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Year : 2021  |  Volume : 70  |  Issue : 1  |  Page : 3-10

Morphometric study of the knee joint in Saudi Arabian population based on magnetic resonance imaging scan

Department of Orthopaedics, College of Medicine, Majmaah University, Al Majmaah, Saudi Arabia

Date of Submission15-Jul-2020
Date of Acceptance26-Dec-2020
Date of Web Publication07-Apr-2021

Correspondence Address:
Dr. Zaheer Ahmed
Department of Orthopaedics, College of Medicine, Majmaah University, Al Majmaah 11952
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JASI.JASI_135_20

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Introduction: Total knee arthroplasty (TKA) is considered a highly recommended procedure, to improve the life of patients suffering from knee arthritis by relieving pain and deformity. Knee morphology and anthropomorphic features have evolved as the most reliable source of information to design TKA prostheses. But unfortunately, the amorphic features of Western patients are the preferred choice of data for the development of suitable implants. This study is conducted for commencing to evaluate the geometric parameters of the knee joints of Saudi Arabian male and female subjects which is indispensable to the design of knee prosthesis used for compatriotic patients. Material and Methods: A total of 13 parameters of tibia and femur were studied in a group of 150 normal subjects including 110 females and 40 males. A subsequent magnetic resonance imaging scan was done for all the studied cases and a reproducible result was obtained. Results: The Saudi females were found to have smaller dimensions of parameters of tibia and femur than those in Saudi males. The results when compared with other reports from different countries, we find marked difference in their dimensions. Discussion and Conclusion: Our study suggests that there exists a morphological mismatch between the knee anatomy of people of Saudi Arabia and people of other countries. Implantation of such implants prepared on the basis of outsider data could not justified to use in the Saudi population.

Keywords: Anatomical conformity, knee arthritis, Saudi knee morphology, total knee arthroplasty

How to cite this article:
Alharbi D, Ahmed Z. Morphometric study of the knee joint in Saudi Arabian population based on magnetic resonance imaging scan. J Anat Soc India 2021;70:3-10

How to cite this URL:
Alharbi D, Ahmed Z. Morphometric study of the knee joint in Saudi Arabian population based on magnetic resonance imaging scan. J Anat Soc India [serial online] 2021 [cited 2021 Jun 14];70:3-10. Available from: https://www.jasi.org.in/text.asp?2021/70/1/3/313155

  Introduction Top

The knee is an important hinge joint that is responsible for weight-bearing and movement. The femur (thigh bone), tibia (shin bone), and patella (knee cap) make up the bones of the knee joint. The knee joint keeps these bones in place with additional support of different ligaments.

Osteoarthritis of Knee is known to be the most common degenerative disease around the world,[1] it is a result of progressive wear and tear of articular cartilage of the joint. The occurrence of OA varies from 3.8% to 70% around the world depending on the methodologies used for its diagnosis and the studied populations.[2],[3],[4] It is most common in elderly women and men. Knee OA can be divided into two types, primary and secondary. Primary OA is articular degeneration without any apparent underlying reason. Secondary OA is the consequence of either an abnormal concentration of force across the joint as with posttraumatic causes or abnormal articular cartilage, such as rheumatoid arthritis. OA is typically a progressive disease that may eventually lead to disability. Knee joint instability is also one of the common sources of problem from which both athletes and nonathletes suffer which leads to OA of the knee joint in long run. It affects a varied population, including professional athletes, older adults, and recreational exercisers.[5] Knee instability has a high incidence rate and has been extensively studied over the last decade. Many countries have health-care systems focused on value-based care, which are systems focused on understanding the cost drivers, implementing high-value therapies, and improving methods and/or techniques to assess knee instability and rehabilitation therapies that could potentially reduce the health-care costs associated with knee injury.[6],[7],[8],[9],[10]

Total knee replacement (TKR) is a surgical procedure in which an artificial joint or prosthesis replaces a damaged knee joint. In recent years, knee prosthesis has improved greatly and it has become one of the most reliable joint replacements. The aim of TKR is pain relief and restoration of knee function and mobility. In fact, TKR is widely considered as an effective treatment for end-stage knee degenerative pathologies.[11],[12],[13],[14] It has a great clinical success rate of nearly 95% after 10 years follow-up. The main prosthesis design has to satisfy specific anatomical, biological, mechanical, and industrial requirement.[15],[16],[17],[18]

In recent years, many studies have identified shape differences in the knee within the Caucasian population. The analyses based on shape have identified sex differences in the femoral midshaft, distal femur, and patella. Using automated three-dimensional (3D) morphologic analysis, difference in knee morphology between the sexes has been identified. Reports of anthropometric studies have confirmed that there is a striking difference in knee morphology between males and females, where females having a smaller mediolateral to anteroposterior ratio and more narrow distal femurs.[19],[20],[21],[22] Furthermore, research on implant mismatching carried out in various Asian countries has suggested that the selection of total knee arthroplasty (TKA) implants blindly is not rationalized since their designs are based on morphological data of a limited studied population of a certain region.[23]

It is thus a great concern that if ethnical differences in the shape and size of the distal femur and proximal tibia exist, there is a need to identify the clinical impact of the current TKA design. Thus, it has become essential to compare the resected knees of the subject population with the existing western implants and quantify the morphological differences so that the performance of TKA can be improved. The aim of the present study is to investigate the morphology of the Saudi Arabian population using three-dimensional knee models and compare the results with the similar studies conducted in different parts of the world for judicial selection of commercially available TKA implants.

  Material and Methods Top

This cross-sectional observational study was conducted in the Department of Orthopaedic Surgery, College of Medicine, Majmaah University, Al Majmaah Saudi Arabia, from May 2019 to January 2020. The study was conducted after prior approval from the Central Research Committee, of our university and the Ministry of Health with Central IRB log number: 2019-0057E.

During the study period, a total of 180 magnetic resonance imaging (MRI) scans of knee joints were done and all of them were considered for the study. Out of which, 23 MRI scans of knee joint had posttraumatic changes in the knee and 7 MRI scans were skeletally immature. Hence, out of 180, 30 MRI scans were excluded and the final sample size of 150 was analyzed in this study. The knee joint data included all patients during the study period which included 40 males and 110 females' knees. As skeletal maturity occurs completely at the age of 18 years and there would not much difference in the morphometric measurements of knee joints, all individuals aged from 18 years to 73 years were included in the study.

These data were collected using MRI scans. MRI scans were used as an assessment tool to study the bony structures and soft tissues, Patients in whom ligament and meniscus injury was identified on MRI were excluded from the study. Only complete and fully ossified bones were included and knee joints with any fracture, unossified or pathological abnormalities such as tumors, deformities, congenital deformities, and metabolic diseases of bones were excluded from this study.

MRI scans of 150 normal subject's dataset of knee joints were obtained from the hospital which covers all geographical regions of Al Majmaah province. The total number of scanning slices was 120 and the range of scanning covered the complete knee joints of both legs with the knee in full extension. The slice thickness was 3 mm. The Digital Imaging and Communications in Medicine (DICOM) images were loaded to 3D SLICER, which is an advanced software platform for the analysis (including registration and interactive segmentation) and visualization (including volume rendering) of medical images and for research in image-guided therapy was used for accurate extraction of all parameters.[24]

Magnetic resonance imaging study

In this study, about 13 morphological features measured were tibia anteroposterior (tAP), tibia medial condyle anteroposterior (tMAP), tibia lateral condyle anteroposterior (tLAP), and tibia medial-lateral (tML), femur epicondylar width (fEW), femur medial condyle anteroposterior (fMAP), femur lateral condyle anteroposterior (fLAP), femoral mediolateral length (fML), femur medial condyle width (fMW), femur lateral condyle width (fLW), intercondylar fossa width (ICW), intercondylar fossa height (ICH), and femoral aspect ratio (ration of femoral ML/AP). To avoid interobserver errors, the measurements were extracted using a highly specific software, namely 3D SLICER using DICOM images in three different view planes such as transverse plane, sagittal plane, and coronal plane of the scan and the same is presented in [Figure 1]a, [Figure 1]b, [Figure 1]c.
Figure 1: (a) Transverse plane view femur. (b) Coronal plane view femur. (c) Sagittal plane view femur

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Femoral cuts

The distal femur plane is selected 9 mm above the most inferior point of femoral condyles in the sagittal plane, which is represented in [Figure 2]a. The posterior condylar axis (PCA) is represented in [Figure 2]b. PCA is the line tangent to the most posterior part of the medial and lateral condyles and this axis is made as the horizontal reference.

Transepicondylar axis (TEA) is measured and it is the distance between the lateral and medial epicondyles. fMAP, fLAP, and fML are illustrated in [Figure 2]c. The femur lateral condyle is measured at the level of the narrowest width of the intercondylar notch in the lateral condyle. Femur medial and lateral condyle is measured at the level of the narrowest width of the intercondylar notch in medial condyle as shown in [Figure 2]c and [Figure 2]d. ICH is the distance between the most anterior point in the intercondylar notch to the point on the PCA and this measurement is taken perpendicular to the PCA as shown in [Figure 2]e. The femoral characteristics are expressed in [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e.
Figure 2: (a) Distal femur plane. (b) Posterior condylar axis. (c) Transepicondylar axis of the femur. (d) Femur lateral and medial condyles. (e) Intercondylar fossa width and height

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A line is drawn at the most inferior part of the femoral condyles. A line parallel to this line at the level of the popliteal groove is shown in [Figure 2]e, where the notch width, medial condyle width (MCW), and lateral condyle width (LCW) were measured as shown in [Figure 2]d. Femoral condyle anteroposterior diameter is measured at a section of axial slice where the maximum anteroposterior diameter of lateral condyle is present. A horizontal line is drawn touching both the posterior surfaces of medial and lateral femoral condyles. The femoral mediolateral length (fML) was referenced by the femoral epicondyle axis, defined as the most salient point between the medial and lateral attachment on the femoral condyle. The femoral medial condyle anteroposterior length (fMAP) was defined as the distance from the most anterior point on the femur medial condyle to the posterior condylar line. The femoral lateral condyle anteroposterior length (fLAP) was taken as the distance from the most anterior point on the femur lateral condyle, [Figure 2]c.

The intercondylar fossa height (FH) is the perpendicular distance from the apex of the notch to the horizontal line at the level of the articular margins of the medial and lateral femoral condyles. It is illustrated in [Figure 2]e.

Tibial cuts

The tML was the maximum length between medial and lateral tibia plateau, parallel to the axis of the femoral condyle. The tibial lateral anteroposterior length (tLAP) was the length from the anterior lateral tibia plateau to the posterior plateau. The tibial medial anteroposterior length (tMAP) was the length from the anterior medial tibia plateau to the posterior plateau, which are illustrated in [Figure 3]a and [Figure 3]b. The femoral aspect ratio (fML/fAP) and tibial aspect ratio (tML/tAP) were considered in our study to interpreting the results of knee shape. All measurements were recorded in millimeters.
Figure 3: (a) Proximal tibial plane. (b) Axial plane of the tibia

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The resected femur was oriented perpendicular to the transverse plane and all measurements were performed on this distal resection plane. The mediolateral axis was taken as the TEA, a line connecting the lateral epicondylar prominence and the medial epicondylar prominence. Tangents parallel to the TEA and passing through the anterior and posterior extremities were constructed. Distance between two medial and lateral extremities in the resected plane measured collinear to the TEA was defined as the femoral mediolateral width (fML). Distance between two tangents parallel to TEA and passing through anterior and posterior extremities of the distal femur was defined as the femoral Anteroposterior width (fAP).

The resected tibia was oriented perpendicular to the transverse plane and all measurements were performed on this proximal resection plane. The mediolateral axis was constructed parallel to the femoral TEA. Tangents parallel to the TEA and passing through the anterior and posterior extremities were constructed. Distance between medial and lateral extremities in the resected plane measured parallel to the mediolateral axis was defined as tibial mediolateral width (tML). Distance between two tangents parallel to TEA and passing through anterior and posterior extremities of the proximal tibia was defined as tibial anteroposterior width (tAP).


To compare the result of our study (i.e., Saudi Arabian knees morphological measurements) with other reports, an extensive literature survey was carried out by retrieving the literature. The aspect ratios were defined as mentioned above in order to make our data coherent with the anthropometric data of other ethnic groups. The data of various parameters of our measurements were compared with that of Chinese, Caucasian, Japanese, Korean, Germany, France, Brazil, Turkey, Malaysia, and Indian population as shown in [Table 1], [Table 2], [Table 3], [Table 4].
Table 1: Comparison of different parameters studied between Saudi Arabia and other countries

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Table 2: Comparison of different parameters studied between Saudi Arabia and other countries

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Table 3: Comparison of different parameters studied between Saudi Arabia and other countries

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Table 4: Comparison of sample size, gender ratio, and radiological tool employed among different countries for the measuring the geometry of knee joint

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Statistical analysis

The data were entered and analyzed using SPSS 25.0. Statistics. Armonk, New York, USA: IBM Corp. Frequencies and percentages are reported for qualitative variables, whereas the quantitative variables were expressed as mean ± standard deviation. One-way analysis of variance was applied to compare the Saudi population parameters with the other countries. Post hoc Scheffe test was further applied to observe with group mean differs. P < 0.05 was considered as statistically significant.

  Results Top

The results of the morphological study conducted on Saudi males and females are summarized in [Table 1], [Table 2], [Table 3]. The measurements of tibial parameters include tAP (ranges from 45.95 ± 4.14 for male to 43.13 ± 3.76 for female), tMAP (ranges from 48.23 ± 3.75 for males to 43.87 ± 3.62 for female), tLAP (ranges from 45.17 ± 3.82 for males to 39.90 ± 3.56 for female), and tML (ranges from 75.93 ± 4.32 for male to 68.06 ± 4.88 for female) this data is summarized in [Table 1].

The measurements of femoral characteristics include fEW (ranges from 79.56 ± 4.43 for males to 71.31 ± 4.98 for female), fMAP (ranges from 58.83 ± 4.21 for males to 53.16 ± 3.72 for female), fLAP (ranges from 61.26 ± 3.82 for males to 56.00 ± 3.27 for female), fML (ranges from 72.61 ± 5.23 for males to 65.09 ± 4.71 for female), fMW (ranges from 24.70 ± 2.83 for male to 26.35 ± 3.83 for female), ICW (ranges from 22.16 ± 2.78 for males to 20.24 ± 2.37 for female), ICH (ranges from 30.13 ± 3.89 for males to 25.95 ± 3.55 for female), femoral aspect ratio, ML/AP (ranges from 1.18 ± 0.08 for males to 1.15 ± 0.06 for female) (P < 0.001) corresponding data is summarized in [Table 1]. The result of the present study was compared with the other similar studies which are shown in [Table 1], [Table 2], [Table 3].

  Discussion Top

The present study entitled, “Morphometric Study of Knee Joint in Saudi Arabian Population by MRI scan Images” hereby conducted in 150 study subjects of both sex and varied age group in the Saudi population. From the result, it is clear that all the studied parameters of tibia, i.e., tAP, tMAP, tLAP, and tML have larger size in males than in females. Similar results are seen in all measurements of the femur, i.e., fEW, fMAP, fLAP, fML, fMW, ICW, ICH, and femoral aspect ratio (ML/AP) (P < 0.001). However, fLW was high in females than studied males (P < 0.001). Our results are in good compliance with the results reported in earlier studies conducted in Chinese,[25] Caucasian,[25] Japanese,[26] Korean,[27] Germany,[15] France,[28] Brazil,[29] Turkey,[30] Malaysia,[31] and Indian[32] population.

Saudi males had lower tAP, tMAP, tLAP, fLAP, fMAP, fEW, fML, fMW, ICH, and femoral aspect ratio (ML/AP) than those of Chinese, Caucasian, Japan, Germany, France, Brazil, Turkey, Malaysian, and Indian population. The tLAP value of males in Saudi Arabia was found to be larger than that of Korean. Similar results were seen with the fMW value of Saudi male and Korean male studied. The fLW value of Saudi males was less than that of Indian males. The tML value of Saudi males was found to be greater than that of Chinese and Caucasian reports, however this was lower in comparison to that exhibited by Korean, Japanese, Germany, Brazilian, and Turkey. Report on tML value was not available in France, Malaysia, and Indian studies. Similar results were seen in ICW values where this parameter was found to have higher value than Chinese, Caucasian, Korean, and German males; however, the result of similar parameters was not studied in the reports from Germany, France, Malaysia, Japan, and India.

Saudi females had lower value of a tMAP, tLAP, fMAP, and fLAP than the other compared reports. The fLW and fMW values for Saudi females were found to be higher in comparison to Korean and German females. The value of Saudi females was however very less than that of Indian females. Reports from the rest of the countries do not include data of fLW and fMW values for females.

The ICW of Saudi females was found to be greater than that of Chinese, Caucasian, Korean, Turkey, and German females, however reports from Japan, France, Brazil, Malaysia, and India do not include this parameter. The ICH of Saudi females was found to be smaller than that of Chinese, Caucasian, Korean, Turkey, and German females; however, reports from Japan, France, Brazil, Malaysia, and India do not include these parameters. The tAP value for Saudi females was found to be smaller than the reported values from all other countries except Germany and France which are otherwise not reported. Data of tML value for Saudi females were found to be greater than tML value from all other countries. The tML was significantly and positively correlated with the tMAP, while the aspect ratio (tML/tMAP) was significantly and negatively correlated with the tMAP. The epicondylar and fML value for Saudi females were lower in comparison to those from Turkey. However, this parameter was not studied in other countries. Based on the reported data, the femoral aspect ratio for females was calculated which comes to be lower for Saudi females than that of other countries, however due to lack of data, it could not be calculated for Korean females. The fML was significantly and positively correlated with the fMAP while the fML/fMAP was significantly and negatively correlated with the fMAP. It is also observed that gender showed significant differences in aspect ratio (tML/tMAP) and nationality showed significant differences in aspect ratio (tML/tMAP) in both males and females. These significant differences in aspect ratio can facilitate the tibial component of TKR prosthesis to be designed more specifically based on gender and ethnicity.

  Conclusion Top

The study is a milestone in the rational designing of knee prostheses for the patients undergoing TKR. The study suggested that not only the TKA prosthesis design should consider the sex factor but also the nationality differences. The morphological differences of femora between Saudi and other countries males and females (P < 0.001) cannot be accounted by the differences in size alone, but also the shape variation between these nationalities. An overhanging prosthesis is more likely to cause soft-tissue imbalance and unfavorable patella-femoral stress distribution. It is often needed to downsize the femoral components during TKA operation to avoid this clinical overcome. However, this may also result in an undesirable complication. For example, notching of the anterior cortex can predispose to periprosthetic fractures and over resection of the posterior femoral condyles resulting in an imbalance between the flexion and extension gaps. Therefore, it is important to consider the morphological factor of the tibia and femur as a whole for the prosthesis design.

The limitations of the present study were a limited study population, a larger study population could have been far better in giving good comparison of study results, and could have been more effective as identical parameters were assessed using similar techniques such as MRI or computed tomography scan.

From the study, we can draw a conclusion that the MRI technique has emerged as a promising semi-quantitative and quantitative approaches for imaging the morphology of the knee. Still the comparison of similar parameters under nonenhanced MRI and contrast-enhanced MRI could enable more accurate assessment for the study of knee morphology.


All the authors of the research article are thankful to the Deanship of Scientific Research, Majmaah University, KSA, for giving us the support and opportunity to conduct this research. We also thank all the medical practitioners of King Khalid general hospital and Biostatician Dr. Waqas Sami from the College of Medicine, Majmaah University, KSA, and all the people who took part in this study.

Financial support and sponsorship

The authors are highly thankful to the Deanship of Scientific Research, Majmaah University, KSA for the financial assistance provided for the conduction of the present study under the project number: 1439-78.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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