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Restoration of neutral mechanical alignment is traditionally considered as one of the prerequisites for successful total knee replacement. The purpose of this study was to investigate whether a certain bias towards undercorrection exists with conventional total knee arthroplasty (TKA) instruments.

A cohort of 456 consecutive patients, who underwent the same standardised TKA with restoration of neutral mechanical alignment as target, was studied. Based on the preoperative alignment, patients were stratified into three categories: valgus, neutral and varus. Component and limb alignment were compared between these groups.

The mean post-operative hip–knee–ankle angle was −0.7° (SD 2.5) in valgus knees, 0.2° (SD 1.9) in neutral knees and 2.4° (SD 3.9) in varus knees (p < 0.001). About 39 …