.org/10.1016/j.arth.2015.11.017.\u003c/li\u003e\n\u003cli\u003eMoghtadaei, M., et al., \u003cem\u003eMorphology of proximal tibia in Iranian population and its correlation with available prostheses.\u003c/em\u003e Medical journal of the Islamic Republic of Iran, 2015. \u003cstrong\u003e29\u003c/strong\u003e: p. 225.\u003c/li\u003e\n\u003cli\u003eAkhlaghi, M., et al., \u003cem\u003eThe value of the anthropometric parameters of the tibia in the forensic identification of the Iranian population over the age of 20.\u003c/em\u003e Journal of Forensic and Legal Medicine, 2011. \u003cstrong\u003e18\u003c/strong\u003e(6): p. 257-263 DOI: https://doi.org/10.1016/j.jflm.2011.05.001.\u003c/li\u003e\n\u003cli\u003eAlinia, C., et al., \u003cem\u003ePhysician induced demand for knee replacement surgery in Iran.\u003c/em\u003e BMC health services research, 2021. \u003cstrong\u003e21\u003c/strong\u003e: p. 1-8 DOI: https://doi.org/10.1186/s12913-021-06697-6.\u003c/li\u003e\n\u003cli\u003eSchnurr, C., et al., \u003cem\u003eHow much tibial resection is required in total knee arthroplasty?\u003c/em\u003e International orthopaedics, 2011. \u003cstrong\u003e35\u003c/strong\u003e: p. 989-994 DOI: https://doi.org/10.1007/s00264-010-1025-5.\u003c/li\u003e\n\u003cli\u003eKarimi, E., et al., \u003cem\u003eCorrelation of anthropometric measurements of proximal tibia in iranian knees with size of current tibial implants.\u003c/em\u003e Archives of Bone and Joint Surgery, 2019. \u003cstrong\u003e7\u003c/strong\u003e(4): p. 339.\u003c/li\u003e\n\u003cli\u003eLakati, K. and B. Ndeleva, \u003cem\u003eAnthropometry of the proximal tibia in a Kenyan population and its correlation with total knee replacement implants.\u003c/em\u003e East African Orthopaedic Journal, 2018. \u003cstrong\u003e12\u003c/strong\u003e(1): p. 3-8.\u003c/li\u003e\n\u003cli\u003eUehara, K., et al., \u003cem\u003eAnthropometry of the proximal tibia to design a total knee prosthesis for the Japanese population.\u003c/em\u003e The Journal of arthroplasty, 2002. \u003cstrong\u003e17\u003c/strong\u003e(8): p. 1028-1032 DOI: http://dx.doi.org/10.1054/arth.2002.35790.\u003c/li\u003e\n\u003cli\u003eLi, P., et al., \u003cem\u003eMorphological measurement of the knee: race and sex effects.\u003c/em\u003e Acta Orthop Belg, 2014. \u003cstrong\u003e80\u003c/strong\u003e(2): p. 260-268.\u003c/li\u003e\n\u003cli\u003eRadzi, S., et al., \u003cem\u003eAssessing the bilateral geometrical differences of the tibia\u0026ndash;are they the same?\u003c/em\u003e Medical Engineering \u0026amp; Physics, 2014. \u003cstrong\u003e36\u003c/strong\u003e(12): p. 1618-1625 DOI: https://doi.org/10.1016/j.medengphy.2014.09.007.\u003c/li\u003e\n\u003cli\u003eEckhoff, D.G., et al., \u003cem\u003eBilateral symmetrical comparison of femoral and tibial anatomic features.\u003c/em\u003e The Journal of Arthroplasty, 2016. \u003cstrong\u003e31\u003c/strong\u003e(5): p. 1083-1090 DOI: https://doi.org/10.1016/j.arth.2015.11.021.\u003c/li\u003e\n\u003cli\u003eYang, B., et al., \u003cem\u003eComputed tomography morphometric study of gender differences in osteoarthritis proximal tibias.\u003c/em\u003e The Journal of Arthroplasty, 2013. \u003cstrong\u003e28\u003c/strong\u003e(7): p. 1117-1120 DOI: https://doi.org/10.1016/j.arth.2012.07.036.\u003c/li\u003e\n\u003cli\u003eZhang, Z., et al., \u003cem\u003eComparison of the coverage and rotation of asymmetrical and symmetrical tibial components: a systematic review and meta-analysis.\u003c/em\u003e BMC Musculoskeletal Disorders, 2024. \u003cstrong\u003e25\u003c/strong\u003e(1): p. 336 DOI: https://doi.org/10.5792/ksrr.2015.27.1.17.\u003c/li\u003e\n\u003cli\u003eDai, Y. and J.E. Bischoff, \u003cem\u003eComprehensive assessment of tibial plateau morphology in total knee arthroplasty: influence of shape and size on anthropometric variability.\u003c/em\u003e Journal of orthopaedic research, 2013. \u003cstrong\u003e31\u003c/strong\u003e(10): p. 1643-1652 DOI: https://doi.org/10.1002/jor.22410.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anthropometry, Ethnic Variation, Knee Prosthesis, Proximal Tibia, Total Knee Arthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-5474087/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5474087/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction.\u003c/h2\u003e \u003cp\u003eTotal knee arthroplasty is a spreading surgery, mainly indicated in severe osteoarthritis patients. The anthropometric features of the prosthesis are one of the main factors affecting the surgery outcome, which varies among different races and genders. Challenges arise when prostheses are poorly matched, leading to suboptimal results and increased revision rates. This study aims to quantify proximal tibial dimensions for ethnically tailored prosthesis design of the Iranian population.\u003c/p\u003e\u003ch2\u003eMaterials and Methods.\u003c/h2\u003e \u003cp\u003eAll adult candidates for total knee arthroplasty were enrolled in this study. A surgical blade of 38 mm in length is placed on the resected surface of the proximal tibia in all patients, acting as a scale. The trained operating room technician takes a high-quality picture of the area using a camera. Photographs of the proximal tibial cut, removed during the surgery, were analyzed to extract its anthropometric features. AutoCAD software measured the anteroposterior (AP) length, mediolateral (ML) length, and 18 lengths parallel to the AP length for a more precise representation of the proximal tibial morphology.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eOverall, 110 patients were enrolled in this study with a mean age of 64.94 (\u0026plusmn;\u0026thinsp;7.57). The mean mediolateral (ML) and medial anteroposterior (AP) lengths were 71.03 (\u0026plusmn;\u0026thinsp;4.58) and 41.71 (\u0026plusmn;\u0026thinsp;4.48) mm, respectively. The mean AP length of women and men were 41.17\u0026thinsp;\u0026plusmn;\u0026thinsp;4.03 mm (95% CI [40.39, 41.95]) and 48.48\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59 mm (95% CI [45.30, 51.66]), respectively. The AP length was also significantly different between the two limbs, but not the ML.\u003c/p\u003e\u003ch2\u003eConclusions.\u003c/h2\u003e \u003cp\u003eThis study provides baseline anthropometric data for the proximal tibia in the Iranian population, highlighting gender and limb asymmetry variations that significantly influence proximal tibial dimensions. These findings offer critical insights for developing ethnically tailored and gender-specific prostheses, potentially improving implant fit, reducing revision rates, and enhancing overall surgical outcomes.\u003c/p\u003e","manuscriptTitle":"Proximal Tibial Anthropometry in the Iranian Population and Its Implications for Custom Total Knee Prosthesis Design","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 08:44:38","doi":"10.21203/rs.3.rs-5474087/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-08T17:06:48+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-31T12:37:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-25T07:10:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-03-24T21:00:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"855cd1f2-ba3b-4cb1-a66d-c6aedf1f55a5","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":46458260,"name":"Health sciences/Anatomy"},{"id":46458261,"name":"Health sciences/Diseases/Rheumatic diseases"},{"id":46458262,"name":"Health sciences/Rheumatology/Musculoskeletal system"}],"tags":[],"updatedAt":"2025-04-14T16:14:09+00:00","versionOfRecord":{"articleIdentity":"rs-5474087","link":"https://doi.org/10.1038/s41598-025-98013-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-04-13 16:05:03","publishedOnDateReadable":"April 13th, 2025"},"versionCreatedAt":"2025-04-02 08:44:38","video":"","vorDoi":"10.1038/s41598-025-98013-z","vorDoiUrl":"https://doi.org/10.1038/s41598-025-98013-z","workflowStages":[]},"version":"v1","identity":"rs-5474087","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5474087","identity":"rs-5474087","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}