Skeletal Radiol (2012) 41:493–501
DOI 10.1007/s00256-011-1297-x
REVIEW ARTICLE
How to read a postoperative knee replacement radiograph
Nawfal Al-Hadithy & Madhavan C. Papanna &
Sana Farooq & Yegappan Kalairajah
Received: 24 May 2011 / Revised: 31 July 2011 / Accepted: 23 September 2011 / Published online: 16 October 2011
# ISS 2011
Abstract Knee replacement surgery is the most common
joint replacement surgery in England and Wales. Postoper-
ative radiographs are associated with long-term outcome at
both early and late stages, and their correct interpretation is
therefore vital. These radiographs will commonly be
assessed by surgical trainees, emergency doctors, orthopae-
dic surgeons, nurse practitioners, and radiologists. The aim
of this paper is to provide the reader with a systematic
approach to assessing these radiographs, whether it be in
the immediate postoperative period or during subsequent
follow-ups, and to provide sufficient knowledge to critique
the procedure. An outline of prostheses and their indica-
tions alongside a comprehensive review of the assessment
of important angles, alignment, and correct positioning of
femoral and tibial components is presented.
Keywords Knee radiograph . Assessment . Postoperative .
Replacement . Arthroplasty
Introduction
In 2009 over 77,000 knee replacements were implanted in
England and Wales, an increase of 2.5% from 2008.
Revision rates are also increasing, from 4.3% in 2007 to
N. Al-Hadithy (*) : M. C. Papanna : Y. Kalairajah
Trauma and Orthopaedics, Luton and Dunstable Hospital,
Lewsey Road,
Luton LU4 0DZ, UK
e-mail: nawfal@yahoo.com
S. Farooq
Accident and Emergency, Barnet General Hospital,
Wellhouse Lane, Barnet,
Herts EN5 3DJ, UK
5.9% in 2009 [1], due to more implants being inserted,
longer life expectancy and increasing patient demand.
There has been evidence to show that postoperative knee
arthroplasty radiographs are associated with long-term
survival, pain, and function [2], and therefore their correct
evaluation is of vital importance. Initial radiographs are
useful for assessing the correct positioning of the prosthesis
and are discussed in detail in this review. Follow-up
radiographs may be useful to assess for periprosthetic
fractures, loosening, infection, or migration.
The purpose of this article is to provide the necessary
framework to assess a postoperative knee radiograph
adequately.
Types of prosthesis
Although there are numerous brands of knee prostheses [56
recorded in the National Joint Registry (NJR) [3]], they fall
into three broad categories: primary total knee replacements
(86%), revision knee replacements (5%), or unicondylar
knee replacements (9%). Unlike hip replacements, where
there is an even distribution of cemented and cementless
arthroplasties [4], knee replacement surgery is currently
90% cemented [1].
The unconstrained primary knee replacement is the most
common joint replacement surgery and is the procedure of
choice in an osteoarthritic knee without fixed flexion
deformity or instability. As the tibial and femoral compo-
nents are not linked together (“unconstrained”), this type of
replacement relies on the intrinsic stability of the existing
ligaments and muscles to maintain stability. It is therefore
vital for the collaterals and posterior cruciate ligament to be
intact; the anterior cruciate ligament is often sacrificed
perioperatively and is therefore not required.
494
There is minimal conformity between the femoral
component and the polyethylene liner on the tibial tray.
This allows for “rollback”: as the knee flexes, the femur
rolls back on the tibia, allowing for greater flexion; up to
135° is required for standing from a seated position [5], and
up to 160° may be required in Asian and Oriental social
customs [6]. In 2010, the most commonly implanted
primary knee replacements were the PFC Sigma Knee
(DePuy, Warsaw, IN) (Fig. 1) and Nexgen (Zimmer,
Warsaw, IN).
The semi-constrained implant (Fig. 2) has greater
conformity between the curvature of the femoral compo-
nent and the tibial tray and therefore has stability in the AP
plane, but it relies on the patient’s own collateral ligaments
for medial-lateral stability. Therefore, semi-constrained
knees will have greater stability than an unconstrained
knee replacement but may have a reduced range of motion
(including knee flexion) and greater wear particles. These
implants can often be recognized by the presence of a box
in the center of the femoral component, which accommo-
dates the polyethylene liner post. However, some designs
eliminate the need for a post by utilizing a large anterior lip
to the polyethylene insert (e.g., Medial Rotation Knee,
MAT Orthopaedics, Surrey, UK)
The patella also needs to be considered during total knee
placement (TKR). It can be simply debrided by removing
the osteophytes, however in the majority of cases, it is
resurfaced [7].There are two types of resurfacing methods:
onset or inset. Onset patella requires the articular surface to
be resected down to bone, and the patellar implant is then
attached. Inset patella requires the patella to be reamed to
the depth of the implant so that it lies within the patella. In
both instances, the implant should cover the articulating
surface and not overhang the patella. Figure 1 shows an
onset patellar.
Constrained knee prostheses are considered for very
unstable knees, for revisions in elderly patients, and as a
salvage procedure. There are two types of hinged prosthe-
sis: the true hinge and the rotating hinge. The true hinge
joint is very rare and accounts for <3% of hinged
Fig. 1 AP and lateral of an
unconstrained total knee place-
ment (PFC Sigma). The patella
has also been resurfaced
Skeletal Radiol (2012) 41:493–501
prosthesis. It restricts normal motion of the knee joint in
all planes and allows for flexion and extension only.
Although extremely stable, due to the limited range of
motion, there are tremendous stresses on the implant bone
interface due to twisting or bending movements, which
leads to a high incidence of prosthetic/periprosthetic
fractures and early loosening [8]. The more common
rotating hinge prosthesis (Fig. 3) was introduced with the
aim of preventing torsional stresses by allowing some
rotation, thus reducing failure rates [9, 10].
Despite these modern designs, failure rates of hinged
prostheses are high, ranging from 32.8% [11] and 35% [12]
at 5 and 6 years postoperatively for revision surgeries up to
91% at 15 years for primary joint replacements in unstable
knees in patients with low demands [13].
Unicondylar knee replacement (UKR) is a partial surface
knee replacement that replaces only the affected knee
compartment. It is indicated in severe unicompartmental
arthritis of the knee joint. As it simply resurfaces the
affected side, the knee must have intact cruciate ligaments,
no fixed deformities, adequate range of motion, and no
cartilage loss on the contralateral side [14, 15]. It is a bone-
preserving procedure that may act to postpone or eliminate
the need for total knee replacement surgery in a young
patient. It had been previously thought that UKR should be
avoided in elderly patients as they tend to outlive their total
knee replacement and gave the possibility, however age is
no longer a contraindication. UKR has been found to have
advantages of reduced hospital stay, lower physiological
impact, and faster recovery in the elderly patient as
compared with TKR [16].
There are two main types of UKR: fixed and mobile
bearing. Fixed bearing UKR involves fixed femoral and
tibial components, with low conformity between the two
articular surfaces. This results in higher stresses on the
tibial component, possibly causing greater wear. Mobile
bearing UKR (Fig. 4) allowa absolute congruency between
the articulating surfaces, however there may be greater
possibility of dislocation. Despite these differences, surviv-
al rates remain similar, and according to the NJR, the 5 year
Skeletal Radiol (2012) 41:493–501
Fig. 2 AP and lateral of a semiconstrained total knee placement. Note
the longer stems of the prosthesis as this was a revision procedure
revision rate is 10.5% [17]. However some high volume
studies have shown 91% survival rate at 20 years [18, 19].
Several other types of isolated unicompartment knee
replacements exist, e.g., patellofemoral and lateral unicom-
partments, but as they are less common, they will not be
discussed further.
Radiographic views
As with any joint replacement surgery, an anteroposterior
(AP) radiograph in combination with a lateral radiograph of
the knee is required for assessment.
For the AP view, the patient is standing with the knee
extended, and the patella pointing straight forward. The
beam is directed perpendicularly to the midshaft of the
Fig. 3 AP and lateral of a hinged prosthesis. The two components are
linked together, “hinged,” restricting freedom of motion, hence
promoting stability
495
Fig. 4 AP and lateral of a unicondylar knee replacement (Oxford) for
medial compartment osteoarthritis. The tibial polyethylene tray is
visible and is therefore a mobile bearing surface
femur and tibia, aiming across the joint line, which should
ideally be determined via palpation. For the lateral view, the
knee is also in extension; however the beam is directed
laterally, again perpendicular to the knee joint. For
assessment of the patella, the skyline view (Fig. 5) is most
commonly used, which involves flexing the knee to 45°,
with the beam inclined downward 30° from the horizontal.
Assessment of angles
In patients undergoing TKR, valgus or more commonly
varus deformities can occur in either the tibial or femoral
components. It is essential that the deformities are
accounted for by the surgeon to optimize load bearing. If
postoperatively a deformity still remains, there will be
increased stresses on the polyethylene component, abnor-
mal gait patterns, and ultimately premature failure of the
prosthesis [20].
Posterior tibial slope
The posterior tibial slope after knee arthroplasty affects
anteroposterior stability, range of motion, and the strain on
Fig. 5 Skyline view of the knee showing a well preserved patello-
femoral joint
496
the posterior cruciate ligament (PCL). It is therefore
recommended that there should be minimal alteration to
the posterior tibial slope during surgery [21]. Most modern
prostheses aim for a posterior slope of 3–7° as the anterior
portion of the tibial surface is weaker. A reduction or at
worst an inclination in this slope causes a reduced range of
knee flexion.
The posterior tibial slope can be assessed with a lateral
knee radiograph (Fig. 6); one line is drawn along the
surface of the tibial component, and another line is drawn
along the posterior tibial cortex; the angle that they intersect
reveals the posterior tibial slope.
Malalignment in the coronal plane
Malalignment in the coronal plane causes pain [22], limited
range of motion [23], prolonged stay in hospital, and
loosening of the implant [24]. However, the acceptable
range remains controversial with some studies stating that it
should be 3–4° valgus [25, 26], whilst others suggest that
there is minimal difference in long term outcome if the
coronal alignment is more than 3° [27, 28]. A tibiofemoral
angle of ∼3° (<7°) still remains necessary for the procedure
to be deemed successful by most orthopaedic surgeons.
The use of computer-assisted knee arthroplasty has now
led to more accurate post-operative coronal alignment with
discrepancies of ±3° [29, 30]. However, it is still important
to measure it due to possible inaccuracies of the computer,
Fig. 6 Posterior tibial slope is assessed by drawing a line along the
posterior tibial cortex and another along the base of the tibial tray. It
should be 0–7°
Skeletal Radiol (2012) 41:493–501
late-migration, and the fact that most surgeons still prefer to
not use computer-assisted knee replacements.
Coronal alignment can be assessed by measuring the
tibiofemoral angle on the AP knee radiograph. Two lines
are drawn; one in the middle of the femur and one in the
middle of the tibia. The angle at which they intersect is the
tibiofemoral angle [31] (Fig. 7). This is also often called the
anatomical axis.
A more accurate method of checking coronal alignment
is to use full-leg radiographs with the patient bearing
weight and the patella pointing forwards. Maquet’s line [32]
(Fig. 8) passes from the center of the femoral head to the
center of the body of the talus; this is also known as the
mechanical axis. The position that the line passes through
on the knee prosthesis represents coronal alignment. Jeffery
et al. [25] found that if Maquet’s line passed through the
middle third of the tibial plate, there was only 3% incidence
of subsequent loosening, as compared with 24% if it passed
too medially or laterally at 8 years of follow up.
Femoral component
The femoral component is difficult to assess on plain
radiographs as it is not possible to check for rotational
malalignment. However, notching of the anterior femoral
cortex should be assessed; notching is associated with
periprosthetic fractures, and its incidence has been noted to
be as high as 27% (180 of 670 knees) [33]. Lesh et al. [34]
performed a biomechanical study in 12 matched cadaveric
knees and found an 18% reduction in the force required to
cause a periprosthetic fracture. Therefore, we recommend
noting anterior femoral notching as it may warrant closer
clinical and radiological follow-up.
Fig. 7 Tibiofemoral angle
should be between 0 and 3°
ideally, however up to 7° is
acceptable
Skeletal Radiol (2012) 41:493–501 497

Fig. 8 Maquet’s line passing

through the middle third of the
tibial component on a whole leg
view (femoral head to ankle
joint) indicates adequate coronal
alignment

Fig. 9 Lateral radiograph to assess the sagittal alignment of the

femoral component. This implant is in 5° of extension

both cortices but not overhang laterally as it may

impinge on the popliteus tendon. On the lateral radio-
graph, anterior/posterior translation can be assessed; the
tibial component should again ideally provide maximum
coverage, however due to prosthesis design there is a
tendency to overhang posteriorly, and this should be
prevented by compromising on AP coverage, with an
aim of more posterior coverage to reduce patellofemoral
joint pressure [37].
The tibial component angle is the angle of intersection
Sagittal plane femoral component position can be between the anatomical axis of the tibia and the
assessed with a lateral knee radiograph; it determines if it horizontal axis of the tibial component (Fig. 10). In knee
is implanted neutral, flexed, or extended in relation to the replacement surgery, it should be 90° [38] (±2° [39]),
femur. There have been no studies that look at the effect of however if it is slightly off, the surgeon may adjust the
sagittal femoral component alignment on survival, and
despite other studies showing that there is no effect on
range of motion provided the implant is within 20° of
neutral [35], most surgeons aim for ±3° [36].
On the lateral radiograph, a line is drawn down the
center of the femoral shaft, and another along the internal
surface of the femoral condylar position of the femoral
component. If they intersect at 90°, it is considered neutral;
any deviation from this indicates that the implant is in either
flexion or extension. Figure 9 shows an implant in 5° of
extension.

Tibial component

On the AP radiograph, medial/lateral translation can be Fig. 10 Tibial component angle should be 90 ± 2°. This tibial
assessed; the tibial component should ideally extend to component is tilted by 1°
498 Skeletal Radiol (2012) 41:493–501

femoral cut to correct the tibiofemoral angle and prevent
coronal malalignment [40].
Unicondylar knee replacement
There are two main areas of focus with regards to assessing
unicondylar radiographs. Firstly, one of the purposes of the
unicondylar knee replacement is to restore normal, pre-
morbid anatomical alignment—usually 3–5° (valgus)—
which offloads the unchanged lateral compartment and
prevents early loosening of the implant [41, 42]. It has also
been recommended that the posterior tibial slope should not
exceed 7° as this puts increased pressure on the lateral
compartment/ACL and increases the chance of dislocations
[43, 44].
Tibial component cement mantle
Radiolucent lines
In any arthroplasty, the cement-bone interface is vital for
ensuring long-term stability. Any deficiencies in this
interface can predispose the prosthesis to aseptic loosening
and failure of the prosthesis [54, 55] and are also a sign of
septic loosening [56]. On behalf of the Knee Society, Ewald
[57] produced a scoring system to assess the extent of
radiolucent lines by adding up the maximum width of all
radiolucent lines across 14 zones (7 in each of the tibial and
femoral components). However, due to the complexity of
Ewald’s system there was large interobserver variability.
Bach et al. [58] simplified the system; the maximum widths
of radiolucent lines are added up in each of the tibial and
femoral components and are scored as either none, narrow
(<4 mm), or wide (>4 mm). Figure 11 shows a loose
revision TKR, which has radiolucent lines >4 mm in both
the tibial and femoral component. The presence of
radiolucent lines warrants closer follow-up.

The tibial component is the most common site of loosening

in TKA [45, 46] as it responds to tensile and shear forces Tibial polyethylene wear and dislocation
[47]. Several studies have shown that the greater the depth
of cement penetration, the greater the resistance to these The polyethylene component of the tibial tray is a contact
forces [48, 49]. A 4 mm penetration has been shown to be surface and therefore can wear similarly to articular
the minimum depth required for bone-cement interface cartilage. On progressive radiographs there will be a loss
resistance in TKA [50, 51]. This can be seen on the AP of joint space.
knee radiograph. The wear particles themselves are not visible on radio-
graphs, however there have been documented cases where
they present as a pseudotumour radiologically [59, 60].
Follow-up time Most manufacturers have also applied radio-opaque
markers within the tibial polyethylene tray to allow easy
Each surgeon and hospital may differ in the follow-up
period for knee arthroplasties, with some centers discharg-
ing patients after 1 year follow-up providing there are no
concerns. With most knee replacements failing after
10 years, there may be little point in following them up
after the acute setting and before a decade. However, the
British Orthopaedic Association has advised that an AP and
lateral radiograph should occur at 5 years and then each
5 years thereafter [52]. This is based on the fact that aseptic
loosening most commonly is asymptomatic, and at time of
presentation there may be huge bone loss, requiring much
more extensive surgery. This has led some surgeons to use
scoring systems to identify those whose arthroplasties
require more regular follow-up. The Oxford Knee Score
(OKS) is a patient-administered questionnaire that does not
require supervision, containing 12 questions, with five
scoring options related to pain and function, for a total
possible score of 48. Kalairajah et al. [53] found that
patients with low OKS were more likely to fail, and
therefore advised closer clinical and radiological follow-up Fig. 11 AP and lateral showing a loose TKR revision. There are
(every 6 months for 5 years). extensive radiolucent lines in both the tibial and femoral components
Skeletal Radiol (2012) 41:493–501
Fig. 12 Tibial tray wear (left) and replaced tibial tray (right). There is
also a lateral femoral condyle fracture (left)
radiological identification; these may be useful in the case
of suspected dislocation of these liners.
Figure 12 shows AP radiographs of severe tibial tray
wear (left) with metal on metal contact on the medial side.
The patient underwent revision surgery where the tibial tray
was replaced (right); the joint space has been restored.
Periprosthetic fracture
Periprosthetic fractures are rare, they account for <3% of
revisions [23] and unfortunately their management is
complicated and is not covered in this paper. There are
numerous classification systems; a simple and useful one
was created by Rorabeck et al. [61] (Table 1) who took into
account the status of the prosthesis (failing or not) and the
displacement of the fracture (displaced or not). Any
periprosthetic fracture is of concern and the patient should
be reassessed by an orthopaedic surgeon. Bone and/or
cement fragments may also be seen on plain radiographs.
Figure 12 (left) shows a minimally displaced periprosthetic
fracture of the lateral condyle with an intact prosthesis; this
was treated conservatively.
Migration of components
Although it had been previously thought that loosening of
the prosthesis only occurred late (10 years), studies have
Table 1 Rorabeck periprosthetic fracture classification
Score Description
I Intact prosthesis + undisplaced fracture
II Intact prosthesis + displaced fracture
III Failing prosthesis
499
Fig. 13 Osteopenia of the distal
femur due to stress shielding.
There is an increased risk of
migration of prosthesis/
periprosthetic fracture
shown that it can be initiated very early after arthroplasty
[62, 63]. Plain radiographs are considered a blunt instru-
ment for detecting migration and can only detect large
movements (>1 mm). Generally, migration of more than
1 mm per year is considered unacceptable [59, 64], and
therefore follow-up radiographs should be compared to
postoperative radiographs if migration is suspected.
Stress shielding
Bone responds to Wolf’s law [65]: it will remodel to suit
the forces applied to it. In the case of knee replacement,
abnormal stresses are going through the bone, and the distal
femur remodels accordingly. Mintzer et al. [66] found that
68% of TKA showed areas of osteopenia with the distal
anterior femur most commonly affected. A subsequent
study by Lenthe et al. [67] found a similar result, however
noting that there was more bone loss on the lateral distal
Table 2 Step by step guide to assessing total knee replacement
radiographs
Patient details and date of radiograph
AP and lateral of knee with or without skyline view
AP radiograph
• Coronal alignment: neutral to 7° valgus (no varus permitted)
• Tibial component
○ Size: implant should not overhang tibia
○ Tibial component angle: 90 ± 2°
○ Adequate cement mantle and 4 mm penetration
• Patella
○ Size: implant should not overhang patella
Lateral radiograph
• Posterior tibial slope: neutral to 7°
• Femoral component
○ Sagittal alignment: 90 ± 3°
○ Notching: report if present
Complications
• Radiolucent lines
• Migration of components: >1 mm per year is significant
• Stress shielding: distal femur osteopenia
• Tibial tray wear: loss of joint space approaching metal on metal
contact
500
femur than the medial, which was due to less load. In both
studies, osteopenic areas were visible on plain radiographs
and did not proceed after 2 years, suggesting remodeling
and that an equilibrium had been reached between bone
stock and forces. It is best seen on the lateral radiograph of
the knee, with a focus on the distal femur (Fig. 13).
Conclusion
As we have seen in this article, the assessment of the
postoperative knee replacement is very important and has
numerous technical aspects that can be approached in a
logical manner (Table 2) that not only judges the immediate
postoperative fixation but will also give some indication of
survivorship. In the majority of cases, progressive AP and
lateral radiographs are adequate in determining the success
and complications of knee replacement surgery, however if
more accurate coronal alignment needs to be assessed, then
long leg views may be required.
We have provided the necessary knowledge and frame-
work to allow a healthcare professional to assess postoperative
knee replacements.
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