Practice Patterns in Femoral Rotational Decision-Making During Total Knee Arthroplasty: A Cross-Sectional Survey Among Brazilian Knee Surgeons

Background Surgeons use different references, balancing strategies, and technology to determine femoral component rotation in total knee arthroplasty. This survey described reported practice patterns among Brazilian knee surgeons. Methods A cross-sectional electronic survey was conducted among knee surgeons practicing in Brazil in February 2026. The questionnaire assessed alignment approach, strategy for femoral rotation and ligament balance, main rotational reference, frequency of use of individual references, scenarios avoiding isolated posterior condylar referencing, and availability and routine use of technology-assisted tools. Associations with routine robotic and navigation use were assessed using Fisher's exact test with odds ratios and 95% confidence intervals. Results Seventy-nine surgeons responded. Mechanical alignment was most common (64.6%). Hybrid technique (48.1%) and gap balancing (36.7%) were more frequent than measured resection alone (13.9%). The most frequent single method was combining references (34.2%), and respondents routinely used a median of 4 individual references (interquartile range, 3-5); only 6 (7.6%) routinely used 1 reference. Isolated posterior condylar referencing was avoided in lateral condylar hypoplasia (86.1%) and severe valgus (70.9%). Robotic instrumentation was available to 64.6% and used routinely by 25.3%; its association with volume attenuated among surgeons with access, whereas its association with named nonmechanical alignment responses persisted after individualized case-by-case responses were excluded. Conclusions Reported femoral rotational decision-making most commonly involved several references and balance-oriented strategies rather than a single landmark. Technology adoption reflected both access and use. These findings describe reported practice rather than measured rotational outcomes or evidence of superiority.