Abstract: Objective To study the rotation of femoral component and tibial component with CT and evaluate the relationship between patellofemoral complications and rotational alignment of the components. Methods Thirty patients with isolated patellofemoral complications after total knee arthroplasty were compared with 20 patients with well functioning total knee replacements free of patellofemoral complications. The epicondylar axis and tibial tubercle were used as references on CT scans to quantify the rotational alignment of the femoral and tibial components. Results Patients with patellofemoral complications had excessive combined (tibial plus femoral) internal component rotation, which was directly proportional to the severity of the patellofemoral complications. Mild combined internal rotation (1°-4°) was correlated with patellar and lateral tracking tilting, moderate rotation (3°-8°) with patellar subluxation, and severe rotation (7°-17°) with early patellar dislocation or late patellar prosthesis failure. The control group had combined external rotation of 10°-0°. Conclusions The direct correlation of combined internal component rotation to the severity of the patellofemoral complication suggests that internal component rotation may be the predominant cause of patellofemoral complications in patients with normal axis alignment. CT scans can be used intraoperatively and postoperatively to determine whether the rotational malalignment is present to require revision of one or both components.