{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T20:15:57Z","timestamp":1778876157779,"version":"3.51.4"},"reference-count":25,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T00:00:00Z","timestamp":1778803200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T00:00:00Z","timestamp":1778803200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["82371927"],"award-info":[{"award-number":["82371927"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100001809","name":"National Natural Science Foundation of China","doi-asserted-by":"publisher","award":["82502328"],"award-info":[{"award-number":["82502328"]}],"id":[{"id":"10.13039\/501100001809","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["esskajournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Knee surg. sports traumatol. arthrosc."],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>To determine whether weight\u2010bearing three\u2010dimensional (3D) spatial hip\u2013knee\u2013ankle (HKA) alignment exhibits severity\u2010dependent changes across knee osteoarthritis (KOA) stages, whether it is more strongly associated with joint structure and symptoms than conventional two\u2010dimensional (2D) HKA alignment, and whether these 3D alignment patterns correspond to distinct cartilage stress distributions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This prospective study enroled 151 patients (296 knees) with radiographic KOA (Kellgren\u2013Lawrence [KL] Grades 1\u20134). Spatial HKA angles, defined as 3D mechanical alignment angles without projection onto any anatomical plane, were measured using weight\u2010bearing cone\u2010beam computed tomography (CBCT) and compared with conventional 2D radiographic HKA angles. Knees were classified into 3D alignment phenotypes based on their alignment orientation: valgus\u2013extension, valgus\u2013flexion, varus\u2013extension and varus\u2013flexion. Joint space narrowing and Western Ontario and McMaster Universities osteoarthritis index (WOMAC) scores were assessed. For each KL grade, the average spatial HKA orientation was incorporated into finite element models to estimate cartilage stress distributions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Spatial HKA angles showed stronger correlations with joint space narrowing (\n                      <jats:italic>r<\/jats:italic>\n                      \u2009=\u20090.52\u20130.61) and WOMAC scores (\n                      <jats:italic>r<\/jats:italic>\n                      \u2009=\u20090.45\u20130.56) than single\u2010plane alignment measures. Spatial HKA angles increased progressively across KL grades. Knees with mild osteoarthritis clustered near neutral, whereas knees with KL Grades 3 and 4 predominantly shifted toward a varus\u2013flexion pattern. The prevalence of varus\u2013flexion alignment increased markedly with severity, reaching 67.2% and 89.1% in KL Grades 3 and 4, respectively. Medial and posterior cartilage stress increased with severe varus\u2013flexion alignment.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The spatial HKA angle derived from weight\u2010bearing CBCT captured severity\u2010dependent multiplanar malalignment and demonstrated stronger structural and symptomatic associations than 2D measures. Advanced KOA was characterized by a dominant varus\u2013flexion alignment phenotype, associated with increased medial and posterior cartilage stress.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Level of Evidence<\/jats:title>\n                    <jats:p>Level IV.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ksa.70435","type":"journal-article","created":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T19:48:03Z","timestamp":1778874483000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Severity\u2010dependent shift in knee osteoarthritis toward a dominant varus\u2013flexion alignment phenotype on weight\u2010bearing 3D imaging"],"prefix":"10.1002","author":[{"given":"Zejun","family":"Liang","sequence":"first","affiliation":[{"name":"Department of Radiology, West China Hospital Sichuan University Chengdu Sichuan China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jianrong","family":"He","sequence":"additional","affiliation":[{"name":"Department of Radiology, West China Hospital Sichuan University Chengdu Sichuan China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fanzhuang","family":"Rong","sequence":"additional","affiliation":[{"name":"R&amp;D Department Shenzhen Angell Technology Co. Ltd. Shenzhen Guangdong China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hanyu","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Purchasing and Supply, West China Hospital Sichuan University Chengdu Sichuan China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yiteng","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Radiology, West China Hospital Sichuan University Chengdu Sichuan China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zengtong","family":"Chen","sequence":"additional","affiliation":[{"name":"R&amp;D Department Shenzhen Angell Technology Co. Ltd. Shenzhen Guangdong China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yu","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Radiology, West China Hospital Sichuan University Chengdu Sichuan China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xiaocheng","family":"Yu","sequence":"additional","affiliation":[{"name":"R&amp;D Department Shenzhen Angell Technology Co. Ltd. Shenzhen Guangdong China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Meng","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Radiology, West China Hospital Sichuan University Chengdu Sichuan China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Han","family":"Zheng","sequence":"additional","affiliation":[{"name":"R&amp;D Department Shenzhen Angell Technology Co. Ltd. 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