Accuracy of Femoral Component Position in Primary Total Knee Arthroplasty Based on Valgus Cut Angle

Accuracy of Femoral Component Position in Primary Total Knee Arthroplasty Based on Valgus Cut Angle | 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 Accuracy of Femoral Component Position in Primary Total Knee Arthroplasty Based on Valgus Cut Angle Salman Ghaffari, Mehran Razavipour, sadegh shirdel, Abolfazl Ghadiri, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7235418/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The distal femur resection in total knee arthroplasty (TKA) is commonly made using a fixed angle by routine use of 5° or 6° for valgus cut angle(VCA). The present study aimed to determine the effect of specific VCA in each person on post-TKA limb alignment. Material and methods In this retrospective study all patients who underwent primary knee replacement surgery performed by a single surgeon by using the individualized VCA method from Imam Khomeini and Shafa hospitals in Sari from 2018 to 2020 were included. Preoperative and post-operative knee radiographs including a standing anteroposterior and lateral view and the long-leg standing anteroposterior radiograph alignment view were collected. Radiographic parameters including Mechanical Femoro-tibial angle (mFTA), Lateral distal femoral angle (LDFA), medial Proximal tibial angle (MPTA), and valgus cut angle (VCA) were compared before and after surgery. Results 139 knees associated with 119 patients were examined. The mean (standard deviation) age of patients was 64.35 Years (7.57). 89.3% were female. In 78% of the cases, the VCA was 5–7 degrees. All radiographic parameters improved significantly after surgery (P < 0.0001). The mean (SD) of Total varus correction (ΔmFTA) was 13.47 (5.64) and ranged from 2 to 26 degrees. mLDFA in 39.3% of knees was in a normal range (85–90). After surgery, this rate increased to 64%. Before surgery based on mFTA, 98.2% of patients' knees had varus alignment and after surgery mFTA in 73% of the patients were in the neutral range. There was a statistically significant association between the valgus cut angle (VCA) and LDFA, mFTA, and total varus correction (ΔmFTA) (p < 0.05). Conclusion This study demonstrates that in the absence of a computer-assisted navigation system, the use of an individual valgus cut angle improves achievement of a neutral, femoral component alignment(LDFA), and mFTA alignment after TKA especially in knees with severe varus deformity. Level of evidence: IV Total Knee Arthroplasty valgus cut angle varus deformity Radiographic Parameters Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The knee joint is more prone to degenerative changes and loss of articular cartilage than any other joint in the body. 1 Primary osteoarthritis, inflammatory arthritis, trauma-induced osteoarthritis, dysplasia, and malignancies are among the causes that lead to total knee arthroplasty (TKA) in their final stages. 1 The demand for these surgeries increases by the society’ aging . 2 On the other hand, reports from patients show that the persistence of TKA has a significant effect on the quality of life of these patients by reducing pain and restoring lower limb function. 2 Therefore, it seems that all efforts are currently being made to reduce the possible error to increase TKA survival. In this regard, many studies have shown that there is a strong correlation between normal postoperative lower limb alignment and TKA durability, 3 Improper alignment of the implant during TKA surgery reduces its survival and many other problems, including patellofemoral problems, which is the main reason for the need for aseptic failure and reoperation in 7% of primary TKA procedures. 4 Studies have shown that the acceptable value for lower limb alignment in the coronal axis is when the tibiofemoral mechanical angle (mTFA) is zero degrees . 5 , 6 To achieve this alignment, it is necessary the exact placement of the prosthesis components is necessary perpendicular to the mechanical axis of the femur and tibia, establishment of the standard hip-knee-ankle angle (HKA) distributes pressure evenly over the internal and external compartment of the knee. 7 The mechanical axis of the lower limb is in 3 degrees of valgus from the vertical axis of the body. The anatomic axis of the femur is in 6 degrees of valgus from the mechanical axis of the lower limb and 9 degrees of valgus from the true vertical axis of the body. The anatomic axis of the tibia lies in 2 to 3 degrees of varus from the vertical axis of the body. Normally, the anatomic axes of the femur and the tibia form a valgus angle of 6 ± 2 degrees. Consequently, to recreate this angle in the TKA procedure, tibial components are generally implanted perpendicular to the mechanical axis of the tibia in the coronal plane, with varying amounts of posterior tilt in the sagittal plane, depending on the articular design of the component to be implanted. The femoral component usually is implanted in 5 to 7 degrees of valgus relative to femoral anatomical axis, the amount necessary to reestablish a neutral mechanical axis of the femur. The proper angle can be calculated from the standing hip-to-knee radiograph by measuring the angle between the mechanical axis of the femur (line from the center of the femoral head to the center of the distal femur) and a line drawn from the entry point of the intramedullary rod to the diaphyseal line that the rod travels. An intramedullary guide is usually used to cut the distal end of the femur and because the intramedullary guide is along the anatomical axis, the cut angle of the distal end of the femur must be equal to the angle between the mechanical and anatomical axis of the femur (Valgus cut angle). 8 , 9 According to some studies, the value of VCA varies from 2 to 9 degrees in different populations. 10 Many surgeons use a fixed Valgus cut angle (VCA) of 5 to 7 degrees for all patients. 10 , 11 Factors such as varus or valgus, the presence of other deformities in the knee, the patient's height (i.e. the length of the femur), the bowing of the femur, the neck-shaft angle of the femur, and the angle between the hip-knee-ankle have a significant effect on VCA in different patients. 11 On the other hand, the point of entry of the intramedullary guide has a very important effect on the location of the femoral implant and determines its alignment in both the coronal axis and the sagittal axis. 9 The rotation of the lower limb in radiological imaging can also affect the alignment, so some use a special protocol for imaging , 9 , 10 , 11 for example, rotating patients' lower limbs 15 degrees inward to place the patella in front. 9 Although some studies conclude that VCA correction and the severity of preoperative limb deformity and postoperative limb alignment are strongly independent of each other and have recommended the routine use of 5° or 6° for VCA as a safe method for uncomplicated primary TKA which may lead to acceptable alignment, 12 many others believe that the use of VCA specific to each patient improves postoperative alignment. 7 Due to inconsistencies in the studies, this study aimed to determine the effect of specific VCA on each person on post-TKA limb alignment. Materials and Methods Study population : In this retrospective study, all patients with varus knee who underwent primary TKA by a single surgeon in Imam Khomeini Hospital and Shafa Hospital in the city of Sari from 2018 to 2020 were included. Exclusion criteria were Ligament laxity caused by reasons other than osteoarthritis, such as connective tissue disease, history of previous knee surgery, and revision surgery. Demographic data was also collected. Preoperative Radiographic Assessment : pre-operative radiographic evaluation included standing anteroposterior (AP) radiographs of the knee, lateral view, patella axial view, and double-limb, standing, full-length, lower-limb radiography (alignment view). All pre-operative radiographs were reviewed to determine Mechanical Femorotibial Angle (mFTA), Mechanical Lateral Distal Femoral Angle (mLDFA), Joint Line Convergence Angle (JLCA), Medial Proximal Tibial Angle (MPTA) and Valgus Cut Angle (VCA) [Figure1]. The varus angle was recorded as positive (+), and the valgus angle was recorded as negative (−). The valgus cut angle (VCA) of the distal femur is determined based on the angle between the distal anatomical (20cm) and mechanical axes of the femur. Two researchers who were blind to the groups measured the radiographic parameters. Surgical Procedure : The same surgeon performed TKA in all cases with a tourniquet and medial parapatellar approach. In all patients, the gap technique was used to balance the varus and valgus, which includes the proximal tibia and distal femur cut, and to re-evaluate the flexion and extension gap. After distal femoral cut with measured VCA using long intramedullary rod proximal tibial cut was done with an extramedullary guide. Then a posterior femoral cut was done and a flexion-extension gap was balanced with an additional bony cut when necessary. The medial release was done first by deep MCL release then by semimembranosus and posteromedial capsule and finally by MCL multiple needling as needed. In all cases, extra bone in medial tibial plateau not covered by tibial component base plate was removed. Post-operative Radiographic Assessment : Alignment views were taken 6 weeks after surgery and Mechanical Femorotibial Angle (mFTA), Lateral Distal Femoral Angle (LDFA), Joint Line Convergence Angle (JLCA), Medial Proximal Tibial Angle (MPTA) were determined [Figure1]. Then, the amount of varus correction (ΔmFTA) was calculated and radiographic parameters before and after surgery were compared in patients. Statistical Analysis: The normality of the distribution of quantitative data was assessed using the Kolmogorov-Smirnov test. Paired t-test or its non-parametric equivalent Mann–Whitney test was used to compare the variables before and after surgery in the groups and a chi-square test was used to examine the association between qualitative variables. Pearson correlation coefficient was used to examine the correlation of the variables. All the tests were performed at a significance level of 0.05 using SPSS version 21. Results 139 knees associated with 119 patients were examined. The mean (standard deviation) age of patients was 64.35 years (7.57). 92 patients (89.3%) were female. 58% of the cases were right knee and the rest were left knee. Intraoperative amount of bone cut, external rotation of femoral component and VCA are shown in [Table 1]. The mean (SD) of VCA was 6.37 (1.48) and it was ranged from 2 to 12 degrees. Radiographic characteristics of patients before and after surgery are shown in [Table 2]. Analysis by the Wilcoxon test showed that all radiographic parameters improved significantly after surgery (P < 0.0001). The mean (SD) of total varus correction (ΔmFTA) was 13.47 (5.64) and ranged from 2 to 26 degrees. [Figure 2] shows a comparison of the frequency percent of mLDFA before and after surgery. mLDFA in 39.3% of knees was in a normal range (90 − 85). After surgery, this rate increased to 64%. In 35.1% of the cases, the VCA was 6 degrees. In 22% of the cases, it was 5 degrees and in the other 21%, it was 7 degrees [Figure 3]. [Figure 4] shows that before surgery based on mFTA, 98.2% of patient's knees had varus alignment and only 1.2% had normal alignment (-3 to 3), which increased to 73% after surgery. 14% and 13% of patients' limbs after surgery were varus and valgus, respectively Correlation analysis with the Spearman test showed there was a statistically significant association among the valgus cut angle (VCA), LDFA, mFTA, and total varus correction (ΔmFTA) (p < 0.05). However, there was no statistically significant relationship between VCA and other variables [Table 3]. Postoperative mFTA was significantly correlated with MPTA, distal and posterior cut of the femur and post-operative JLCA. ΔmFTA was significantly correlated with LDFA, MPTA, JLCA, mFTA, VCA, External rotation cut angle and post-operative LDFA and post-operative mFTA. Multiple linear regression was calculated to predict post-operative mFTA based on mLDFA, MPTA, mFTA, JLCA, and VCA where all were measured in degrees and only JLCA was a significant predictor of VCA (p = 0.02).[Table 3] Discussion In the present study, all radiographic parameters including LDFA, MPTA, JLCA, and mFTA improved significantly after surgery (P < 0.0001) by using individualized VCA. The mean (SD) of preoperative mFTA was 14.01 (5.99) and the mean (SD) of postoperative mFTA was 0.29 (2.86) and a significant improvement in mFTA based on individual VCA was observed (p = 0.0001) and after surgery 73% of all knees were within 3 degrees of neutral alignment. 96% of postoperative LDFA was between 87 to 93 degree (24% was 90 degree), 2% lower than 87 degrees and 2% was greater than 93 degrees. Malposition and deviation from a neutral, mechanical alignment may increase the risk of aseptic failure of TKA. Controversy exists as to whether acceptable coronal mechanical alignment can be achieved by utilizing a fixed distal femoral VCA of 4° to 7° instead of a patient-specific VCA measured on preoperative HTA radiographs . 13 Although some authors concluded that routine use of 5° or 6° for VCA is safe for uncomplicated primary TKA and lead to acceptable alignment, 12 , 13 many others believe that routine cut of 5° or 6° may lead to inaccuracy in a significant percentage of knees. 14 In a meta-analysis of 29 studies by Mason et al, only 68.2% of TKAs had a hip-knee-ankle (HKA) alignment within 3_ of neutral with the use of conventional methods. 15 In Davis’s study, the average preoperative MFT angle in the individual VCA group was 4.6° and the average MFT angle in the fixed group was 3.8°. In this study, individual VCA group had an average postoperative MFT angle of 2.6° and the fixed group had an average of 1.3°. There were no statistically significant differences between study groups in alignment, the severity of the residual deformity, or the number of knees within + 3° of neutral (55% vs 68%). In a study by Nam et al, 16 320 patients in the two groups of fixed and variable valgus cut angle were compared with each other. A total of 80.2% of femoral components in the variable and 63.1% in the fixed VCA were within (0 ± 2) and as the femoral component alignment, the mean HKA alignment was significantly improved in the variable VCA group (-1.4 (varus) ± 3.3 vs -2.6 ± 3.3, P < .001). Deakin et al, 10 have previously demonstrated similar results and significant improvements in the mFTA with the use of an individual variable distal femur cut angle technique vs a fixed resection angle after TKA. In a study comparing 124 TKAs performed using a fixed distal femur resection angle vs 87 TKAs performed using a variable VCA, they found 85% of variable VCA patients to have a mechanical femorotibial angle within 0_ ± 3_ (vs 69% in the fixed group, P = 006). A retrospective study of 788 consecutive TKAs by Andrews et al, 17 demonstrated that a standard distal femoral cut of 6° resulted in a neutral alignment (− 3° < mFTA < 3°) in 86% of patients. These results are close to our study in which 73% of knees reached the normal alignment. In Andrews study, following TKA, mFTA alignment for all patients was 0.0° ± 2.3° (range, − 7.0° to 8.0°) which is similar to our study using individual VCA. Palanisami et al (8), after analysis of VCA in the 227 limbs, showed that 70 knees (31%) had a VCA angle outside 5–7°. Their study also showed a significant improvement in both femoral component placement and postoperative alignment by using individualized VCA in the knees with varus 10–15° (p 0.002) and varus > 15° (p 0.002). This study showed that there was a statistically significant association between the valgus cut angle (VCA) and LDFA, mFTA, and total varus correction (ΔmFTA). Also, post-operative mFTA was significantly correlated with MPTA, distal and posterior cut of the femur, and post-operative JLCA. It was also shown that JLCA was a significant predictor of VCA (R 2 = 14%). Based on a study by Palanisami et al., coronal bowing, neck-shaft angle of the femur and preoperative deformity significantly affect VCA, 7 although according to Drexler's study, gender and distal femoral joint angle were not associated with VCA, and only femoral height and femoral offset were two independent determinants of VCA. In other words, tall patients with small femoral offset have a smaller VCA and vice versa. Therefore, the use of a fixed amount of VCA for all patients is not recommended, 11 In Davis's study, both the preoperative MFT angle (R 2 = 33%) and TCA (R 2 = 58%) were independent predictors for postoperative alignment (MFT angle). 13 In the present study, care was taken to ensure that the lower extremities were placed with the patellae facing forward with the hope of controlling for rotation and minimizing the error of variability in lower extremity rotation during alignment view. All procedure was done by a single surgeon, which is an advantage for our study. The limitation of our study, however, was the short follow-up period and lack of a control group. Non-consideration of BMI, as well as the duration of varus deformity, postoperative complications, patient performance, as well as lack of stress view data and a small number of subjects, are other limitations of the study. Therefore, multicentre studies with a larger sample size are recommended. In conclusion, this study demonstrates that, in the absence of computer-assisted navigation in non-developed countries, the use of an individual valgus cut angle improves achievement of a neutral, femoral component alignment (LDFA) and mFTA alignment after TKA, especially in knees with severe varus deformity. Declarations Ethical Consideration: The Ethics Committee meeting of Mazandaran University of Medical Sciences approved our study with the registration number of IR.MAZMUS.IMAMHOSPITAL.REC1399.088. All patients completed the informed consent form. The names and other details of the patients will remain confidential. In addition, all the principles of research ethics mentioned in the Helsinki Declaration as well as the regulations of the Ethics Committee for the protection of the subject in the medical sciences research were observed. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors. Conflict of interest The authors declared no conflict of interest. This work was done in orthopedic research center of mazandaran university of medical science. The author(s) received NO financial support for the preparation, research, authorship, and publication of this manuscript. Ethical approval for this study was obtained with IR.MAZUMS.IMAMHOSPITAL.REC.1399.088 on 23/09/2020. There is no information (names, initials, hospital identification numbers, or photographs) in the submitted manuscript that can be used to identify patients. References Varacallo M, Luo TD, Johanson NA. Total Knee Arthroplasty Techniques. In: StatPearls . Treasure Island (FL): StatPearls Publishing;2023./ Guo EW, Sayeed Z, Padela MT, et al. Improving Total Joint Replacement with Continuous Quality Improvement Methods and Tools. Orthop Clin North Am. 2018;397-403. doi:10.1016/j.ocl.2018. Shetty GM, Mullaji A, Khalifa AA, Ray A. Windswept deformities - An indication to individualise valgus correction angle during total knee arthroplasty. J Orthop . 2016;70-72. Published 2016. doi:10.1016/j.jor.2016 Schroer WC, Berend KR, Lombardi AV, et al. Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty. 2013;116-119. doi:10.1016/j.arth.2013. Bonner TJ, Eardley WG, Patterson P, Gregg PJ. The effect of post-operative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years. J Bone Joint Surg Br. 2011;1217-1222. doi:10.1302/0301-620X.93B9.26573 Parratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am. 2010;2143-2149. doi:10.2106/JBJS.I.01398 Palanisami D, Iyyampillai G, Shanmugam S, Natesan R, S R. Individualised distal femoral cut improves femoral component placement and limb alignment during total knee replacement in knees with moderate and severe varus deformity. Int Orthop. 2016;40(10):2049-2054. doi:10.1007/s00264-016-3123-5 Mullaji AB, Shetty GM, Kanna R, Vadapalli RC. The influence of preoperative deformity on valgus correction angle: an analysis of 503 total knee arthroplasties. J Arthroplasty . 2013;20-27. doi:10.1016/j.arth.2012. Thippanna RK, Kumar MN. Lateralization of Femoral Entry Point to Improve the Coronal Alignment During Total Knee Arthroplasty in Patients With Bowed Femur. J Arthroplasty . 2016;1943-1948. doi:10.1016/j.arth.2016. Deakin AH, Sarungi M. A comparison of variable angle versus fixed angle distal femoral resection in primary total knee arthroplasty. J Arthroplasty. 2014;1133-1137. doi:10.1016/j.arth.2013. Drexler M, Abolghasemian M, Barbuto R, et al. Patient's Height and Hip Medial Offset Are the Main Determinants of the Valgus Cut Angle During Total Knee Arthroplasty. J Arthroplasty. 2017;1496-1501. doi:10.1016/j.arth.2016. Kharwadkar N, Kent RE, Sharara KH, Naique S. 5 degrees to 6 degrees of distal femoral cut for uncomplicated primary total knee arthroplasty: is it safe?. Knee . 2006;57-60. doi:10.1016/j.knee.2005. Davis JA, Hogan C, Dayton M. Postoperative Coronal Alignment After Total Knee Arthroplasty: Does Tailoring the Femoral Valgus Cut Angle Really Matter?. J Arthroplasty. 2015;1444-1448. doi:10.1016/j.arth.2015. Bardakos N, Cil A, Thompson B, Stocks G. Mechanical axis cannot be restored in total knee arthroplasty with a fixed valgus resection angle: a radiographic study. J Arthroplasty. 2007;85-89. doi:10.1016/j.arth.2007. Mason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007;1097-1106. doi:10.1016/j.arth.2007. Nam D, Vajapey S, Haynes JA, Barrack RL, Nunley RM. Does Use of a Variable Distal Femur Resection Angle Improve Radiographic Alignment in Primary Total Knee Arthroplasty?. J Arthroplasty. 2016;91-96. doi:10.1016/j.arth.2016. Andrews SN, Beeler DM, Parke EA, Nakasone CK, Stickley CD. Fixed Distal Femoral Cut of 6° Valgus in Total Knee Arthroplasty: A Radiographic Review of 788 Consecutive Cases. J Arthroplasty. 2019;755-759. doi:10.1016/j.arth.2018. Tables [Table 1]: Intraoperative variables VARIABLES N MEAN MEDIAN RANGE SD VCA 139 6.37 6 2-12 1.48 Distal femur cut (mm) 139 9.45 9 7-15 1.22 Posterior femur cut(mm) 139 8.90 9 4-14 1.60 Proximal tibia cut(mm) 139 6.45 6 2-12 1.77 External rotation cut angle 139 2.92 3 0-3 0.38 [Table 2]: Comparison of radiographic criteria before and after TKA Variable BEFORE SURGERY AFTER SURGERY P-VALUE N MEAN MEDIAN SD N MEAN MEDIAN SD LDFA 139 91.21 91.5 2.49 128 90.10 90 1.80 0.0001 MPTA 139 85.28 85 3.18 128 89.81 90 1.96 0.0001 MFTA 139 14.01 14 5.99 128 0.29 0 2.86 0.0001 JLCA 139 6.58 6 3.58 128 0.24 0.5 0.66 0.0001 [Table 3] correlation between preoperative radiographic and intraoperative variables age LDFA MPTA mFTA JLCA VCA ER Distal femur cut Post. femur cut Proximal tibia cut Post .LDFA Post. MPTA Post. JLCA Post. mFTA ΔmFTA AGE 1.000 -.170 .074 -.011 .058 .115 .094 .102 .101 -.008 -.134 .052 -.113 -.109 -.053 LDFA 1.000 -.253 ** .472 ** -.002 .450 ** .007 -.087 -.093 -.043 .039 -.103 .075 .160 .402 ** MPTA 1.000 -.579 ** -.009 -.048 .171 .092 .002 -.188 -.111 .263 ** -.011 -.281 ** -.442 ** mFTA 1.000 .509 ** .307 ** -.238 * -.062 -.008 -.023 .028 -.117 -.008 .155 .876 ** JLCA 1.000 -.007 -.117 -.134 -.072 -.117 -.114 .070 .020 -.187 .592 ** VCA 1.000 .088 -.154 .088 -.146 -.122 .093 -.176 -.025 .259 * External rotation 1.000 -.138 .093 -.077 -.015 .057 .076 .002 -.240 * Distal femur cut 1.000 .171 .042 -.133 .147 .031 -.205 * .005 Posterior femur cut 1.000 .056 -.176 .265 ** -.043 -.220 * .042 Proximal tibia cut 1.000 -.062 .059 -.106 -.183 .052 Post .LDFA 1.000 -.255 * .198 * .521 ** -.209 * Post.MPTA 1.000 -.158 -.549 ** .133 Post.JLCA 1.000 .312 ** -.114 Post.mFTA 1.000 -.312 ** ΔmFTA 1.000 Additional Declarations No competing interests reported. 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yahaghi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYFACHgYGxgYJEMuAgaECSDEzN5Ci5QxICyNRWhggWhjbQDQBLQbHzx78+HWHRWJ//+GNnwvn1UbztwO1/KjYhlvLmbxkadkzEokzDhwrlp657XjujMOMDYw9Z27j1nIgx0Bask0iseFgj4E077ZjuQ1ALcyMbXi0nH9j/BukZf5hHuPfvHOO5c4nqOVGjpnkR6CWDcd4zKR5G2pyNxDSInnjjZk1Y5uE8cYzbGXWPMcO5G4EajmIzy9853OMb/5sq5Odd/7w5ts8NXW5QMbBBz8qcGtROACMO2DUODZA+IfB5AGc6oFAHqiU8QcDgz2UX4dP8SgYBaNgFIxQAABYrmJofUThwgAAAABJRU5ErkJggg==","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"yazdan","middleName":"","lastName":"yahaghi","suffix":""},{"id":495444571,"identity":"af0b9528-32c4-4147-b82d-870d4e0435c0","order_by":7,"name":"Mojtaba Dehghan","email":"","orcid":"","institution":"Mazandaran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mojtaba","middleName":"","lastName":"Dehghan","suffix":""}],"badges":[],"createdAt":"2025-07-28 15:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7235418/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7235418/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88411291,"identity":"92782947-c74d-4497-9a48-e7e8e43c4d0b","added_by":"auto","created_at":"2025-08-06 08:24:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":351547,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of preoperative and postoperative radiological parameters\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7235418/v1/f0001adfaa420220a86d4286.jpg"},{"id":88411314,"identity":"40f66e8e-9caa-4ec0-9fc5-5f29ce4467a3","added_by":"auto","created_at":"2025-08-06 08:24:27","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60636,"visible":true,"origin":"","legend":"\u003cp\u003efrequency percent of mLDFA before and after surgery\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7235418/v1/907ccd3a80b0aefc711cd39e.jpg"},{"id":88411303,"identity":"b56576c5-a20a-450f-a3cc-9ac16d217703","added_by":"auto","created_at":"2025-08-06 08:24:25","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38489,"visible":true,"origin":"","legend":"\u003cp\u003eHistogram of frequency percent of valgus cut angle\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7235418/v1/3ba46b980821af37919cccad.jpg"},{"id":88411301,"identity":"3e73768d-6d97-41f6-af6d-a5847184c034","added_by":"auto","created_at":"2025-08-06 08:24:25","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":77513,"visible":true,"origin":"","legend":"\u003cp\u003ePie chart of frequency percent of mFTA before and after surgery\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7235418/v1/55c61b2d5e484a9f3372083b.jpg"},{"id":88413310,"identity":"e4643805-b7f5-4fec-896a-bf11810710b3","added_by":"auto","created_at":"2025-08-06 08:40:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1100667,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7235418/v1/48b25c77-9820-434a-afd7-1b901cd08679.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAccuracy of Femoral Component Position in Primary Total Knee Arthroplasty Based on Valgus Cut Angle\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe knee joint is more prone to degenerative changes and loss of articular cartilage than any other joint in the body. \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Primary osteoarthritis, inflammatory arthritis, trauma-induced osteoarthritis, dysplasia, and malignancies are among the causes that lead to total knee arthroplasty (TKA) in their final stages. \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The demand for these surgeries increases by the society\u0026rsquo; aging .\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e On the other hand, reports from patients show that the persistence of TKA has a significant effect on the quality of life of these patients by reducing pain and restoring lower limb function.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003eTherefore, it seems that all efforts are currently being made to reduce the possible error to increase TKA survival. In this regard, many studies have shown that there is a strong correlation between normal postoperative lower limb alignment and TKA durability,\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Improper alignment of the implant during TKA surgery reduces its survival and many other problems, including patellofemoral problems, which is the main reason for the need for aseptic failure and reoperation in 7% of primary TKA procedures.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eStudies have shown that the acceptable value for lower limb alignment in the coronal axis is when the tibiofemoral mechanical angle (mTFA) is zero degrees .\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003eTo achieve this alignment, it is necessary the exact placement of the prosthesis components is necessary perpendicular to the mechanical axis of the femur and tibia, establishment of the standard hip-knee-ankle angle (HKA) distributes pressure evenly over the internal and external compartment of the knee.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe mechanical axis of the lower limb is in 3 degrees of valgus from the vertical axis of the body. The anatomic axis of the femur is in 6 degrees of valgus from the mechanical axis of the lower limb and 9 degrees of valgus from the true vertical axis of the body. The anatomic axis of the tibia lies in 2 to 3 degrees of varus from the vertical axis of the body. Normally, the anatomic axes of the femur and the tibia form a valgus angle of 6\u0026thinsp;\u0026plusmn;\u0026thinsp;2 degrees. Consequently, to recreate this angle in the TKA procedure, tibial components are generally implanted perpendicular to the mechanical axis of the tibia in the coronal plane, with varying amounts of posterior tilt in the sagittal plane, depending on the articular design of the component to be implanted. The femoral component usually is implanted in 5 to 7 degrees of valgus relative to femoral anatomical axis, the amount necessary to reestablish a neutral mechanical axis of the femur. The proper angle can be calculated from the standing hip-to-knee radiograph by measuring the angle between the mechanical axis of the femur (line from the center of the femoral head to the center of the distal femur) and a line drawn from the entry point of the intramedullary rod to the diaphyseal line that the rod travels.\u003c/p\u003e\u003cp\u003eAn intramedullary guide is usually used to cut the distal end of the femur and because the intramedullary guide is along the anatomical axis, the cut angle of the distal end of the femur must be equal to the angle between the mechanical and anatomical axis of the femur (Valgus cut angle).\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e According to some studies, the value of VCA varies from 2 to 9 degrees in different populations.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Many surgeons use a fixed Valgus cut angle (VCA) of 5 to 7 degrees for all patients.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Factors such as varus or valgus, the presence of other deformities in the knee, the patient's height (i.e. the length of the femur), the bowing of the femur, the neck-shaft angle of the femur, and the angle between the hip-knee-ankle have a significant effect on VCA in different patients.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e On the other hand, the point of entry of the intramedullary guide has a very important effect on the location of the femoral implant and determines its alignment in both the coronal axis and the sagittal axis.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The rotation of the lower limb in radiological imaging can also affect the alignment, so some use a special protocol for imaging ,\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e for example, rotating patients' lower limbs 15 degrees inward to place the patella in front.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAlthough some studies conclude that VCA correction and the severity of preoperative limb deformity and postoperative limb alignment are strongly independent of each other and have recommended the routine use of 5\u0026deg; or 6\u0026deg; for VCA as a safe method for uncomplicated primary TKA which may lead to acceptable alignment,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e many others believe that the use of VCA specific to each patient improves postoperative alignment.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDue to inconsistencies in the studies, this study aimed to determine the effect of specific VCA on each person on post-TKA limb alignment.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cb\u003eStudy population\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIn this retrospective study, all patients with varus knee who underwent primary TKA by a single surgeon in Imam Khomeini Hospital and Shafa Hospital in the city of Sari from 2018 to 2020 were included. Exclusion criteria were Ligament laxity caused by reasons other than osteoarthritis, such as connective tissue disease, history of previous knee surgery, and revision surgery. Demographic data was also collected.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePreoperative Radiographic Assessment\u003c/b\u003e:\u003c/p\u003e\u003cp\u003epre-operative radiographic evaluation included standing anteroposterior (AP) radiographs of the knee, lateral view, patella axial view, and double-limb, standing, full-length, lower-limb radiography (alignment view). All pre-operative radiographs were reviewed to determine Mechanical Femorotibial Angle (mFTA), Mechanical Lateral Distal Femoral Angle (mLDFA), Joint Line Convergence Angle (JLCA), Medial Proximal Tibial Angle (MPTA) and Valgus Cut Angle (VCA) [Figure1].\u003c/p\u003e\u003cp\u003eThe varus angle was recorded as positive (+), and the valgus angle was recorded as negative (\u0026minus;). The valgus cut angle (VCA) of the distal femur is determined based on the angle between the distal anatomical (20cm) and mechanical axes of the femur. Two researchers who were blind to the groups measured the radiographic parameters.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical Procedure\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe same surgeon performed TKA in all cases with a tourniquet and medial parapatellar approach. In all patients, the gap technique was used to balance the varus and valgus, which includes the proximal tibia and distal femur cut, and to re-evaluate the flexion and extension gap. After distal femoral cut with measured VCA using long intramedullary rod proximal tibial cut was done with an extramedullary guide. Then a posterior femoral cut was done and a flexion-extension gap was balanced with an additional bony cut when necessary. The medial release was done first by deep MCL release then by semimembranosus and posteromedial capsule and finally by MCL multiple needling as needed. In all cases, extra bone in medial tibial plateau not covered by tibial component base plate was removed.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePost-operative Radiographic Assessment\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAlignment views were taken 6 weeks after surgery and Mechanical Femorotibial Angle (mFTA), Lateral Distal Femoral Angle (LDFA), Joint Line Convergence Angle (JLCA), Medial Proximal Tibial Angle (MPTA) were determined [Figure1]. Then, the amount of varus correction (ΔmFTA) was calculated and radiographic parameters before and after surgery were compared in patients.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003eThe normality of the distribution of quantitative data was assessed using the Kolmogorov-Smirnov test. Paired t-test or its non-parametric equivalent Mann\u0026ndash;Whitney test was used to compare the variables before and after surgery in the groups and a chi-square test was used to examine the association between qualitative variables. Pearson correlation coefficient was used to examine the correlation of the variables. All the tests were performed at a significance level of 0.05 using SPSS version 21.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e139 knees associated with 119 patients were examined. The mean (standard deviation) age of patients was 64.35 years (7.57). 92 patients (89.3%) were female. 58% of the cases were right knee and the rest were left knee. Intraoperative amount of bone cut, external rotation of femoral component and VCA are shown in [Table\u0026nbsp;1]. The mean (SD) of VCA was 6.37 (1.48) and it was ranged from 2 to 12 degrees.\u003c/p\u003e\u003cp\u003eRadiographic characteristics of patients before and after surgery are shown in [Table\u0026nbsp;2]. Analysis by the Wilcoxon test showed that all radiographic parameters improved significantly after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The mean (SD) of total varus correction (ΔmFTA) was 13.47 (5.64) and ranged from 2 to 26 degrees.\u003c/p\u003e\u003cp\u003e[Figure 2] shows a comparison of the frequency percent of mLDFA before and after surgery. mLDFA in 39.3% of knees was in a normal range (90\u0026thinsp;\u0026minus;\u0026thinsp;85). After surgery, this rate increased to 64%. In 35.1% of the cases, the VCA was 6 degrees. In 22% of the cases, it was 5 degrees and in the other 21%, it was 7 degrees [Figure 3].\u003c/p\u003e\u003cp\u003e[Figure 4] shows that before surgery based on mFTA, 98.2% of patient's knees had varus alignment and only 1.2% had normal alignment (-3 to 3), which increased to 73% after surgery. 14% and 13% of patients' limbs after surgery were varus and valgus, respectively Correlation analysis with the Spearman test showed there was a statistically significant association among the valgus cut angle (VCA), LDFA, mFTA, and total varus correction (ΔmFTA) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, there was no statistically significant relationship between VCA and other variables [Table\u0026nbsp;3]. Postoperative mFTA was significantly correlated with MPTA, distal and posterior cut of the femur and post-operative JLCA.\u003c/p\u003e\u003cp\u003eΔmFTA was significantly correlated with LDFA, MPTA, JLCA, mFTA, VCA, External rotation cut angle and post-operative LDFA and post-operative mFTA.\u003c/p\u003e\u003cp\u003eMultiple linear regression was calculated to predict post-operative mFTA based on mLDFA, MPTA, mFTA, JLCA, and VCA where all were measured in degrees and only JLCA was a significant predictor of VCA (p\u0026thinsp;=\u0026thinsp;0.02).[Table\u0026nbsp;3]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, all radiographic parameters including LDFA, MPTA, JLCA, and mFTA improved significantly after surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) by using individualized VCA. The mean (SD) of preoperative mFTA was 14.01 (5.99) and the mean (SD) of postoperative mFTA was 0.29 (2.86) and a significant improvement in mFTA based on individual VCA was observed (p\u0026thinsp;=\u0026thinsp;0.0001) and after surgery 73% of all knees were within 3 degrees of neutral alignment. 96% of postoperative LDFA was between 87 to 93 degree (24% was 90 degree), 2% lower than 87 degrees and 2% was greater than 93 degrees.\u003c/p\u003e\u003cp\u003eMalposition and deviation from a neutral, mechanical alignment may increase the risk of aseptic failure of TKA. Controversy exists as to whether acceptable coronal mechanical alignment can be achieved by utilizing a fixed distal femoral VCA of 4\u0026deg; to 7\u0026deg; instead of a patient-specific VCA measured on preoperative HTA radiographs .\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Although some authors concluded that routine use of 5\u0026deg; or 6\u0026deg; for VCA is safe for uncomplicated primary TKA and lead to acceptable alignment,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e many others believe that routine cut of 5\u0026deg; or 6\u0026deg; may lead to inaccuracy in a significant percentage of knees.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e In a meta-analysis of 29 studies by Mason et al, only 68.2% of TKAs had a hip-knee-ankle (HKA) alignment within 3_ of neutral with the use of conventional methods.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn Davis\u0026rsquo;s study, the average preoperative MFT angle in the individual VCA group was 4.6\u0026deg; and the average MFT angle in the fixed group was 3.8\u0026deg;. In this study, individual VCA group had an average postoperative MFT angle of 2.6\u0026deg; and the fixed group had an average of 1.3\u0026deg;. There were no statistically significant differences between study groups in alignment, the severity of the residual deformity, or the number of knees within +\u0026thinsp;3\u0026deg; of neutral (55% vs 68%).\u003c/p\u003e\u003cp\u003eIn a study by Nam et al,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e 320 patients in the two groups of fixed and variable valgus cut angle were compared with each other. A total of 80.2% of femoral components in the variable and 63.1% in the fixed VCA were within (0\u0026thinsp;\u0026plusmn;\u0026thinsp;2) and as the femoral component alignment, the mean HKA alignment was significantly improved in the variable VCA group (-1.4 (varus)\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 vs -2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3, P\u0026thinsp;\u0026lt;\u0026thinsp;.001). Deakin et al,\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e have previously demonstrated similar results and significant improvements in the mFTA with the use of an individual variable distal femur cut angle technique vs a fixed resection angle after TKA. In a study comparing 124 TKAs performed using a fixed distal femur resection angle vs 87 TKAs performed using a variable VCA, they found 85% of variable VCA patients to have a mechanical femorotibial angle within 0_ \u0026plusmn; 3_ (vs 69% in the fixed group, P\u0026thinsp;=\u0026thinsp;006).\u003c/p\u003e\u003cp\u003eA retrospective study of 788 consecutive TKAs by Andrews et al,\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e demonstrated that a standard distal femoral cut of 6\u0026deg; resulted in a neutral alignment (\u0026minus;\u0026thinsp;3\u0026deg; \u0026lt; mFTA\u0026thinsp;\u0026lt;\u0026thinsp;3\u0026deg;) in 86% of patients. These results are close to our study in which 73% of knees reached the normal alignment. In Andrews study, following TKA, mFTA alignment for all patients was 0.0\u0026deg; \u0026plusmn; 2.3\u0026deg; (range, \u0026minus;\u0026thinsp;7.0\u0026deg; to 8.0\u0026deg;) which is similar to our study using individual VCA. Palanisami et al (8), after analysis of VCA in the 227 limbs, showed that 70 knees (31%) had a VCA angle outside 5\u0026ndash;7\u0026deg;. Their study also showed a significant improvement in both femoral component placement and postoperative alignment by using individualized VCA in the knees with varus 10\u0026ndash;15\u0026deg; (p 0.002) and varus\u0026thinsp;\u0026gt;\u0026thinsp;15\u0026deg; (p 0.002).\u003c/p\u003e\u003cp\u003eThis study showed that there was a statistically significant association between the valgus cut angle (VCA) and LDFA, mFTA, and total varus correction (ΔmFTA). Also, post-operative mFTA was significantly correlated with MPTA, distal and posterior cut of the femur, and post-operative JLCA. It was also shown that JLCA was a significant predictor of VCA (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;14%). Based on a study by Palanisami et al., coronal bowing, neck-shaft angle of the femur and preoperative deformity significantly affect VCA,\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e although according to Drexler's study, gender and distal femoral joint angle were not associated with VCA, and only femoral height and femoral offset were two independent determinants of VCA. In other words, tall patients with small femoral offset have a smaller VCA and vice versa. Therefore, the use of a fixed amount of VCA for all patients is not recommended,\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e In Davis's study, both the preoperative MFT angle (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;33%) and TCA (R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;58%) were independent predictors for postoperative alignment (MFT angle).\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn the present study, care was taken to ensure that the lower extremities were placed with the patellae facing forward with the hope of controlling for rotation and minimizing the error of variability in lower extremity rotation during alignment view. All procedure was done by a single surgeon, which is an advantage for our study. The limitation of our study, however, was the short follow-up period and lack of a control group. Non-consideration of BMI, as well as the duration of varus deformity, postoperative complications, patient performance, as well as lack of stress view data and a small number of subjects, are other limitations of the study. Therefore, multicentre studies with a larger sample size are recommended.\u003c/p\u003e\u003cp\u003eIn conclusion, this study demonstrates that, in the absence of computer-assisted navigation in non-developed countries, the use of an individual valgus cut angle improves achievement of a neutral, femoral component alignment (LDFA) and mFTA alignment after TKA, especially in knees with severe varus deformity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Consideration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee meeting of Mazandaran University of Medical Sciences approved our study with the registration number of IR.MAZMUS.IMAMHOSPITAL.REC1399.088.\u003c/p\u003e\n\u003cp\u003eAll patients completed the informed consent form. The names and other details of the patients will remain confidential. In addition, all the principles of research ethics mentioned in the Helsinki Declaration as well as the regulations of the Ethics Committee for the protection of the subject in the medical sciences research were observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no conflict of interest.\u003c/p\u003e\n\u003cp\u003eThis work was done in orthopedic research center of mazandaran university of medical science.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The author(s) received NO financial support for the preparation, research, authorship, and publication of this manuscript.\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained with IR.MAZUMS.IMAMHOSPITAL.REC.1399.088 on 23/09/2020.\u003c/p\u003e\n\u003cp\u003eThere is no information (names, initials, hospital identification numbers, or photographs) in the submitted manuscript that can be used to identify patients.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVaracallo M, Luo TD, Johanson NA. Total Knee Arthroplasty Techniques. In: \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL): StatPearls Publishing;2023./\u003c/li\u003e\n\u003cli\u003eGuo EW, Sayeed Z, Padela MT, et al. Improving Total Joint Replacement with Continuous Quality Improvement Methods and Tools. Orthop Clin North Am. 2018;397-403. doi:10.1016/j.ocl.2018.\u003c/li\u003e\n\u003cli\u003eShetty GM, Mullaji A, Khalifa AA, Ray A. Windswept deformities - An indication to individualise valgus correction angle during total knee arthroplasty. \u003cem\u003eJ Orthop\u003c/em\u003e. 2016;70-72. Published 2016. doi:10.1016/j.jor.2016\u003c/li\u003e\n\u003cli\u003eSchroer WC, Berend KR, Lombardi AV, et al. Why are total knees failing today? Etiology of total knee revision in 2010 and 2011. J Arthroplasty. 2013;116-119. doi:10.1016/j.arth.2013.\u003c/li\u003e\n\u003cli\u003eBonner TJ, Eardley WG, Patterson P, Gregg PJ. The effect of post-operative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years. J Bone Joint Surg Br. 2011;1217-1222. doi:10.1302/0301-620X.93B9.26573\u003c/li\u003e\n\u003cli\u003eParratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am. 2010;2143-2149. doi:10.2106/JBJS.I.01398\u003c/li\u003e\n\u003cli\u003ePalanisami D, Iyyampillai G, Shanmugam S, Natesan R, S R. Individualised distal femoral cut improves femoral component placement and limb alignment during total knee replacement in knees with moderate and severe varus deformity. Int Orthop. 2016;40(10):2049-2054. doi:10.1007/s00264-016-3123-5\u003c/li\u003e\n\u003cli\u003eMullaji AB, Shetty GM, Kanna R, Vadapalli RC. The influence of preoperative deformity on valgus correction angle: an analysis of 503 total knee arthroplasties. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 2013;20-27. doi:10.1016/j.arth.2012.\u003c/li\u003e\n\u003cli\u003eThippanna RK, Kumar MN. Lateralization of Femoral Entry Point to Improve the Coronal Alignment During Total Knee Arthroplasty in Patients With Bowed Femur. \u003cem\u003eJ Arthroplasty\u003c/em\u003e. 2016;1943-1948. doi:10.1016/j.arth.2016.\u003c/li\u003e\n\u003cli\u003eDeakin AH, Sarungi M. A comparison of variable angle versus fixed angle distal femoral resection in primary total knee arthroplasty. J Arthroplasty. 2014;1133-1137. doi:10.1016/j.arth.2013.\u003c/li\u003e\n\u003cli\u003eDrexler M, Abolghasemian M, Barbuto R, et al. Patient\u0026apos;s Height and Hip Medial Offset Are the Main Determinants of the Valgus Cut Angle During Total Knee Arthroplasty. J Arthroplasty. 2017;1496-1501. doi:10.1016/j.arth.2016.\u003c/li\u003e\n\u003cli\u003eKharwadkar N, Kent RE, Sharara KH, Naique S. 5 degrees to 6 degrees of distal femoral cut for uncomplicated primary total knee arthroplasty: is it safe?. \u003cem\u003eKnee\u003c/em\u003e. 2006;57-60. doi:10.1016/j.knee.2005.\u003c/li\u003e\n\u003cli\u003eDavis JA, Hogan C, Dayton M. Postoperative Coronal Alignment After Total Knee Arthroplasty: Does Tailoring the Femoral Valgus Cut Angle Really Matter?. J Arthroplasty. 2015;1444-1448. doi:10.1016/j.arth.2015.\u003c/li\u003e\n\u003cli\u003eBardakos N, Cil A, Thompson B, Stocks G. Mechanical axis cannot be restored in total knee arthroplasty with a fixed valgus resection angle: a radiographic study. J Arthroplasty. 2007;85-89. doi:10.1016/j.arth.2007.\u003c/li\u003e\n\u003cli\u003eMason JB, Fehring TK, Estok R, Banel D, Fahrbach K. Meta-analysis of alignment outcomes in computer-assisted total knee arthroplasty surgery. J Arthroplasty. 2007;1097-1106. doi:10.1016/j.arth.2007.\u003c/li\u003e\n\u003cli\u003eNam D, Vajapey S, Haynes JA, Barrack RL, Nunley RM. Does Use of a Variable Distal Femur Resection Angle Improve Radiographic Alignment in Primary Total Knee Arthroplasty?. J Arthroplasty. 2016;91-96. doi:10.1016/j.arth.2016.\u003c/li\u003e\n\u003cli\u003eAndrews SN, Beeler DM, Parke EA, Nakasone CK, Stickley CD. Fixed Distal Femoral Cut of 6\u0026deg; Valgus in Total Knee Arthroplasty: A Radiographic Review of 788 Consecutive Cases. J Arthroplasty. 2019;755-759. doi:10.1016/j.arth.2018.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e[Table 1]: Intraoperative variables\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.3355%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eVARIABLES\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8039%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eN\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8558%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMEAN\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.128%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMEDIAN\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2901%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eRANGE\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5867%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eSD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.3355%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eVCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8039%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8558%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e6.37\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.128%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2901%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e2-12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5867%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.48\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.3355%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eDistal femur cut (mm)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8039%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8558%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e9.45\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.128%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2901%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e7-15\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5867%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.22\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.3355%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePosterior femur cut(mm)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8039%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8558%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e8.90\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.128%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2901%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e4-14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5867%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.60\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.3355%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eProximal tibia cut(mm)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8039%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8558%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e6.45\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.128%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2901%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e2-12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5867%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.77\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.3355%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eExternal rotation cut angle\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8039%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8558%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e2.92\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.128%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.2901%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0-3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5867%;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.38\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e[Table 2]: Comparison of radiographic criteria before and after TKA\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eVariable\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eBEFORE SURGERY\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAFTER SURGERY\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eP-VALUE\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMEAN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMEDIAN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSD\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMEAN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eMEDIAN\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eSD\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eLDFA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e91.21\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e91.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e2.49\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e90.10\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e90\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.80\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMPTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e85.28\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e85\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e3.18\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e89.81\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e90\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.96\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMFTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e14.01\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e5.99\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.29\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e2.86\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eJLCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e139\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e6.58\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e6\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e3.58\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e128\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.24\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.66\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e0.0001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e[Table 3] correlation between preoperative radiographic and intraoperative variables\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 120px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eage\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eLDFA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMPTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003emFTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eJLCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eVCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eER\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eDistal femur cut\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost. femur cut\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eProximal tibia cut\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.LDFA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost.\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMPTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost.\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eJLCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost.\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003emFTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026Delta;mFTA\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"15\" valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAGE\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.170\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.074\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.011\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.058\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.115\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.094\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.102\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.101\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.008\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.134\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.052\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.113\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.109\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.053\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eLDFA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.253\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.472\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.002\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.450\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.007\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.087\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.093\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.043\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.039\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.103\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.075\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.160\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.402\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eMPTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.579\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.009\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.048\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.171\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.092\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.002\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.188\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.111\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.263\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.011\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.281\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.442\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003emFTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.509\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.307\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.238\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.062\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.008\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.023\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.028\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.117\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.008\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.155\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.876\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eJLCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.007\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.117\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.134\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.072\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n 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style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003e.592\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eVCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.088\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.154\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.088\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.146\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.122\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.093\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.176\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.025\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.259\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eExternal rotation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.138\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.093\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.077\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.015\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.057\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.076\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.002\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.240\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eDistal femur cut\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.171\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.042\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.133\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.147\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.031\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.205\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.005\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePosterior femur cut\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.056\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.176\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.265\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.043\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.220\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.042\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eProximal tibia cut\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.062\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.059\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.106\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.183\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.052\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost .LDFA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.255\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.198\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.521\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.209\u003csup\u003e*\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost.MPTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.158\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.549\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.133\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost.JLCA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e.312\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.114\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003ePost.mFTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 53px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e1.000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e-.312\u003csup\u003e**\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026Delta;mFTA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n 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\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Total Knee Arthroplasty, valgus cut angle, varus deformity, Radiographic Parameters","lastPublishedDoi":"10.21203/rs.3.rs-7235418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7235418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe distal femur resection in total knee arthroplasty (TKA) is commonly made using a fixed angle by routine use of 5° or 6° for valgus cut angle(VCA). The present study aimed to determine the effect of specific VCA in each person on post-TKA limb alignment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective study all patients who underwent primary knee replacement surgery performed by a single surgeon by using the individualized VCA method from Imam Khomeini and Shafa hospitals in Sari from 2018 to 2020 were included. Preoperative and post-operative knee radiographs including a standing anteroposterior and lateral view and the long-leg standing anteroposterior radiograph alignment view were collected. Radiographic parameters including Mechanical Femoro-tibial angle (mFTA), Lateral distal femoral angle (LDFA), medial Proximal tibial angle (MPTA), and valgus cut angle (VCA) were compared before and after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e139 knees associated with 119 patients were examined. The mean (standard deviation) age of patients was 64.35 Years (7.57). 89.3% were female. In 78% of the cases, the VCA was 5–7 degrees. All radiographic parameters improved significantly after surgery (P \u0026lt; 0.0001). The mean (SD) of Total varus correction (ΔmFTA) was 13.47 (5.64) and ranged from 2 to 26 degrees. mLDFA in 39.3% of knees was in a normal range (85–90). After surgery, this rate increased to 64%. Before surgery based on mFTA, 98.2% of patients' knees had varus alignment and after surgery mFTA in 73% of the patients were in the neutral range. There was a statistically significant association between the valgus cut angle (VCA) and LDFA, mFTA, and total varus correction (ΔmFTA) (p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study demonstrates that in the absence of a computer-assisted navigation system, the use of an individual valgus cut angle improves achievement of a neutral, femoral component alignment(LDFA), and mFTA alignment after TKA especially in knees with severe varus deformity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence:\u003c/strong\u003e IV\u003c/p\u003e","manuscriptTitle":"Accuracy of Femoral Component Position in Primary Total Knee Arthroplasty Based on Valgus Cut Angle","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 08:23:50","doi":"10.21203/rs.3.rs-7235418/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9746acc0-9b7a-4494-9b0c-71c0019fe169","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T08:24:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 08:23:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7235418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7235418","identity":"rs-7235418","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}