Malalignment of the lower extremity may be a cause for gonarthrosis and failure of total knee prosthetic components. Neutral lower limb alignment is considered straight alignment of the axes formed from the center of the femoral head to the center of the knee and from the center of the knee to the center of the ankle joint (the mechanical axes of the thigh and shank). Malalignment of the mechanical axis (measured by δv, the angle between the femoral and the tibial mechanical axes) occurs when varus moves the line of action farther medially from the knee joint center. Malalignment due to varus results in increases in medial compartment loading and has been attributed to medial compartment articular cartilage degeneration. External rotation of the hip and knee compared to the direction of gait is another form of malalignment. In external rotation, the knee displaces from the midline at stance phase. Knee loading and the consequences of external rotation on cartilage degeneration are not well understood. The purpose of our study was to develop a mathematical model that would calculate forces and moments in knees for gait and study how they vary with varus and external rotation malalignment. An additional objective was to develop a finite element model of total knee replacement to study stress patterns on the polyethylene insert during malaligned gait. We hypothesized that medial compartment loads would be increased by both varus and external rotation alignment of the knee compared to the direction of gait. We also hypothesize that stress patterns on total knee replacement (TKR) inserts under conditions related to malaligned gait will correlate with wear patterns observed in retrieval studies. It was found that for varus and external rotation, there is a shift towards adduction moment, which resulted in an increase in medial compartment loads, supporting our hypothesis. It was also found that the malalignment in gait results in alterations in tibial tray load magnitudes and load distribution that support elevated wear in the medial compartment as observed clinically
