Distribution and Correlates of Hip-Knee-Ankle Angle in Early Osteoarthritis and Preoperative Total Knee Arthroplasty Patients

Taghi Ramazanian, Shi Yan, Pouria Rouzrokh, Cody C. Wyles, Thomas J. O Byrne, Michael J. Taunton, Hilal Maradit Kremers

Research output: Contribution to journalArticlepeer-review


Background: Several studies have investigated the distribution of hip-knee-ankle (HKA) angle in healthy populations; however, few have evaluated this metric in patients undergoing total knee arthroplasty (TKA). The purpose of this study is to compare HKA angle distribution in early and advanced knee osteoarthritis (OA) patients. Methods: Full limb radiographs were used to measure HKA angle for 983 subjects from the Osteoarthritis Initiative (OAI) cohort and 4,901 pre-TKA patients from an institutional cohort. Measurements were made using a previously validated deep learning algorithm. Linear regression models were used to determine the association of HKA alignment angle with patient characteristics. Results: The mean ± standard deviation HKA angle was −1.3° ± 3.2° in the OAI cohort and −4.1° ± 6.1° in the pre-TKA cohort. In the OAI cohort, normal alignment (64%) was the most common knee alignment followed by varus (29%), and valgus (7%). In pre-TKA patients, the most common alignment was varus (62%), followed by normal (27%) and valgus (11%). In pre-TKA patients, mean HKA angle in primary knee OA, post-traumatic knee OA, and rheumatoid arthritis patients were −4.3° ± 6.1°, −3.2° ± 6.4°, and −2.9° ± 6.1°, respectively. HKA angle was strongly associated (P < .001) with gender and body mass index. Conclusion: TKA patients have a wider alignment distribution and more severe varus and valgus alignment than individuals “at risk” for knee OA from the OAI cohort. These epidemiologic findings improve our understanding of HKA angle distribution and its correlation with demographic characteristics in early and late-stage arthritis.

Original languageEnglish (US)
Pages (from-to)S170-S175
JournalJournal of Arthroplasty
Issue number6
StatePublished - Jun 2022


  • artificial intelligence
  • deep learning
  • knee arthroplasty
  • knee coronal alignment
  • osteoarthritis epidemiology

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine


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