Biomechanical Analysis of Surgical Alignment and Design in Total Knee Arthroplasty

Biomechanical Analysis of Surgical Alignment and Design in Total Knee Arthroplasty | 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 Research Article Biomechanical Analysis of Surgical Alignment and Design in Total Knee Arthroplasty Bernardo Innocenti, Edoardo Bori This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7463007/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 8 You are reading this latest preprint version Abstract Introduction : The design of TKA implants is defined by manufacturers according to a specific alignment philosophy; however, in-vivo performance strongly depends on the surgeon’s decisions regarding component position, orientation, and soft tissue management. Mechanical Alignment (MA) and Kinematic Alignment (KA) are the most widely used strategies. Several studies have compared their clinical outcomes, but no definitive conclusions exist, and long-term multicentric follow-ups are lacking. Surgeons sometimes select the surgical alignment independently of the implant’s design rationale, meaning components designed for MA may be implanted following KA, potentially affecting outcomes and complicating interpretation. The aim of this study is therefore to compare different alignment philosophies in various TKA designs using a validated finite element model. Materials and Methods: Four implanted knee configurations were obtained by modifying accordingly a TKA starting design: standard MA with symmetric polyethylene (MA-Std, obtaining an orthogonal joint line), MA with asymmetric polyethylene (MA-Asymm, obtaining a physiological joint line), KA with tibial stem orthogonal to the tibial cut, and KA with tibial stem aligned to the tibial axis. Each model underwent a 2500 N vertical load simulating peak walking force. Polyethylene and bone stresses were extracted and compared in multiple regions of interest. Results : Tibio-femoral interaction showed distinct contact area and pressure patterns for each configuration. Differences were minor, but KA configurations exhibited larger contact areas medially and laterally than MA configurations. The MA-Std configuration showed a medial-to-lateral force ratio close to physiological (>50%), while MA-Asymm and KA-Std exhibited slightly higher lateral forces. Bone-implant interaction differences were minimal, primarily localized in the proximal region, reflecting variations in medio-lateral load distribution. Conclusions : Each combination of alignment approach and prosthesis design produces a specific stress distribution at both tibio-femoral and prosthesis-bone interfaces. Surgeons should consider these biomechanical effects when selecting an implant and determining the alignment strategy to adopt. TKA Kinematic Alignment Mechanical Alignment Design Biomechanics Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 13 Sep, 2025 Reviews received at journal 12 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviewers invited by journal 01 Sep, 2025 Editor assigned by journal 28 Aug, 2025 Submission checks completed at journal 28 Aug, 2025 First submitted to journal 26 Aug, 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. 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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-7463007","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514469236,"identity":"a990ed04-9ff2-4462-a7fb-23f97c333a3f","order_by":0,"name":"Bernardo 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08:53:00","extension":"json","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5005,"visible":true,"origin":"","legend":"","description":"","filename":"f6c3b5f9af5440a992cf47afed06e6b0.json","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/05a7eebf48b180f95a994cf0.json"},{"id":91826998,"identity":"206b8585-0fb4-4347-9570-acbf3e4d0918","added_by":"auto","created_at":"2025-09-22 08:45:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":491467,"visible":true,"origin":"","legend":"\u003cp\u003eFrontal view of the 4 different configurations analyzed in the present study.. To better visualize the change in the designs and the direction of the tibial stem, half of the proximal tibia was hidden in each figure. The red vertical lines represent the collateral ligaments.\u003c/p\u003e","description":"","filename":"Figures01.png","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/a2c64fefe7c26f5b8946a9ee.png"},{"id":91830193,"identity":"0b7f269c-52fa-490e-9a5b-efdefd5a2672","added_by":"auto","created_at":"2025-09-22 09:01:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":115272,"visible":true,"origin":"","legend":"\u003cp\u003emedial and lateral contact areas for the 4 different configurations analyzed in the study.\u003c/p\u003e","description":"","filename":"Figure02.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/df764e57618aa98062c00e82.jpg"},{"id":91827001,"identity":"0065b05c-7fcb-4cde-8022-bac30cb0d3e7","added_by":"auto","created_at":"2025-09-22 08:45:00","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":69100,"visible":true,"origin":"","legend":"\u003cp\u003eproportion between the medial and lateral contact force expressed as the ratio of the medial contact force and the total contact force\u003c/p\u003e","description":"","filename":"Figure03.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/5933f360a4c5cf43df2d0a8d.jpg"},{"id":91827006,"identity":"9e0809d8-8b2a-4233-8598-9d833d377c47","added_by":"auto","created_at":"2025-09-22 08:45:00","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":283086,"visible":true,"origin":"","legend":"\u003cp\u003equalitatively overview of the Von Mises cortical Stress for the different configurations: A) MA-Std, B) MA-Asymm, C) KA-Std, D) KA-Ortho.\u003c/p\u003e","description":"","filename":"Figure04.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/cc3821c789225d25b57f440b.jpg"},{"id":91828181,"identity":"699a50f1-bc58-4741-96e2-59f1695ae20f","added_by":"auto","created_at":"2025-09-22 08:53:00","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":108768,"visible":true,"origin":"","legend":"\u003cp\u003eMedial and Lateral Bone stress (in MPa) in the proximal region of the tibia for the different configurations. To emphasize the differences a range of 2 MPa was chosen to illustrate the results.\u003c/p\u003e","description":"","filename":"Figure05.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/80dd80f1ec3bfee2c67e07bc.jpg"},{"id":91830194,"identity":"08831136-eef4-4641-b17a-2c4110461f0c","added_by":"auto","created_at":"2025-09-22 09:01:00","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":96952,"visible":true,"origin":"","legend":"\u003cp\u003eMedial and Lateral Bone stress (in MPa) in the proximal region of the tibia for the different configurations. A range of 2MPa was chosen to illustrate the results.\u003c/p\u003e","description":"","filename":"Figure06.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/c5ae91784ad1aac4ff68be23.jpg"},{"id":91830195,"identity":"ebba7388-1a3b-4fd0-a61b-958a3613ea38","added_by":"auto","created_at":"2025-09-22 09:01:00","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":286616,"visible":true,"origin":"","legend":"\u003cp\u003eQualitative overview of the shear cortical Stress for the different configurations: A) MA-Std, B) MA-Asymm, C) KA-Std, D) KA-Ortho.\u003c/p\u003e","description":"","filename":"Figure07.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/f049aea1a5ee211a317c05a1.jpg"},{"id":91828184,"identity":"3810d8dd-3176-48b7-aff8-ca4cccbabf88","added_by":"auto","created_at":"2025-09-22 08:53:00","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":104300,"visible":true,"origin":"","legend":"\u003cp\u003eand Lateral Bone shear stress (in MPa) in the distal region of the tibia for the different configurations analyzed.\u003c/p\u003e","description":"","filename":"Figure08.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1/f4bb95ac386ceafefcf0f468.jpg"},{"id":103251131,"identity":"d4ed82e1-2690-4b42-ae8e-8b334ebf5be6","added_by":"auto","created_at":"2026-02-23 16:04:41","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1686909,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscriptrevisedaots02.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7463007/v1_covered_6c83ee3c-718a-4ad9-aab5-cd3b347307a5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eBiomechanical Analysis of Surgical Alignment and Design in Total Knee Arthroplasty\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"TKA, Kinematic Alignment, Mechanical Alignment, Design, Biomechanics","lastPublishedDoi":"10.21203/rs.3.rs-7463007/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7463007/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: The design of TKA implants is defined by manufacturers according to a specific alignment philosophy; however, in-vivo performance strongly depends on the surgeon’s decisions regarding component position, orientation, and soft tissue management. Mechanical Alignment (MA) and Kinematic Alignment (KA) are the most widely used strategies. Several studies have compared their clinical outcomes, but no definitive conclusions exist, and long-term multicentric follow-ups are lacking. Surgeons sometimes select the surgical alignment independently of the implant’s design rationale, meaning components designed for MA may be implanted following KA, potentially affecting outcomes and complicating interpretation. The aim of this study is therefore to compare different alignment philosophies in various TKA designs using a validated finite element model.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e Four implanted knee configurations were obtained by modifying accordingly a TKA starting design: standard MA with symmetric polyethylene (MA-Std, obtaining an orthogonal joint line), MA with asymmetric polyethylene (MA-Asymm, obtaining a physiological joint line), KA with tibial stem orthogonal to the tibial cut, and KA with tibial stem aligned to the tibial axis. Each model underwent a 2500 N vertical load simulating peak walking force. Polyethylene and bone stresses were extracted and compared in multiple regions of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Tibio-femoral interaction showed distinct contact area and pressure patterns for each configuration. Differences were minor, but KA configurations exhibited larger contact areas medially and laterally than MA configurations. The MA-Std configuration showed a medial-to-lateral force ratio close to physiological (\u0026gt;50%), while MA-Asymm and KA-Std exhibited slightly higher lateral forces. Bone-implant interaction differences were minimal, primarily localized in the proximal region, reflecting variations in medio-lateral load distribution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Each combination of alignment approach and prosthesis design produces a specific stress distribution at both tibio-femoral and prosthesis-bone interfaces. Surgeons should consider these biomechanical effects when selecting an implant and determining the alignment strategy to adopt.\u003c/p\u003e","manuscriptTitle":"Biomechanical Analysis of Surgical Alignment and Design in Total Knee Arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 08:44:55","doi":"10.21203/rs.3.rs-7463007/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-13T05:20:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-12T19:28:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78671746686002608646614935707015377016","date":"2025-09-02T21:53:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277151307886914716196038699713041151709","date":"2025-09-02T14:08:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-02T03:00:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T11:51:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-28T11:50:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-08-26T12:26:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c2c1728b-77bb-41fc-aba6-30acd5d8ac9c","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-7463007","link":"https://doi.org/10.1007/s00402-026-06195-6","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2026-02-19 15:57:25","publishedOnDateReadable":"February 19th, 2026"},"versionCreatedAt":"2025-09-22 08:44:55","video":"","vorDoi":"10.1007/s00402-026-06195-6","vorDoiUrl":"https://doi.org/10.1007/s00402-026-06195-6","workflowStages":[]},"version":"v1","identity":"rs-7463007","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7463007","identity":"rs-7463007","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}