X-ray of knee prosthesis

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Author: Mikael Häggström [notes 1]

Post-operative evaluation

Overhang (arrow) does not seem to have any detrimental effect.[1] It is therefore not necessary to measure or report.

Knee replacement is evaluated by the following measures:


In Swedish healthcare[5], the numbers of the angles are not reported if being within normal limits. Example of an normal case:

  • Postoperative images of knee implant in unremarkable position.

Also, unless you know the referring physician is familiar with the same angle terminology, preferably report any deviating angles as varus/valgus deviation or ventral/dorsal angulation, such as:

  • An abnormally increased valgus angulation of __° of the femur component in relation to femoral diaphysis.
  • A abnormal ventral angulation of __° of the tibial diaphysis in relation to the tibial component.
See also: General notes on reporting


Potential complications that need to be evaluated on follow-up are as follows.

Radiolucent lines

KS (Knee Society) zones, for localizing radiolucent zones or other focal changes.[6]
KS zones, AP view.[6]

Radiolucent lines may indicate loosening of the implant. A radiolucent line thinner than than 2 mm can be tolerated at the cement-bone interface (for cemented implants) or implant-bone interface (for cementless implants) if it remains stable and appears within the first 6 months (cemented implants) or the first 2 years (cementless implants) after surgery.[7] There are various classification systems for specifying the location of radiolucent spaces,[8][9] including by KS (Knee Society) zones published in 2015.[6]


A change in position is indicated by a significant change in either of the angles listed in the post-operative evaluation section above.[7]


Signs of infection include:[7]

  • Rapidly progressing radiolucency and/or osteolysis
  • Periosteal reaction
  • Bubbles of air within soft tissue or fluid collection.

Other complications

  • Fractures of prosthesis components.
  • Wear of the polyethylene insert, which is the case when progressive thinning occurs over time.
  • Dissociation of the polyethylene insert from the patellar component or tibial baseplate.


In Swedish healthcare[10], an example report of a normal case may be:

  • No changes since previous images on <date>.

For localization of focal changes using zones, specify what zone system is used, since there are several. For example:

  • Since previous exam on <date>, a 2 mm thick radiolucent line has appeared in KS zone 2.
See also: General notes on reporting


  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.


  1. S.G.F. Abram, A.G Marsh, F. Nicol, A.S. Brydone, A. Mohammed, S.J. Spencer (2018-02-21). "The Impact Of Tibial Component Overhang On Outcome Scores And Pain In Total Knee Replacement ". Orthopaedic Proceedings. 
  2. Inui, Hiroshi; Taketomi, Shuji; Nakamura, Kensuke; Takei, Seira; Takeda, Hideki; Tanaka, Sakae; Nakagawa, Takumi (2013). "Influence of navigation system updates on total knee arthroplasty ". Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 5 (1): 10. doi:10.1186/2052-1847-5-10. ISSN 1758-2555. PMID 23638774.  (CC-BY-2.0)
  3. 3.0 3.1 3.2 Gromov, Kirill; Korchi, Mounim; Thomsen, Morten G; Husted, Henrik; Troelsen, Anders (2014). "What is the optimal alignment of the tibial and femoral components in knee arthroplasty? ". Acta Orthopaedica 85 (5): 480–487. doi:10.3109/17453674.2014.940573. ISSN 1745-3674. PMID 25036719. 
  4. Lee, Ju Hong; Wang, Seong-Il (2015). "Risk of Anterior Femoral Notching in Navigated Total Knee Arthroplasty ". Clinics in Orthopedic Surgery 7 (2): 217. doi:10.4055/cios.2015.7.2.217. ISSN 2005-291X. 
  5. NU Hospital Group, Sweden, Sep 2018
  6. 6.0 6.1 6.2 Meneghini, R. Michael; Mont, Michael A.; Backstein, David B.; Bourne, Robert B.; Dennis, Doug A.; Scuderi, Giles R. (2015). "Development of a Modern Knee Society Radiographic Evaluation System and Methodology for Total Knee Arthroplasty ". The Journal of Arthroplasty 30 (12): 2311–2314. doi:10.1016/j.arth.2015.05.049. ISSN 08835403. 
  7. 7.0 7.1 7.2 Cyteval, C. (2016). "Imaging of knee implants and related complications ". Diagnostic and Interventional Imaging 97 (7-8): 809–821. doi:10.1016/j.diii.2016.02.015. ISSN 22115684. 
  8. Napier, Richard J.; O’Neill, Christopher; O’Brien, Seamus; Doran, Emer; Mockford, Brian; Boldt, Jens; Beverland, David E. (2018). "A prospective evaluation of a largely cementless total knee arthroplasty cohort without patellar resurfacing: 10-year outcomes and survivorship ". BMC Musculoskeletal Disorders 19 (1). doi:10.1186/s12891-018-2128-1. ISSN 1471-2474. 
  9. Kumar, Nishikant; Yadav, Chandrashekhar; Raj, Rishi; Anand, Sumit (2014). "How to Interpret Postoperative X-rays after Total Knee Arthroplasty ". Orthopaedic Surgery 6 (3): 179–186. doi:10.1111/os.12123. ISSN 17577853. 
  10. NU Hospital Group, Sweden, Oct 2018