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Kenanidis E, Milonakis N, Maslaris A, Tsiridis E. Robotic evaluation of articular laxity (REAL) classification: a new intraoperative knee soft-tissue laxity classification using ROSA robotic software. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2025; 35:139. [PMID: 40156716 PMCID: PMC11954700 DOI: 10.1007/s00590-025-04265-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Accepted: 03/12/2025] [Indexed: 04/01/2025]
Abstract
PURPOSE Currently, there is no widely accepted method for measuring soft-tissue laxity and defining a balanced total knee arthroplasty (TKA). We aim to evaluate whether robotic technology can facilitate the categorization of intraoperative knee laxity. METHODS Our study was conducted in two phases. A senior surgeon performed imageless robotically assisted TKAs (ra-TKAs) using functional alignment. The first phase included 120 patients. Following the surgical approach, the medial and lateral soft-tissue laxity was recorded in extension and 90° flexion. The distribution of the difference and sum of laxities in extension and 90° flexion was assessed to classify laxity phenotypes. The second phase validated the classification in 102 additional ra-TKAs. Laxity phenotypes were evaluated at the start and end of the procedure. RESULTS Laxity difference followed a normal distribution, facilitating categorization into three groups, with a standard deviation of 2.5 mm. Three categories of mediolateral laxity severity difference were established: < 2.5 mm, 2.5-5 mm, and > 5 mm. These laxity groups were coded in extension as 1, 2, and 3 and in flexion as A, B, and C, respectively. Nine laxity phenotypes emerged from the combination of the extension and flexion categories (1A-C, 2A-C, and 3A-C). Phenotypes 1A and 1B were the most common at the operation' beginning, while phenotypes 3B and 1C were the rarest. At the end of the operation, 93% were categorized as class 1A and 1B, defining the "balanced area". CONCLUSION Our study recognized nine intraoperative soft-tissue knee laxity phenotypes, potentially laying the groundwork for a surgical consensus on knee balancing.
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Affiliation(s)
- Eustathios Kenanidis
- Academic Orthopaedic Department, General Hospital Papageorgiou, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece.
- Center for Interdisciplinary Research and Innovation (CIRI), Centre of Orthopaedic and Regenerative Medicine (CORE), Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nikolaos Milonakis
- Academic Orthopaedic Department, General Hospital Papageorgiou, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI), Centre of Orthopaedic and Regenerative Medicine (CORE), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandros Maslaris
- Academic Orthopaedic Department, General Hospital Papageorgiou, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI), Centre of Orthopaedic and Regenerative Medicine (CORE), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftherios Tsiridis
- Academic Orthopaedic Department, General Hospital Papageorgiou, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI), Centre of Orthopaedic and Regenerative Medicine (CORE), Aristotle University of Thessaloniki, Thessaloniki, Greece
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Cheng Q, Wang Y, Liu Y, Mu J, Wang Z, Lin X, Yin G, Li S. A novel grid-assisted pie-crusting technique for achieving soft tissue balance in total knee arthroplasty. Front Surg 2025; 12:1566642. [PMID: 40171007 PMCID: PMC11958710 DOI: 10.3389/fsurg.2025.1566642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2025] [Accepted: 02/28/2025] [Indexed: 04/03/2025] Open
Abstract
Background To evaluate the effectiveness of a novel grid-based pie-crusting technique for soft tissue release at different locations of the medial collateral ligament (MCL) during total knee arthroplasty (TKA). Methods Twelve fresh-frozen cadaveric knee joints were dissected. A novel grid was designed to cover the entire surface of the MCL. The specimens were divided into two groups: Group A, where only the central portion of the ligament underwent pie-crusting release, and Group B, where selective release targeted the femoral and tibial attachment points of the MCL. Mechanical testing was conducted via a Shimadzu AG-X precision instrument. Each group underwent twelve punctures, and data were collected to calculate deformation and stiffness metrics. The mean elongation and stiffness values were analyzed, and regression analysis was performed to evaluate correlations between the number of punctures and changes in elongation and stiffness. Results No significant differences in initial stiffness were observed between the two groups (P = 0.42). Following 12 punctures, the stiffness decreased by 6.47 ± 4.06 N/mm in Group A and 1.08 ± 1.32 N/mm in Group B (P = 0.006). Despite this disparity in stiffness reduction, no significant differences in MCL elongation were observed between the groups. Group A demonstrated an elongation of 0.171 ± 0.180 mm, whereas Group B exhibited an elongation of 0.164 ± 0.123 mm (P = 0.47). A linear relationship was identified between stiffness reduction and the number of punctures (R 2 = 0.61 ± 0.29), as well as between ligament elongation and the number of punctures (R 2 = 0.89 ± 0.09). Conclusion The grid-assisted pie-crusting technique, which uniformly covers the MCL, enables precise and controlled soft tissue release. This approach provides valuable insights for clinicians performing MCL release during TKA, facilitating improved soft tissue balance and potentially enhancing surgical outcomes.
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Affiliation(s)
- Qisheng Cheng
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
| | - Yang Wang
- The First Operation Room, The First Hospital of Jilin University, Changchun, China
| | - Yi Liu
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
| | - Jie Mu
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
| | - Zhenyan Wang
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
| | - Xu Lin
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
| | - Guanchen Yin
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
| | - Shuqiang Li
- Department of Orthopedic Center, The First Hospital of Jilin University, Changchun, China
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Tuengler TL, Sterneder CM, Haralambiev L, Boettner F. What does the patients' perception of alignment tell us about alignment targets in total knee arthroplasty? Arch Orthop Trauma Surg 2025; 145:145. [PMID: 39862299 DOI: 10.1007/s00402-025-05765-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Accepted: 01/15/2025] [Indexed: 01/27/2025]
Abstract
INTRODUCTION Knee alignment significantly impacts the outcome of total knee arthroplasty (TKA). Understanding patient perceptions of their knee alignment in relation to objective measurements is essential to ensure optimal surgical outcomes and to meet patients' expectations. This study reports patients' perception of pre- and postoperative knee alignment in relation to radiographic alignment measurements. MATERIALS AND METHODS The study included 141 patients with primary osteoarthritis of the knee (mean age: 65.4 years, BMI: 30.8). Patients categorized their knee alignment before and after surgery using a picture-based rating scale: very bow-legged (> 10° varus), bow-legged (2.1-10° varus), straight (2° varus to 2° valgus), knock-kneed (2.1-10° valgus), and very knock-kneed (> 10° valgus). Hip-to-ankle films were performed to compared actual knee alignment with patients' assessments retrospectively. RESULTS Preoperatively, 15.1% of patients with severe varus, 55.6% with varus, and 86.7% with neutral alignment perceived their knees as straight. None of the patients with valgus or severe valgus alignment considered their knees as straight. Overall, 40.2% of patients with radiographic varus alignment classified their knees as straight, while nobody with valgus alignment did. Postoperatively patients with preoperative varus considered their knees as straight with an average of 1.8 ± 1.7 deg. mechanical varus alignment, while patients with preoperative valgus alignment considered their knees straight with an average of 0.4 ± 0.9 deg. mechanical valgus alignment. CONCLUSION Patients predominantly desire a straight knee postoperatively, however, most patients tend to perceive some varus alignment as straight. This is most common in patients with up to 5 degrees of varus deformity and suggests that a restricted or inverse kinematic alignment with up to 5 degrees of varus can meet the expectations of most patients. In contrast, patients with valgus deformity are sensitive to any remaining valgus deformity and leaving the knees in more than 2 deg. of valgus will unlikely satisfy the patients' overall desire for a straight knee after surgery.
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Affiliation(s)
- Tim Ludwig Tuengler
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, USA
| | | | - Lyubomir Haralambiev
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, USA
- Department of Orthopedics, Greifswald University Hospital, Greifswald, Germany
| | - Friedrich Boettner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, USA.
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Pierre-Henri V, Vincent G, Bertrand B, Frédéric F, Thomas N, Rémi P. Can robotic arm-assisted total knee arthroplasty be applied to valgus deformity. Arch Orthop Trauma Surg 2025; 145:137. [PMID: 39849167 DOI: 10.1007/s00402-025-05756-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 01/07/2025] [Indexed: 01/25/2025]
Abstract
INTRODUCTION Total knee arthroplasty (TKA) in valgus knees is challenging. Optimal ligament balance, implant neutral or moderate valgus alignment are crucial but conventional instrumentations usually lead to outliers. Robotic arm assisted TKA (RATKA) advantages could answer this challenge. Objectives were to assess RATKA frontal alignment accuracy for valgus knees, rotational femoral component reliability, revision surgery rate and functional outcomes for this population. METHODS This study is based on a continuous series of 454 RATKA. Implants were positioned according to a patient-specific alignment and postero-stabilised inserts were used. Valgus values, range of motion, KOOS and revision surgery rates were assessed at one-year postoperative. Femoral component rotation was analysed intraoperatively. RESULTS MAKO navigation system confirmed valgus preoperative deformity for 34 patients. Mean postoperative valgus value was - 1.5°±1.53 (range, -5 to 1), 85% patients had a residual valgus between 0 and - 3°, 97% of patients had a difference < 3° between valgus planned and valgus measured at one year postoperatively. Mean femoral rotation was + 2.65°±1.87 (range, 0 to 6.8°) of external rotation related to posterior condylar angle. No revision surgery has been performed. Mean KOOS value at one year was 80.79. 76% of patients (n = 26) had a good (70-80) or excellent (> 80) KOOS score. Mean flexion value was 133°±12 (range, 100 to 140). CONCLUSION RATKA can be applicable in valgus knee, offering high precision in component positioning with very few outliers. It also facilitates component rotation positioning, providing excellent functional results and ROM.
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Affiliation(s)
- Vermorel Pierre-Henri
- Department of Orthopaedic Surgery, University Hospital centre (Saint Etienne), Avenue Albert Raimond, Saint-priest-en-Jarez, 42270, France.
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université Jean Monnet Saint-Etienne, CHU Saint-Etienne, Lyon 1, Université Savoie Mont-Blanc, Saint-Etienne, F-42023, France.
| | - Genestoux Vincent
- Department of Orthopaedic Surgery, University Hospital centre (Saint Etienne), Avenue Albert Raimond, Saint-priest-en-Jarez, 42270, France
| | - Boyer Bertrand
- Department of Orthopaedic Surgery, University Hospital centre (Saint Etienne), Avenue Albert Raimond, Saint-priest-en-Jarez, 42270, France
| | - Farizon Frédéric
- Department of Orthopaedic Surgery, University Hospital centre (Saint Etienne), Avenue Albert Raimond, Saint-priest-en-Jarez, 42270, France
| | - Neri Thomas
- Department of Orthopaedic Surgery, University Hospital centre (Saint Etienne), Avenue Albert Raimond, Saint-priest-en-Jarez, 42270, France
- Laboratoire Interuniversitaire de Biologie de la Motricité, Université Jean Monnet Saint-Etienne, CHU Saint-Etienne, Lyon 1, Université Savoie Mont-Blanc, Saint-Etienne, F-42023, France
| | - Philippot Rémi
- Department of Orthopaedic Surgery, University Hospital centre (Saint Etienne), Avenue Albert Raimond, Saint-priest-en-Jarez, 42270, France
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Dhungana H, Jangid S, Goyal M. Alignment Techniques in Total Knee Arthroplasty: Where do We Stand Today? CHINESE MEDICAL SCIENCES JOURNAL = CHUNG-KUO I HSUEH K'O HSUEH TSA CHIH 2024; 39:217-225. [PMID: 39099407 DOI: 10.24920/004372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Achieving optimal alignment in total knee arthroplasty (TKA) is a critical factor in ensuring optimal outcomes and long-term implant survival. Traditionally, mechanical alignment has been favored to achieve neutral post-operative joint alignment. However, contemporary approaches, such as kinematic alignments and hybrid techniques including adjusted mechanical, restricted kinematic, inverse kinematic, and functional alignments, are gaining attention for their ability to restore native joint kinematics and anatomical alignment, potentially leading to enhanced functional outcomes and greater patient satisfaction. The ongoing debate on optimal alignment strategies considers the following factors: long-term implant durability, functional improvement, and resolution of individual anatomical variations. Furthermore, advancements of computer-navigated and robotic-assisted surgery have augmented the precision in implant positioning and objective measurements of soft tissue balance. Despite ongoing debates on balancing implant longevity and functional outcomes, there is an increasing advocacy for personalized alignment strategies that are tailored to individual anatomical variations. This review evaluates the spectrum of various alignment techniques in TKA, including mechanical alignment, patient-specific kinematic approaches, and emerging hybrid methods. Each technique is scrutinized based on its fundamental principles, procedural techniques, inherent advantages, and potential limitations, while identifying significant clinical gaps that underscore the need for further investigation.
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Affiliation(s)
- Hemanta Dhungana
- Department of Orthopedics, Fortis Hospital, Gurgaon, Haryana, India.
| | - Subhash Jangid
- Department of Orthopedics, Fortis Hospital, Gurgaon, Haryana, India
| | - Meghal Goyal
- Department of Orthopedics, Fortis Hospital, Gurgaon, Haryana, India
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Gorur A, Czerwonka N, El-Othmani MM, Held MB, Neuwirth AL, Geller JA. Outcomes of Image-Free Robotic Assisted Total Knee Arthroplasty in Patients Who Have Valgus Knee Deformities. J Arthroplasty 2024; 39:S235-S240. [PMID: 38518959 DOI: 10.1016/j.arth.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Valgus knee deformities pose a unique challenge in total knee arthroplasty (TKA) due to the complexity of achieving ligamentous balance and satisfactory alignment compared to varus or neutral deformities. Robotic-assisted (RA) TKA could aid in achieving improved component alignment and balance. METHODS We retrospectively evaluated a matched cohort of patients to compare image-free RA-TKA (n = 44) versus conventional manual (CM) TKA (n = 30) techniques in patients who have valgus deformity of 5 to 15 degrees, including radiographic and patient-reported outcomes measures (PROMs) over a 3-year period. The patient reported outcome measures (PROMs) studied to determine outcomes were: Western Ontario McMaster University Arthritis Index, Knee Society Score-Function Score, and Short Form 12-item Survey. RESULTS Overall, the RA-TKA cohort showed faster improvement in PROMs (37.16 ± 1 8.8 versus 25.74 ± 17.7, P = .02), shorter length of stay (1.41 versus 2.29 days, P = .02), and shorter operating room times (120.79 versus 123.67 minutes, P = .02) than CM-TK). Additionally, there was no difference in the use of primary versus varus-valgus constrained polyethylene liners between the cohorts. CONCLUSIONS In this investigation, RA-TKA yielded a slightly faster patient recovery, more objective measurements of ligamentous balance, and proved noninferior PROMs compared to CM-TKA for preoperative valgus knee deformities.
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Affiliation(s)
- Alaka Gorur
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Natalia Czerwonka
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Mouhanad M El-Othmani
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael B Held
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander L Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Chaiyakit P, Wattanapreechanon P. Coronal plane stability of cruciate-retaining total knee arthroplasty in valgus gonarthrosis patients: A mid-term evaluation using stress radiographs. World J Orthop 2024; 15:764-772. [PMID: 39165866 PMCID: PMC11331327 DOI: 10.5312/wjo.v15.i8.764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/01/2024] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) using implants with a high level of constraint has generally been recommended for patients with osteoarthritis (OA) who have valgus alignment. However, studies have reported favorable outcomes even with cruciate-retaining (CR) implants. AIM To evaluate the coronal plane stability of CR-TKA in patients with valgus OA at the mid-term follow-up. METHODS Patients with primary valgus OA of the knee who underwent TKA from January 2014 to January 2021 were evaluated through stress radiography using a digital stress device with 100 N of force on both the medial and lateral side. Gap openings and degrees of angulation change were determined. Descriptive statistical analysis was performed for both continuous and categorical variables. Inter-rater reliability of the radiographic measurements was evaluated using Cronbach's alpha. RESULTS This study included 25 patients (28 knees) with a mean preoperative mechanical valgus axis of 11.3 (3.6-27.3) degrees. The mean follow-up duration was 3.4 (1.04-7.4) years. Stress radiographs showed a median varus and valgus gap opening of 1.6 (IQR 0.6-3.0) mm and 1.7 (IQR 1.3-2.3) mm and varus and valgus angulation changes of 2.5 (IQR 1.3-4.8) degrees and 2.3 (IQR 2.0-3.6) degrees, respectively. No clinical signs of instability, implant loosening, or revision due to instability were observed throughout this case series. CONCLUSION The present study demonstrated that using CR-TKA for patients with valgus OA of the knee promoted excellent coronal plane stability.
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Affiliation(s)
- Pruk Chaiyakit
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand
| | - Pichayut Wattanapreechanon
- Department of Orthopaedics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand
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MacDessi SJ, van de Graaf VA, Wood JA, Griffiths-Jones W, Bellemans J, Chen DB. Not all knees are the same. Bone Joint J 2024; 106-B:525-531. [PMID: 38821506 DOI: 10.1302/0301-620x.106b6.bjj-2023-1292.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
The aim of mechanical alignment in total knee arthroplasty is to align all knees into a fixed neutral position, even though not all knees are the same. As a result, mechanical alignment often alters a patient's constitutional alignment and joint line obliquity, resulting in soft-tissue imbalance. This annotation provides an overview of how the Coronal Plane Alignment of the Knee (CPAK) classification can be used to predict imbalance with mechanical alignment, and then offers practical guidance for bone balancing, minimizing the need for soft-tissue releases.
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Affiliation(s)
- Samuel J MacDessi
- CPAK Research Group, Sydney, Australia
- School of Clinical Medicine, University of NSW Medicine and Health, Sydney, Australia
- Sydney Knee Specialists, Kogarah, Australia
| | | | - Jil A Wood
- Sydney Knee Specialists, Kogarah, Australia
| | | | - Johan Bellemans
- CPAK Research Group, Sydney, Australia
- University Hasselt, ZOL Hospitals Genk, ArthroClinic Leuven, Leuven, Belgium
| | - Darren B Chen
- CPAK Research Group, Sydney, Australia
- Sydney Knee Specialists, Kogarah, Australia
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Rezaei A, Moon J, Lichtig A, Mera B, Drake B, Choubey AS, Kim S, Tueni N, Piponov H, Koh J, Karam J, Amirouche F. Precision soft tissue balancing: grid-assisted pie-crusting in total knee arthroplasty. Front Surg 2024; 11:1331902. [PMID: 38645507 PMCID: PMC11026714 DOI: 10.3389/fsurg.2024.1331902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction The varus and valgus knee deformities result from imbalance in tension between medial and lateral soft tissue compartments. These conditions need to be addressed during total knee arthroplasty (TKA). However, there is no consensus on optimal soft-tissue release techniques for correcting varus and valgus deformities during TKA. We assessed the efficacy of a novel grid-based pie-crusting technique on soft-tissue release. Methods Cadaver knees were dissected, leaving only the femur and tibia connected by an isolated MCL or the femur and fibula connected by an isolated LCL. Bone cuts were made as performed during primary TKA. Mechanical testing was performed using an MTS machine. A 3D-printed 12-hole grid was placed directly over the MCL and LCL. Using an 18-gauge needle, horizontal in-out perforations were made 3 mm apart. Deformation and stiffness of the ligaments were collected after every 2 perforations. Means were calculated, and regression analyses were performed. Results A total of 7 MCL and 6 LCL knees were included in our analysis. The mean medial femorotibial (MFT) space increased from 6.018 ± 1.4 mm-7.078 ± 1.414 mm (R2 = 0.937) following 12 perforations. The mean MCL stiffness decreased from 32.15 N/mm-26.57 N/mm (R2 = 0.965). For the LCL group, the mean gap between the femur and fibula increased from 4.287 mm-4.550 mm following 8 perforations. The mean LCL stiffness decreased from 29.955 N/mm-25.851 N/mm. LCL stiffness displayed a strong inverse relationship with the number of holes performed (R2 = 0.988). Discussion Our results suggest that using this novel grid for pie-crusting of the MCL and LCL allows for gradual lengthening of the ligaments without sacrificing their structural integrity. Our proposed technique may serve as a valuable piece in the soft-tissue release toolkit for orthopaedic surgeons performing TKA in varus and valgus deformed knees.
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Affiliation(s)
- Arash Rezaei
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - John Moon
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Asher Lichtig
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Barbara Mera
- University of Illinois College of Medicine, Chicago, IL, United States
| | - Brett Drake
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Apurva S. Choubey
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Sunjung Kim
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Nicole Tueni
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Hristo Piponov
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Jason Koh
- Department of Orthopaedic Surgery, Northshore University Health System, Skokie, IL, United States
| | - Joseph Karam
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
| | - Farid Amirouche
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, IL, United States
- Department of Orthopaedic Surgery, Northshore University Health System, Skokie, IL, United States
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Noguchi T, Hirao M, Okamura G, Tsuiji S, Hashimoto J. Midterm Outcomes After Total Knee Arthroplasty With Lateral Approach for Valgus Knee Deformity in Patients With Rheumatoid Arthritis. Cureus 2024; 16:e58197. [PMID: 38741841 PMCID: PMC11090069 DOI: 10.7759/cureus.58197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Background Valgus knee deformity is often seen in rheumatoid arthritis (RA) cases. Usually, the medial approach has been often utilized for total knee arthroplasty (TKA), even in valgus deformity cases; however, the medial approach is feared to induce further instability in the medial side because it could further break the soft tissue structure, including medial collateral ligament (MCL) and medial patellofemoral ligament (MPFL). Consequently, loosening of the implant, recurrence of valgus knee deformity, and pain due to instability might be induced in the early period after surgery. In this study, a lateral approach for TKA against valgus deformity in RA cases was utilized to avoid further damage on the medial side. Methods Eleven valgus knees in 10 patients with RA (mean age, 61.1 years; mean follow-up, 33.1 months) underwent primary TKA with the lateral approach. Iliotibial band (ITB) dissection and/or peroneal nerve release were performed if necessary. Radiological and clinical investigations were evaluated pre- and postoperatively. Results The average operating time was 106 minutes, which was no longer compared with the time after the medial approach described previously. The extension angle was significantly improved from -15.0 ± 10.2 to -5.5 ± 4.2 degrees (P = 0.03), while the flexion angle showed no significant change (from 111.8 ± 15.9 to 115.0 ± 13.2 degrees). The hip-knee-ankle angle (HKA) was also significantly corrected from -9 ± 4.9 to 0.4 ± 1.7 degrees (P < 0.001). The 2011 Knee Score System (KSS) scores were significantly improved from 6.9 ± 3.4 to 21.5 ± 2.9 (P < 0.001) in symptoms, from 15.6 ± 2.7 to 31.1 ± 4.1 (P < 0.001) in satisfaction, and from 31.5 to 59.5 (P < 0.01) in activity. Conclusion Midterm outcomes after lateral approach TKA were good, and knee alignment was significantly improved. The lateral approach TKA for valgus deformity in patients with RA was not complicated and difficult because it required no additional operating time compared with the medial approach. From the perspective of preventing further damage to the soft tissue structure on the medial side, the lateral approach was meaningful for valgus deformity in patients with RA.
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Affiliation(s)
- Takaaki Noguchi
- Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, JPN
| | - Makoto Hirao
- Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, JPN
| | - Gensuke Okamura
- Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, JPN
| | | | - Jun Hashimoto
- Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, Kawachinagano, JPN
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Kv A, Ramesh G, Chakrapani AS, Akheja S. Appraisal of Clinical Improvement With Total Knee Arthroplasty in Valgus Knee Deformities: A Case Series. Cureus 2024; 16:e58039. [PMID: 38606027 PMCID: PMC11008559 DOI: 10.7759/cureus.58039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction This case series explores the efficacy of unassisted total knee arthroplasty (TKA) in addressing valgus knee deformity secondary to osteoarthritis. The study aims to evaluate functional outcomes pre- and post-surgery using the Knee Society Score (KSS) and radiological assessments in short-term follow-up. Six patients underwent TKA and were evaluated retrospectively. Statistical analysis revealed significant improvements in the angle of deformity, KSS, and range of motion postoperatively. The study underscores the success of TKA in correcting valgus deformity, improving knee function, and enhancing patient satisfaction. TKA is a highly successful treatment for osteoarthritis, providing functional recovery and improved quality of life. However, valgus knee deformity presents a challenge in TKA, affecting approximately 10% of patients. This study aims to assess the functional outcomes of TKA for valgus deformity using KSS and radiological evaluation in short-term follow-up. Materials and methods A retrospective observational study was conducted from November 2022 to December 2023, involving six patients with valgus knee deformity secondary to osteoarthritis. TKA was performed with no technological assistance, and patients were assessed pre- and post-surgery using KSS and radiological measurements. Statistical analysis was performed using paired t-tests. Case description Six patients with grade two valgus deformity underwent technology-unassisted TKA. The postoperative assessment revealed significant improvements in the tibiofemoral angle, KSS, and range of motion. The medial parapatellar approach for TKA was utilized with a standard unconstrained primary TKA prosthesis, resulting in successful correction of deformity and improved knee alignment. Discussion TKA is a widely performed and reliable surgical intervention, with valgus knee deformity posing specific challenges. This study demonstrates the effectiveness of conventional TKA in correcting valgus deformity, improving knee function, and enhancing patient satisfaction in a very small case series. Comparison with previous studies supports the findings of the pre-existing literature, highlighting the importance of appropriate surgical approach and patient selection. Conclusion TKA utilizing a medial parapatellar approach proved effective in our small case series in correcting valgus deformity, improving knee function, and enhancing patient satisfaction. Short-term follow-up reveals significant improvements in stability, posture, and KSS scores. Further assessments and longer-term follow-up are warranted to confirm the long-term effectiveness of this approach.
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Affiliation(s)
- Alok Kv
- Trauma and Orthopaedics, Osmania Medical College, Hyderabad, IND
| | - Garipalli Ramesh
- Trauma and Orthopaedics, Osmania Medical College, Hyderabad, IND
| | | | - Sanyam Akheja
- Trauma and Orthopaedics, Osmania Medical College, Hyderabad, IND
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Xu K, Zhang L, Yu T, Zhao X, Zhang Y. Effect of Knee Valgus Deformity on Symptomatic Venous Thromboembolism and Prosthesis Revision Risk after Total Knee Arthroplasty: A Multicenter Retrospective Study. Orthop Surg 2024; 16:654-661. [PMID: 38342627 PMCID: PMC10925503 DOI: 10.1111/os.13986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 02/13/2024] Open
Abstract
OBJECTIVE Symptomatic venous thromboembolism (VTE) and prosthesis failure are the most serious complications after total knee arthroplasty (TKA). However, whether knee valgus deformity aggravates these complications has not been fully clarified. To study the difference between perioperative symptomatic VTE and prosthesis revision rate in patients with valgus knee osteoarthritis by comparing with patients undergoing TKA for varus deformity and analyze the reasons for revision. At the same time, the distribution and radiographic features of lower extremity deep venous thrombosis were recorded. METHODS The data of patients who underwent TKA in two tertiary hospitals from January 2016 to December 2020 were retrospectively reviewed, and a total of 8917 patients were included. According to preoperative manifestations of knee malformations, all patients were divided into two groups: valgus group (n = 412) and varus group (n = 8505). Main indicators included the incidence of symptomatic VTE and prosthesis revision. Secondary outcomes included general information on operative time, Kellgren and Lawrence score, total hospital stay, and total costs. The patient data of the two groups were analyzed by Pearson chi-square test, Student t test, or Mann-Whitney U test. The revision was evaluated using Kaplan-Meier survival analysis. RESULTS The proportion of valgus knees in TKA patients was 4.62% (412/8917). The incidence of VTE was 6.23‰ (53/8505) and 16.99‰ (7/412) in the varus and valgus groups, and the results were statistically different (p = 0.009). There was no significant difference in echogenicity, number of occluded vessels, and thrombus length between the valgus group (p = 0.102; p = 0.645; p = 0.684). Patients with valgus deformity had 12.14‰ (5/412) prosthesis revision, the incidence of varus deformity was 4.82‰ (41/8505), and the revision risk of valgus group was 2.5 times higher than varus group, and the results were statistically different (p = 0.043). The operation time and hospital stay in the valgus group were longer than those in the varus group, and the results were statistically different (p = 0.018; p < 0.001). CONCLUSIONS Valgus deformity increases risk of symptomatic VTE and prosthesis revision after TKA. These results have guiding significance for the prevention of complications after TKA in patients with valgus deformity.
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Affiliation(s)
- Kuishuai Xu
- Department of Sports MedicineThe Affiliated Hospital of Qingdao UniversityQingdaoChina
| | - Liang Zhang
- Department of Abdominal ultrasoundAffiliated Hospital of Qingdao UniversityQingdaoChina
| | - Tengbo Yu
- Institute of Sports Medicine and Health, Qingdao UniversityQingdaoChina
- Department of Orthopedic SurgeryQingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital)QingdaoChina
| | - Xia Zhao
- Department of Sports MedicineThe Affiliated Hospital of Qingdao UniversityQingdaoChina
| | - Yingze Zhang
- Department of Sports MedicineThe Affiliated Hospital of Qingdao UniversityQingdaoChina
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Yang Y, Jiang L, Zhou X, Zhou X, Chen H, Chen Z. Robotic-assisted total knee arthroplasty improves implant position and early functional recovery for the knee with severe varus/valgus deformity. BMC Musculoskelet Disord 2024; 25:92. [PMID: 38267884 PMCID: PMC10809628 DOI: 10.1186/s12891-024-07203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024] Open
Abstract
PURPOSE Robotic-assisted total knee arthroplasty (r-TKA) facilitates precise bone resection and lower limb alignment, yet accuracy and functional recovery for severe varus/valgus deformity is not well-documented. The aim of study was to investigate whether r-TKA improves implant alignment in the coronal and sagittal view and early functional recovery compared to conventional TKA(c-TKA). METHODS This comparative study included 86 patients with symptomatic knee arthritis who underwent primary TKA at our institution between 1st May and 31th November 2021. Radiological parameters evaluated included hip-knee-ankle angle (HKAA), femoral varus-valgus angle (FVVA), tibial varus-valgus angle (TVVA), posterior tibial slope angle (PTSA), femoral sagittal angle (FSA), posterior condylar offset ratio, and Insall-Salvati index. Operative time, stay length, and complications were reviewed from patient records. The hospital for special surgery (HSS), Visual Analogue Scale (VAS) and knee joint motion range were evaluated at the six-month follow-up. RESULTS The c-TKA and r-TKA groups had no significant differences in HKAA (179.73 ± 3.76°, range: 172.10-188.90° vs. 180.53 ± 2.91°, range: 173.30-188.32°, p = 0.277), FVVA (96.13 ± 2.61°, range: 90.27-101.52° vs. 96.38 ± 2.23°, range: 90.98-100.95°, p = 0.636), and TVVA (88.74 ± 2.03°, range: 83.75-92.74° vs. 89.43 ± 1.83°, range: 85.32-94.15°, p = 1.000). Outlier of mechanical alignment incidence (> 3°) was significantly lower in r-TKA compared with c-TKA, 17.50% (7/40) vs. 41.30% (19/46), (p = 0.017). PTSA of r-TKA remained significantly lower than c-TKA (p = 0.009) in mild-deformity patients. For severe varus/valgus deformity, r-TKA had a significantly lesser HKAA-outlier incidence (p = 0.025), PTSA-outlier incidence (p = 0.019), and lower PTSA (p < 0.001) compared with c-TKA. The r-TKA functional outcome was better than c-TKA regarding HSS (93.12 ± 1.97, range: 90-95, 95%CI:92.11-94.13 vs. 91.33 ± 2.50, range: 85-95, 95%CI:90.20-92.69, p = 0.036), and VAS (0.24 ± 0.44, range:0-1 vs. 0.72 ± 0.75, range:0-2, p = 0.026), knee joint flexion (118.53° ± 8.06, range: 105-130°, 95%CI:114.39-122.67° vs. 112.22 ± 8.09°, range: 100-130°, 95%CI:108.20-116.24° ,p = 0.027) for severe varus/valgus deformity. CONCLUSION r-TKA improved lower-limb coronal alignment, sagittal implant position, and early functional recovery for patients with severe varus/valgus deformity of the knee. r-TKA did not confer substantial advantages over c-TKA in both radiological and clinical outcomes for the mild varus/valgus deformity.
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Affiliation(s)
- Yang Yang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai City, 317000, Zhejiang Province, China
| | - Lingjun Jiang
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai City, 317000, Zhejiang Province, China
| | - Xiaoxiao Zhou
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu hospital, Shanghai, China
| | - Xiaobo Zhou
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai City, 317000, Zhejiang Province, China
| | - Haixiao Chen
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai City, 317000, Zhejiang Province, China.
| | - Zhongyi Chen
- Department of Orthopedics, Taizhou Hospital of Zhejiang Province, Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai City, 317000, Zhejiang Province, China.
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Palanisami D, Dhanasekaran S, Kanugula SK, Natesan R, Shanmuganathan R. Outcomes of lateral femoral sliding osteotomy in primary total knee arthroplasty for type two fixed valgus deformity. INTERNATIONAL ORTHOPAEDICS 2024; 48:111-117. [PMID: 37648763 DOI: 10.1007/s00264-023-05950-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE The aim of our study was to determine the surgical outcomes of patients who underwent lateral femoral sliding osteotomy (LFSO) with total knee arthroplasty (TKA) for Ranawat's type 2 fixed valgus deformity. METHODS The consecutive patients who underwent primary TKA with posterior-stabilized implant and LFSO for fixed valgus deformity were reviewed. The radiological parameters analyzed were pre- and postoperative hip-knee-ankle (HKA) angle and tibio-femoral angle in varus-valgus stress views. The clinical outcome was measured by Oxford knee score (OKS), knee society score (KSS), and functional score (KSS-F). The complications and any reoperation were noted in the follow-up. RESULTS There were total 28 patients included with an average follow-up time of 47.2 ± 24.9 months. The average arc of motion was 101.3 ± 23.8° preoperatively and 102.7 ± 11.8° postoperatively (p > 0.05). The average deformity in varus and valgus stress views was 196.6 ± 4.8 and 207.8 ± 7.4°, respectively. There was significant improvement in HKA from 205.2 ± 8.3° preoperatively to 181.9 ± 3.7° postoperatively (p < 0.05). At the final follow-up, bony union of the osteotomy fragment was noted in all the patients. There was significant improvement in OKS, KSS, and KSS-F score from a preoperative 15.1 ± 3.9, 35.1 ± 10.6, and 26.6 ± 12.6 to 40.3 ± 2.9, 85.6 ± 4.8, and 89.4 ± 7.7, postoperatively (p < 0.05), respectively. One patient had acute periprosthetic joint infection that was managed with debridement and polyethylene insert exchange. CONCLUSION Lateral femoral sliding osteotomy is an effective technique for optimal soft tissue balance in fixed valgus deformity. It provides satisfactory clinical outcome with restoration of knee alignment without using the constrained implants.
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Affiliation(s)
| | | | - Sandeep Kumar Kanugula
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043, India
| | - Rajkumar Natesan
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043, India
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Soundarrajan D, Singh R, Venkataraman S, Dhanasekararaja P, Rajkumar N, Rajasekaran S. Prophylactic Common Peroneal Nerve Decompression Avoids Nerve Palsy in Total Knee Arthroplasty for Severe Fixed Valgus Deformity: A Report of Four Cases and Review of Literature. Indian J Orthop 2024; 58:113-118. [PMID: 38161402 PMCID: PMC10754794 DOI: 10.1007/s43465-023-01055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 11/11/2023] [Indexed: 01/03/2024]
Abstract
Common peroneal nerve (CPN) injury is a serious complication following total knee arthroplasty (TKA). We aim to report four patients (five knees) who underwent prophylactic peroneal nerve decompression for severe rigid valgus deformity with or without associated fixed flexion deformity that was not correctable under anaesthesia. The preoperative deformity of 31.1° valgus by femorotibial angle (range 22.6-37.9°) improved to 7.1° valgus (range 4.3-9.1°) postoperatively (p < 0.05). For two knees, varus-valgus constrained was used due to medial laxity and the other three had posterior-stabilised prosthesis. All four patients had normal motor or sensory nerve function of the CPN nerve postoperatively. There was a significant improvement in the functional outcome by knee society score and knee society functional score from 17.8 ± 6.8, 25 ± 16.2 to 84 ± 8.7, 83 ± 10.3, respectively (p < 0.05). No complications were noted in the mean follow-up of 1.2 years. Prophylactic peroneal nerve decompression allows safe, adequate and optimal lateral soft-tissue release. It is effective in preventing common peroneal nerve palsy in high-risk patients like severe valgus and flexion deformity during total knee arthroplasty.
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Affiliation(s)
| | - Rithika Singh
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043 India
| | - Sagar Venkataraman
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043 India
| | | | - Natesan Rajkumar
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043 India
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Pasquinelly A, Blood D, Elattar O, Hanna M. Optimal Sequence of Corrective Surgeries for Concomitant Valgus Knee and Rigid Pes Planus Deformities: The Knee-First Approach. Arthroplast Today 2023; 24:101265. [PMID: 38023651 PMCID: PMC10652122 DOI: 10.1016/j.artd.2023.101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/08/2023] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
In patients requiring surgical correction of ipsilateral valgus knee and rigid pes planovalgus deformities, the optimal operative sequence is controversial. Growing evidence suggests these 2 deformities are related in etiology and interrelated in disease course. We present the case of a 72-year-old female with concomitant valgus knee and rigid pes planovalgus deformities successfully treated with total knee arthroplasty followed by triple arthrodesis and Achilles lengthening. Surgical correction of these deformities must be carefully planned between the operating surgeons to avoid over- or under-correction of alignment that could further impact gait. In contrast with the limited available literature, the authors recommend correction at the knee first and the foot and ankle second. Further prospective studies are needed to elucidate the best operative sequence in these patients.
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Affiliation(s)
- Adam Pasquinelly
- University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Dalton Blood
- Department of Orthopedic Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Osama Elattar
- Department of Orthopedic Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Maged Hanna
- Department of Orthopedic Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
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Migliorini F, Feierabend M, Hofmann UK. Fostering Excellence in Knee Arthroplasty: Developing Optimal Patient Care Pathways and Inspiring Knowledge Transfer of Advanced Surgical Techniques. J Healthc Leadersh 2023; 15:327-338. [PMID: 38020721 PMCID: PMC10676205 DOI: 10.2147/jhl.s383916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023] Open
Abstract
Osteoarthritis of the knee is common. Early sports trauma or cartilage defects are risk factors for osteoarthritis. If conservative treatment fails, partial or total joint replacement is often performed. A joint replacement aims to restore physiological biomechanics and the quality of life of affected patients. Total knee arthroplasty is one of the most performed surgeries in musculoskeletal medicine. Several developments have taken place over the last decades that have truly altered the way we look at knee arthroplasty today. Some of the fascinating aspects will be presented and discussed in the present narrative review.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, 52074, Germany
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, 39100 Bolzano, Italy
| | - Martina Feierabend
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, 52074, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Aachen, 52074, Germany
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Villa M, Farrar J, Larkin K, Satpathy J, Isaacs J, Patel N. Prophylactic Common Peroneal Nerve Release for Total Arthroplasty of the Valgus Knee: Surgical Technique and Early Outcomes. Arthroplast Today 2023; 23:101205. [PMID: 37649876 PMCID: PMC10463189 DOI: 10.1016/j.artd.2023.101205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 09/01/2023] Open
Abstract
Background Common peroneal nerve (CPN) palsy after primary total knee arthroplasty represents a relatively rare but serious complication. Recently, there has been a growing interest in prophylactic CPN decompression in high-risk patients with significant combined valgus and flexion deformity. This study aimed to examine outcomes at our institution in those undergoing prophylactic CPN decompression at the time of total knee arthroplasty. Methods A retrospective evaluation of a single-institution experience with selected patients at high risk for CPN palsy who underwent prophylactic nerve decompression through a separate incision at the time total knee arthroplasty was performed between July 1, 2018 and December 31, 2022. Patient demographics as well as perioperative and intraoperative clinical and radiographic measurements were collected and analyzed. Results A total of 14 patients (15 knees) met our inclusion criteria. The mean preoperative femorotibial angle was 18.6° of valgus (range 13°-22°). The mean preoperative flexion contracture was 4.3° (range 0°-25°). The patients with flexion contractures preoperatively had a mean combined valgus/flexion contracture deformity of 28.8° (range 23°-38°) . There was preservation of nerve function in all knees. No knees required subsequent operative intervention within 90 days of surgery. Conclusions Early experience with prophylactic CPN release in our high-risk population demonstrates preservation of nerve function in all patients and is reasonable to consider in patients with a large preoperative combined valgus/flexion deformity. Further studies with larger sample sizes would be beneficial in verification of the results with this technique, as well as determining an angular deformity threshold for which CPN release should be considered.
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Affiliation(s)
- Morgan Villa
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jacob Farrar
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Kevin Larkin
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jibanananda Satpathy
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jonathan Isaacs
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Nirav Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Tiftikçi U, Serbest S, Kaya Ö, Keskinkiliç SI, Kilinç CY, Firat A. Does measuring the medial gap before bone resection in total knee arthroplasty provide optimum gap adjustment and prevent bone recutting? Acta Orthop Belg 2023; 89:463-468. [PMID: 37935230 DOI: 10.52628/89.3.10208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
This study aimed to demonstrate that measuring the medial gap before bone resection during total knee arthroplasty (TKA) provides an optimum gap adjustment in varus knees. In this study, patients were separated into two groups. Group 1 included patients whose medial joint gap was measured before bone resection and Group 2 included patients who underwent conventional technique without measuring. The medial joint gap was measured with a custom-made gap measuring device up to the point that the knee was corrected and aligned along its mechanical axis. Medial joint gap distances, distal medial femoral bone cut thicknesses, amounts of tibial resection calculated; gap internal distances measured after cutting and the thicknesses of the trial inserts were recorded. A comparison was made between the groups concerning the number of patients requiring an additional tibial bone cut and the distribution of insert thicknesses. Extra tibial bone resections were performed in two (5.7%) patients in Group 1 and 10 (28.6%) patients in Group 2. In Group 1, where the medial joint gap was measured, the need for an additional bone resection was statistically less (p=0.018). In comparing the distribution of insert size by group, the number of patients on whom an 8 mm insert had been used was significantly greater in Group 1 (p=0.024). The findings obtained in this study suggest that measuring the medial joint gap before bone resection in total knee arthroplasty may prevent repeated bone recutting and additional bone resections.
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Effect of total knee arthroplasty for valgus knee correction on clinical outcome and patellar position. INTERNATIONAL ORTHOPAEDICS 2023; 47:735-743. [PMID: 36645475 PMCID: PMC9931837 DOI: 10.1007/s00264-023-05689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/01/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE The purpose was to investigate the effect of different degrees of valgus deformity correction on patellar position and clinical outcome in patients with valgus knees after total knee arthroplasty (TKA). METHODS We retrospectively analyzed and followed 118 patients with valgus knees. Based on the post-operative hip-knee-ankle (HKA), patients were divided into three groups: neutral (±3°), mild (3-6°), and severe (> 6°). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion (ROM), and Knee Society Score (KSS) were used to evaluate post-operative clinical efficacy. Also, the patellar tilt angle (ε-angle), congruence angle (θ-angle), and Insall-Salvati index (ISI) were used to represent the patellar position. Post-operative observation indicators included HKA, angle of the femur (α-angle), tibial angle (β-angle), femoral component flexion angle (γ-angle), and tibial component posterior slope angle (δ-angle). RESULTS All patients showed significant improvements in HKA, ROM, WOMAC, and KSS after operation (P < 0.001). Regarding patellar position, the ISI values decreased to varying degrees (P < 0.05). The patellar tilt angle was significantly increased in the severe valgus group compared to that in the mild valgus and neutral groups (P < 0.001). Univariate analysis showed that the degree of post-operative residual valgus was significantly affected by WOMAC, KSS, α-, ε-, and θ-angles. CONCLUSION Minor valgus undercorrection did not affect the short-term outcome after TKA; however, when the residual valgus angle was > 6°, the post-operative scores were significantly reduced. Inadequate valgus correction does not result in significant changes in patellar height but may increase the risk of poor patellar tracking.
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Medially congruent total knee arthroplasty in valgus knee deformities yields satisfactory outcomes: a multicenter, international study. Knee Surg Sports Traumatol Arthrosc 2023; 31:407-412. [PMID: 34596693 DOI: 10.1007/s00167-021-06754-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Postoperative instability represents one of the most common complications following primary total knee arthroplasty (TKA). To prevent this outcome, valgus deformities have been historically treated using more constrained implants. The purpose of this study was to evaluate the outcome of treating a moderate valgus deformity by combining a surgical technique used to release the postero-lateral soft tissue envelope with the use of a medially congruent (MC) TKA design without using classical, semi-constrained inserts. METHODS Seventy-nine MC TKAs were performed by three surgeons at three institutions between 2016 and 2018 as part of a multicenter, international study. Inclusion criteria were: radiographic late-stage osteoarthritic knees with Ranawat's type 1 or 2 classification of valgus deformity and integrity of the medial capsular-ligament complex (less than 10 mm of medial opening during valgus stress test at 10° of knee flexion). Exclusion criteria were: BMI > 40; neuromuscular, metabolic, or immunologic disorders; or the inability to complete outcome measures or radiographic assessment. RESULTS Seventy-seven patients (79 knees), 59 males and 18 females, were evaluated at 2-year minimum follow-up according to the Knee Society Score (KSS) and Forgotten Joint Score (FJS). Mean age at surgery was 70 years (range 48-91). The mean range of motion (ROM) improved from 110° (range 85°-130°) preoperatively to 121° (range 105°-135°) (p < 0.001) at the time of the last follow-up. Preoperative knee extension significantly improved from 3° (range - 15° to 20°) to 1° (range - 5° to 5°) of flexion at the last follow-up in all the patients. KSS and KSS Functional scores were 89 (range 65-100) and 82 points (range 55-100), respectively. The FJS obtained at the last follow-up was 72 (range 49-88). Two patients (2.5%) had major postoperative complications (one periprosthetic joint infection; one postoperative patellar fracture) requiring surgical interventions. CONCLUSIONS In different surgeon's hands, the use of a modern medially congruent TKA design yielded good clinical outcomes at 2 years in a consecutive series of TKA in valgus arthritic knees. Postoperative instability was not recorded in this series and this finding was related to the high conformity design of the MC polyethylene insert, which significantly differs from classical posterior-stabilized (PS) designs. LEVEL OF EVIDENCE IV.
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Song J, Koh DTS, Liow LMH, Chia SL, Lo NN, Yeo SJ, Chen JY. Alignment prior to total knee arthroplasty in high tibial osteotomy patients has no effect on subsequent functional outcomes. J Orthop Surg (Hong Kong) 2022; 30:10225536221132052. [PMID: 36250492 DOI: 10.1177/10225536221132052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The influence of prior high tibial osteotomy (HTO) on total knee arthroplasty (TKA) functional outcomes remains widely debated. Alignment of failed HTO can pose technical challenges with subsequent TKA. The primary aim of this study was to evaluate the influence of HTO alignment on the clinical outcomes of subsequent TKA. The secondary aim was to compare the time to TKA for each HTO alignment type. METHODS Patients who underwent TKA post lateral closing-wedge HTO for symptomatic medial compartment osteoarthritis between 2001 and 2014 were prospectively followed up for 2 years. A total of 159 patients were assigned to three groups based on their pre-TKA femora tibia angles using long lower limb radiographs: varus alignment (VrA) ≤ 3o valgus, neutral alignment (NA) 3-9o valgus alignment, valgus alignment (VlA) ≥ 9o valgus. Functional outcomes were quantified using Knee Society Function Score and Knee Scores (KSFS and KSKS respectively), modified Oxford Knee Score (OKS), Short Form 36 Physical Component Score (SF-36 PCS), and SF-36 Mental Component Score (SF-36 MCS). Pre-operative and post-operative knee range of motion were also measured. RESULTS Mean pre-TKA KSKS in VrA patients (35 ± 18) was significantly lower than both NA (51 ± 19) and VlA (40 ± 21) patients (p < .05). Otherwise, there was no significant difference in functional outcome scores (KSFS, KSKS, OKS, SF-36 PCS and SF-36 MCS) or range of motion at 6 months and 2 years post-TKA. The mean duration from HTO to TKA was 12 ± 7 years with no significant differences between VrA, NA, and VlA HTO to TKA (13 ± 7 years, 13 ± 6 years and12 ± 8 years respectively, p > .05). CONCLUSION HTO alignment did not influence time to subsequent TKA. HTO alignment did not influence early outcomes as well as radiological outcomes of subsequent TKA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joshua Song
- Department of Orthopaedic Surgery, 37581Singapore General Hospital, Singapore
| | - Don Thong Siang Koh
- Department of Orthopaedic Surgery, 37581Singapore General Hospital, Singapore
| | | | - Shi-Lu Chia
- Department of Orthopaedic Surgery, 37581Singapore General Hospital, Singapore
| | - Ngai Nung Lo
- Department of Orthopaedic Surgery, 37581Singapore General Hospital, Singapore
| | - Seng Jin Yeo
- Department of Orthopaedic Surgery, 37581Singapore General Hospital, Singapore
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Dudek P, Marczak D, Okoń T, Grzelecki D, Szneider J, Kowalczewski J. Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study. J Clin Med 2022; 11:jcm11195953. [PMID: 36233820 PMCID: PMC9572376 DOI: 10.3390/jcm11195953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/21/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2−10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student’s t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value—0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.
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Affiliation(s)
- Piotr Dudek
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, 01-813 Warsaw, Poland
- Correspondence:
| | - Dariusz Marczak
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, 01-813 Warsaw, Poland
| | - Tomasz Okoń
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, 01-813 Warsaw, Poland
| | - Dariusz Grzelecki
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, 01-813 Warsaw, Poland
| | - Jan Szneider
- Centre of Postgraduate Medical Education, Department of Orthopaedics, 01-813 Warsaw, Poland
| | - Jacek Kowalczewski
- Centre of Postgraduate Medical Education, Department of Orthopaedics and Rheumoorthopaedics, 01-813 Warsaw, Poland
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Eller K, Scior W, Graichen H. Dynamic gap analysis of valgus knees shows large inter-individual variability of gaps. Knee Surg Sports Traumatol Arthrosc 2022; 31:1398-1404. [PMID: 36083353 DOI: 10.1007/s00167-022-07088-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/24/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to investigate the dynamic gap widths of valgus knees in extension and flexion to evaluate the influence of deformity on gap differences and to find out whether different ligamentous subtypes in valgus knees exist. METHODS Dynamic gap widths of 1000 consecutive total knee arthroplasty (TKA) patients were measured at different flexion angles by applying a computer-assisted surgery (CAS) technique. 198 knees showed a valgus deformity and were assessed regarding its degree of fulfillment of the following criteria of valgus knee: 1. Medial extension gap greater than lateral; 2. Medial flexion gap greater than lateral; 3. Flexion gap greater than extension gap. A single-factor ANOVA subgroup analysis was performed, based on the amount of deformity. The effect of other patient factors (age, gender, weight) on gap differences was investigated. RESULTS The medial extension gap (3.7 ± 2.2 mm) was significantly (p < 0.01) larger than the lateral extension gap (1.1 ± 2.9 mm). The amount of deformity correlated highly with gap difference in extension (r2 = 0.67) but not in flexion. In 92.4% (183), the flexion gap (6.2 ± 3.1 mm) was significantly (p < 0.01) larger than the extension gap (2.4 ± 2.3 mm). Only 29.3% (58) of patients met all three criteria, this was mainly due to the fact that in flexion the medial gap was larger than the lateral in only 35.4% (70). Patient factors showed no significant influences (NS) on the gap widths. CONCLUSION Valgus knees show large variability in terms of gap widths. The extent of deformity correlates highly with gap difference in extension, but not in other flexion angles. Vast majority of valgus knees were valgus in extension only. Because of this variability, it should be aimed for an individualized balancing technique based on intraoperative gap sizes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kim Eller
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany.
| | - Wolfgang Scior
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany
| | - Heiko Graichen
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany
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Lv SJ, Wang XJ, Huang JF, Mao Q, He BJ, Tong PJ. Total knee arthroplasty in Ranawat II valgus deformity with enlarged femoral valgus cut angle: A new technique to achieve balanced gap. World J Clin Cases 2022; 10:6406-6416. [PMID: 35979319 PMCID: PMC9294892 DOI: 10.12998/wjcc.v10.i19.6406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/10/2021] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nearly 10% of patients undergoing primary total knee arthroplasty (TKA) have valgus deformity (VD) of the knee. For severe VD of the knee, a more lateral structural release is needed to achieve balance between medial and lateral space and neutral femorotibial mechanical axis (FTMA), which is challenging and technical. AIM To introduce a new surgical technique of resection, soft tissue release, and FTMA for Ranawat type-II VD with a 5-year follow-up. METHODS A retrospective study was conducted on patients who underwent TKA from December 2011 to December 2014. Hip-knee-ankle (HKA), range of motion (ROM), Oxford knee score (OKS), and knee society score (KSS) were used to assess the joint activity of patients in the new theory TKA group (NT-TKA) and were compared with those of the conventional TKA group (C-TKA). RESULTS A total of 103 people (103 knees) were included in this study, including 42 patients with an average follow-up period of 83 mo in the C-TKA group and 61 patients with an average follow-up period of 76 mo in the NT-TKA group. Six patients had constrained prosthesis, one had common peroneal nerve injury, and two had joint instability in the C-TKA group, but none of these occurred in the NT-TKA group. There were significant statistical differences in constrained prosthesis usage and complications between the groups (P = 0.002 and P = 0.034, respectively). The KSS at 1 mo post-operation for the C-TKA and NT-TKA groups were 11.2 ± 3.8 and 13.3 ± 2.9, respectively, with a significant difference (P = 0.007). However, the data of HKA, ROM, OKS KSS, and prosthesis survival rate were insignificant (P > 0.05) in both the preoperative and follow-up periods. CONCLUSION Adopting 5°-7° valgus cut angle for VD and sacrificing 2° neutral FTMA for severe VD which cannot be completely corrected during TKA can reduce the need for soft tissue release, maintain early joint stability, reduce the use of constrained prostheses, and minimize postoperative complications.
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Affiliation(s)
- Shuai-Jie Lv
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Xiao-Jian Wang
- The First Clinical Medical School, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province, China
| | - Jie-Feng Huang
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Qiang Mao
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Bang-Jian He
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
| | - Pei-Jian Tong
- Department of Orthopedics and Traumatology, The First Affiliated Hospital and First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310006, Zhejiang Province, China
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Li T, Liu Y, Li C, Zhang H. SMOC approach for total knee arthroplasty in valgus knees. J Orthop Surg Res 2022; 17:120. [PMID: 35193617 PMCID: PMC8862505 DOI: 10.1186/s13018-022-03002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 02/04/2022] [Indexed: 11/19/2022] Open
Abstract
Objective This study was performed to compare clinical outcomes among patients with valgus knees undergoing total knee arthroplasty via the medial parapatellar approach and the subvastus with minimal oblique cut approach. Methods A total of 232 patients (246 knees) undergoing total knee arthroplasty between December 2014 and December 2016 were retrospectively included in the investigation. The study population consisted of 120 patients (128 knees; 32 men and 88 women) with a mean age of 62.43 ± 8.12 years treated via the medial parapatellar approach, and 112 patients (118 knees; 30 men and 82 women with a mean age of 63.15 ± 7.83 years) treated via the subvastus with minimal oblique cut approach. Nine preoperative parameters (number of patients, sex, age, body mass index, number of knees, valgus angle, visual analogue scale score, range of motion, Hospital for Special Surgery score), five perioperative parameters (operative time, amount of drainage, Visual analogue scale score at 24 h after the operation, time to straight leg raising, radiological alignment), and two postoperative parameters (range of motion, Hospital for Special Surgery score) were assessed at 1 day, 1 week, 6 weeks, 8 weeks and 1 year after the operation, along with postoperative complications. Results There were no significant differences in the nine preoperative parameters between the two groups. The subvastus with minimal oblique cut group had a longer operative time, while the parapatellar approach group showed more drainage and a higher mean Visual analogue scale score. Compared to the medial parapatellar group, the subvastus with minimal oblique cut group had a shorter time to straight leg raising. There were no differences in radiological alignment between the two groups. The groups showed similar range of motion and Hospital for Special Surgery scores at 8 weeks and 1 year, but both were higher in the subvastus with minimal oblique cut group at 1 day, 1 week and 6 weeks. During postoperative follow-up, postoperative subluxation of the patella occurred in five cases in the medial parapatellar group. Neither group showed any instability, recurrent valgus deformity or radiographic loosening. Conclusion The subvastus with minimal oblique cut approach provides excellent early recovery for total knee arthroplasty of valgus knees with no increase in complications.
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Affiliation(s)
- Tao Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Yikai Liu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Chenkai Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Haining Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
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Li F, Wang C, Zhao MW, Geng X, Li JY, Zhou G, Sun D, Tian H. Modified Medial Collateral Ligament Indentation Technique in Total Knee Arthroplasty with Severe Type II Valgus Deformity. Orthop Surg 2022; 14:663-670. [PMID: 35174652 PMCID: PMC9002074 DOI: 10.1111/os.13230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To explore the feasibility and clinical efficacy of a modified medial collateral ligament indentation technique in total knee arthroplasty (TKA) with severe type II valgus deformity. Methods Consecutive patients with Krackow type II valgus deformity >20° who underwent a primary unilateral TKA between May 2008 and June 2017 were studied retrospectively. A medial collateral ligament indentation technique was performed in 20 patients (MCLI group), and 23 patients received the routine lateral structures release technique (LSR group). Radiological parameters, such as the valgus angle (VA), and functional outcomes including the use of constraint implants, Knee Society Score (KSS), Knee Society Function score (KSF), and thickness of the polyethylene insert were compared between the two groups. Results A total of 43 consecutive patients had a minimum 2‐year follow‐up. The preoperative VA was comparable between the MCLI (23.5° ± 5.8°) and LSR groups (21.3° ± 3.2°, P = 0.134), as was the postoperative VA (1.1° ± 2.1° and 2.5° ± 3.0°, respectively, P = 0.084). The mean KSS and KSF scores in the MCLI group were 30.2 ± 4.8 and 38.8 ± 4.8, respectively, before surgery, and they increased to 91.3 ± 2.6 and 86.5 ± 2.4 at the last follow‐up. The scores in the LSR group were 31.5 ± 7.5 and 36.5 ± 7.8 before surgery and 92.4 ± 3.5 and 88.5 ± 3.6 at the last follow‐up. While no statistically significant differences in pre‐ or postoperative functional scores were found between the two groups, the MCLI group had thinner polyethylene inserts (9.5 ± 1.1 mm vs 12.9 ± 1.5 mm) and less use of constrained condylar inserts (15% vs 69.6%). During follow‐up, the MCLI group had fewer complications. Conclusion A modified MCLI technique can achieve good outcomes in TKA with type II valgus deformity of >20°. It can maintain a normal joint line level, reduce the use of constrained condylar knee prostheses, and is a reliable choice for severe genu valgum.
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Affiliation(s)
- Feng Li
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Cheng Wang
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Min-Wei Zhao
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Xiao Geng
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Jun-Yang Li
- Centre for Robotics and Automation, Shenzhen Research Institute of City University of Hong Kong, Shenzhen, China
| | - Ge Zhou
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Dong Sun
- Centre for Robotics and Automation, Shenzhen Research Institute of City University of Hong Kong, Shenzhen, China
| | - Hua Tian
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
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Rajgopal A, Kumar S, Aggarwal K. Recognizing the Role of the Posterolateral Corner in Patients Undergoing Total Knee Arthroplasty for Fixed Varus Deformity. Orthop Res Rev 2021; 13:171-177. [PMID: 34675694 PMCID: PMC8519409 DOI: 10.2147/orr.s329367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/24/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Varus deformity is the commonest presentation of the arthritic knee requiring surgical intervention. While correctable deformities lend themselves to realignment options like unicompartmental replacement, fixed deformities often need a total knee replacement. Current treatment options for patients with fixed coronal varus malalignment undergoing total knee arthroplasty include varying degrees of medial soft tissue releases, often leading to infringement of the medial collateral ligament complex and increased use of constrained options. We describe the role of the posterolateral (PL) tether in a select subgroup of patients needing release to achieve correction and minimising use of constrained options. Patients and Methods A total of 384 patients with fixed varus deformity were retrospectively evaluated and categorised on the basis of weight bearing x-rays into four groups, namely, knees with angulation (F1), angulation with subluxation and torsion (F2), medial translation (F3) and deformity with major medial bone loss (F4). From this cohort, we identified patients with a tight PL tether that needed release to achieve good correction. These were predominantly in the F2 and F3 subgroups. Functional scores and outcomes were evaluated at a mean follow-up of 120.23 months. Results F1 cohort achieved good correction with medial soft tissue release, while F2 and F3 cohorts often needed a PL release. While functional outcomes and scores were comparable in both groups, survivorship was better in the group where release was done. Conclusion We recognise the role of the PL tether in a subgroup of patients with recalcitrant fixed varus deformities. Sequential release helped achieve good outcomes with minimal use of constrained options. Level of Evidence Three.
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Affiliation(s)
- Ashok Rajgopal
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta- The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Sumit Kumar
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta- The Medicity Hospital, Gurugram, Haryana, 122001, India
| | - Kalpana Aggarwal
- Institute of Musculoskeletal Disorders and Orthopaedics, Medanta- The Medicity Hospital, Gurugram, Haryana, 122001, India
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Rueckl K, Runer A, Jungwirth-Weinberger A, Kasparek MF, Faschingbauer M, Boettner F. Severity of valgus knee osteoarthritis has no effect on clinical outcomes after total knee arthroplasty. Arch Orthop Trauma Surg 2021; 141:1385-1391. [PMID: 33515324 DOI: 10.1007/s00402-021-03785-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Advanced valgus osteoarthritis (OA) is one of the most challenging indications for total knee arthroplasty (TKA). There is no information in the literature about the optimal timing of surgery. The current study investigates the impact of the preoperative deformity and degree of arthritis on postoperative outcome after TKA. MATERIAL AND METHODS The study evaluated 133 knees in 107 patients with valgus OA that failed nonoperative treatment with a minimum 2-year follow-up. Mechanical alignment, Kellgren and Lawrence (K/L) score, and minimal joint space width (minJSW) were measured on AP- and hip-to-ankle radiographs. All knees had advanced OA (i.e., K/L grades 3 or 4 and less than 50% minJSW). Pre- and postoperative WOMAC, VR-12, UCLA, VAS, ROM were recorded. RESULTS There was no difference in clinical outcome (WOMAC, UCLA, VR-12, VAS or ROM) between patients with different degrees of valgus deformities (< 5.0 deg., 5.0-9.9 deg., 10.0-14.9 deg., ≥ 15.0 deg.). There was also no correlation between K/L score or minimal joint space width and any of the outcome parameters. CONCLUSIONS The degree of valgus deformity and the grade of osteoarthritis do not predict the outcome of TKA in patients with valgus OA. Since the risk of complication and the need for implant constraint increases with increasing deformity and instability of the knee, surgery appears to be justified in patients with advanced OA that failed nonoperative treatment, regardless of the degree of deformity.
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Affiliation(s)
- Kilian Rueckl
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.,Department of Orthopedic, University of Wuerzburg, Wuerzburg, Germany
| | - Armin Runer
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Maximilian F Kasparek
- Department of Orthopedics, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Martin Faschingbauer
- Department of Orthopedic Surgery, Ulm University Hospital, University of Ulm, Ulm, Germany
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Liu Z, Zeng WN, Luo Z, Zhao E, Li H, Zhou Z. Mid-long-term results of total knee arthroplasty followed by ipsilateral total hip arthroplasty versus total hip arthroplasty subsequent to ipsilateral total knee arthroplasty: a case-control analysis. BMC Musculoskelet Disord 2021; 22:581. [PMID: 34167505 PMCID: PMC8223306 DOI: 10.1186/s12891-021-04455-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 04/16/2021] [Indexed: 02/08/2023] Open
Abstract
Background The aim of the present study was to compare the outcomes of patients who underwent different sequences of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods We retrospectively identified 47 patients who underwent TKA followed by ipsilateral THA (THA-TKA) and 36 patients who received THA subsequent to ipsilateral TKA (TKA-THA) for rheumatoid arthritis or osteoarthritis between January 2008 and April 2014. Twenty-eight patients were selected for each group after case-control matching with preoperative demographics and protheses of THA. Clinical scores, radiographic results, complication rates, and survivorship were compared. The median duration of follow-up was 110 (range 80–149) months. Results Both groups showed significant improvement in Harris Hip Scores, Knee Society Score, and Short Form-12 at the last follow-up compared to baseline (p < .001). At the last follow-up, all clinical scores were actually lower in the THA-TKA group, but those differences were not statistically significant. Otherwise, there was no significant difference in radiological alignment or complication rates. The survivorship of THA and TKA in the THA-TKA group was 94.7 and 95.7%, respectively, compared with 92.4 and 100.0% in the TKA-THA group at 8 years (log rank, p = .939 and .187). Conclusions Patients who underwent ipsilateral THA and TKA with different sequences achieved similar favorable outcomes. Total joint arthroplasty can be performed safely with excellent outcomes in patients with a history of prior ipsilateral THA or TKA. Trial registration The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2000035147) dated 2 August 2020.
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Affiliation(s)
- Zunhan Liu
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Wei-Nan Zeng
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Zhenyu Luo
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Enze Zhao
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Hao Li
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China
| | - Zongke Zhou
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, Sichuan Province, 610041, People's Republic of China.
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Kaneko T, Igarashi T, Yoshizawa S, Takada K, Ikegami H, Musha Y. Robotic-Assisted Total Knee Arthroplasty for Distal Femur Fracture with Lateral Knee Osteoarthritis. Case Rep Orthop 2021; 2021:5576955. [PMID: 34007500 PMCID: PMC8100416 DOI: 10.1155/2021/5576955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/02/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction. Open reduction and internal fixation (ORIF) of compound fractures around the knee in elderly patient raise concerns about long-term postoperative external fixation and complications. Total knee arthroplasty (TKA) has been proposed as an alternative solution. We report a case where robotic-assisted (RA) TKA was used to treat lateral knee osteoarthritis (OA) with distal femur fracture. Case Presentation. A 90-year-old female visited our hospital with complications of sustained knee pain after a fall at home. Fracture line from the trochlea to the intercondylar notch was diagnosed on plain radiographs, and prior to this injury, the patient was receiving conservative treatment for lateral OA. We selected a conventional TKA over ORIF because the latter is associated with residual pain and the need for long-term immobilization, which can lead to other complications. However, the fracture site was the entry point for intramedullary rod, and there was concern that the fracture site would be displaced by conventional TKA. Therefore, the unique aspect of the case is that the technique utilized involved robotic milling using the Navio system while temporarily stabilizing the fracture using two tracker pins. RA TKA could determine osteotomy and implant placement by predicting the postoperative patient's soft tissue balance for no medial loosening and lateral contracture. The arthritic cartilage and bone were then methodically removed using the handheld sculptor. After immobilizing the fracture site with a bone grasper before removing the pin tracker, reaming of the femur and insertion of a stem prosthesis with semiconstrained were performed. Primary RA TKA is a viable option for intra-articular fractures in elderly patients with advanced knee osteoarthritis.
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Affiliation(s)
- Takao Kaneko
- Ichinomiya Onsen Hospital, Adult Reconstruction Center, Japan
| | | | - Shu Yoshizawa
- Department of Orthopedic Surgery, Toho University School of Medicine, Japan
| | - Kazutaka Takada
- Department of Orthopedic Surgery, Toho University School of Medicine, Japan
| | - Hiroyasu Ikegami
- Department of Orthopedic Surgery, Toho University School of Medicine, Japan
| | - Yoshiro Musha
- Department of Orthopedic Surgery, Toho University School of Medicine, Japan
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Sekeitto AR, van der Jagt K, Sikhauli N, van der Jagt DR. Total knee replacement in Osteogenesis Imperfecta: a case report and review of the literature. ARTHROPLASTY 2021; 3:4. [PMID: 35236441 PMCID: PMC8796353 DOI: 10.1186/s42836-020-00061-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A review of the literature revealed that only 9 total knee replacements were performed on patients with osteogenesis imperfecta (OI), with one being a revision procedure of a periprosthetic fracture. Of the 9 primary procedures, all used cemented prostheses, and 3 patients had an osteotomy at the same procedure. Our patient required a hinged prosthesis because of collateral ligament incompetence and is the first such case reported in the literature. CASE PRESENTATION Presented here is a total knee replacement performed on a 52-year-old patient with osteogenesis imperfecta (OI) who injured her left knee and ruptured her anterior cruciate ligament. Her right knee suffered from severe degenerative changes with an incompetent medial collateral ligament. It was decided to replace the right knee before addressing the left knee injury. A hinged revision prosthesis was used. The smallest components available were used because of the small anatomical bony dimensions. CONCLUSION This is the first reported case of a hinged prosthesis and highlights the soft tissue component of osteogenesis imperfecta. We also highlight the technical problems with these patients, including mal-alignment, small bony dimensions and bone fragility.
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Affiliation(s)
- Allan Roy Sekeitto
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, South Africa.
| | - Kaeriann van der Jagt
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, South Africa
| | - Nkhodiseni Sikhauli
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, South Africa
| | - Dick Ronald van der Jagt
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, South Africa
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Abstract
Aims A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA). Methods A radiological analysis of 500 healthy and 500 osteoarthritic (OA) knees was used to assess the applicability of the CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (aHKA) that estimates constitutional limb alignment and joint line obliquity (JLO). Intraoperative balance was compared within each phenotype in a cohort of 138 computer-assisted TKAs randomized to KA or MA. Primary outcomes included descriptive analyses of healthy and OA groups per CPAK type, and comparison of balance at 10° of flexion within each type. Secondary outcomes assessed balance at 45° and 90° and bone recuts required to achieve final knee balance within each CPAK type. Results There was similar frequency distribution between healthy and arthritic groups across all CPAK types. The most common categories were Type II (39.2% healthy vs 32.2% OA), Type I (26.4% healthy vs 19.4% OA) and Type V (15.4% healthy vs 14.6% OA). CPAK Types VII, VIII, and IX were rare in both populations. Across all CPAK types, a greater proportion of KA TKAs achieved optimal balance compared to MA. This effect was largest, and statistically significant, in CPAK Types I (100% KA vs 15% MA; p < 0.001), Type II (78% KA vs 46% MA; p = 0.018). and Type IV (89% KA vs 0% MA; p < 0.001). Conclusion CPAK is a pragmatic, comprehensive classification for coronal knee alignment, based on constitutional alignment and JLO, that can be used in healthy and arthritic knees. CPAK identifies which knee phenotypes may benefit most from KA when optimization of soft tissue balance is prioritized. Further, it will allow for consistency of reporting in future studies. Cite this article: Bone Joint J 2021;103-B(2):329–337.
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Affiliation(s)
- Samuel J MacDessi
- CPAK Research Group, Sydney, Australia.,Sydney Knee Specialists, St George Private Hospital, Kogarah, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Ian A Harris
- Orthopaedic Surgery, University of New South Wales, South Western Sydney Clinical School, Liverpool, NSW, Australia.,Whitlam Orthopaedic Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Johan Bellemans
- CPAK Research Group, Sydney, Australia.,Department of Orthopaedic Surgery, Hasselt University, ZOL Hospitals, Genk, Belgium.,ArthroClinic, Leuven, Belgium
| | - Darren B Chen
- CPAK Research Group, Sydney, Australia.,Sydney Knee Specialists, St George Private Hospital, Kogarah, Australia
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Alesi D, Meena A, Fratini S, Rinaldi VG, Cammisa E, Lullini G, Vaccari V, Zaffagnini S, Marcheggiani Muccioli GM. Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021? Musculoskelet Surg 2021; 106:1-8. [PMID: 33587251 PMCID: PMC8881420 DOI: 10.1007/s12306-021-00695-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/02/2021] [Indexed: 10/31/2022]
Abstract
Total knee arthroplasty in valgus knee deformities continues to be a challenge for a surgeon. Approximately 10% of patients who undergo total knee arthroplasty have a valgus deformity. While performing total knee arthroplasty in a severe valgus knee, one should aware with the technical aspects of surgical exposure, bone cuts of the distal femur and proximal tibia, medial and lateral ligament balancing, flexion and extension gap balancing, creating an appropriate tibiofemoral joint line, balancing the patellofemoral joint, preserving peroneal nerve function, and selection of the implant regarding constraint. Restoration of neutral mechanical axis and correct ligament balance are important factors for stability and longevity of the prosthesis and for good functional outcome. Thus, our review aims to provide step by step comprehensive knowledge about different surgical techniques for the correction of severe valgus deformity in total knee arthroplasty.
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Affiliation(s)
- D Alesi
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - A Meena
- VMMC and Safdarjung Hospital, Central Institute of Orthopedics, New Delhi, 110029, India
| | - S Fratini
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - V G Rinaldi
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - E Cammisa
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - G Lullini
- UO Medicina Riabilitativa e Neuroriabilitazione, IRCCS Istituto delle Scienze Neurologiche, Via Altura 3, 40139, Bologna, Italy
| | - V Vaccari
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - S Zaffagnini
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - G M Marcheggiani Muccioli
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy. .,University of Bologna, Bologna, Italy.
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Savov P, Mielke E, Windhagen H, Calliess T, Richter A, Ettinger M. Higher revision rate for posterior cruciate-retaining than posterior-stabilized total knee arthroplasty for the treatment of valgus osteoarthritis. Arch Orthop Trauma Surg 2021; 141:305-312. [PMID: 33104898 DOI: 10.1007/s00402-020-03618-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 09/30/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE Determining the point at which a valgus deformity requires a more invasive therapy-in this case PS TKA-is surgically challenging. Retaining the posterior cruciate ligament has both advantages and disadvantages. The aim was to evaluate the failure rate and clinical outcomes. METHODS 248 patients with valgus gonarthrosis underwent surgical treatment: 167 CR TKA cases and 81 PS TKA cases. The KOOS and the OKS were recorded, and 201 patients (133 CR, 68 PS) were recruited into the retrospective study. The influence of BMI and degree of preoperative valgus deformity on the clinical outcome was determined. The revision rate was documented and analysed. RESULTS Of 201 patients, 10 required revision surgery owing to instability (10/133 CR, 0/68 PS). Based on the KOOS and the OKS, no significant difference between CR TKA and PS TKA was found. BMI and degree of valgus deformity had no effect on the clinical outcome. CONCLUSIONS No difference in the clinical outcome between the CR and PS TKA patients was found. In the CR group, significantly more patients showed 'excellent' OKS than in the PS group. However, 8.0% of the patients in the CR group and none in the PS group underwent surgery due to instability. A higher rate of dissatisfied patients in the CR group is likely. In our clinic, we no longer perform CR TKA for valgus cases.
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Affiliation(s)
- Peter Savov
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany.
| | - Evelyn Mielke
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Henning Windhagen
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Tilman Calliess
- Articon Christenorto AG, Schänzlistrasse 39, 3013, Bern, Switzerland
| | - Alena Richter
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany
| | - Max Ettinger
- Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Strasse 1-7, 30625, Hanover, Germany.
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Lei K, Liu LM, Xiang Y, Chen X, Fan HQ, Peng Y, Luo JM, Guo L. Clinical value of CT-based patient-specific 3D preoperative design combined with conventional instruments in primary total knee arthroplasty: a propensity score-matched analysis. J Orthop Surg Res 2020; 15:591. [PMID: 33298106 PMCID: PMC7724895 DOI: 10.1186/s13018-020-02123-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/25/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose To evaluate the operation and early clinical effect in primary total knee arthroplasty (TKA) about the novel combination of CT-based patient-specific three-dimensional (3D) preoperative design and conventional osteotomy instruments, compared with the conventional method. Methods After a 1:1 propensity score-matching (PSM), patients were matched to the novel technique group and the conventional group, 109 cases in each group. The conventional group adopted a preoperative design based on a full-length radiograph (FLX) and received TKA with conventional osteotomy instruments. The novel technique group used a CT-based patient-specific 3D preoperative design combined with conventional osteotomy instruments; during the surgery, the femoral entry point, femoral valgus osteotomy angle, the fix point of tibial plateau extramedullary guide pin, and the position of tibial extramedullary positioning rod were accurately selected according to the preoperative 3D design to ensure accurate intraoperative implementation. The lower limb alignment, component position, operation time, tourniquet time, hospital stay, blood loss volume, incidence of postoperative complications, visual analog scale (Vas) score, and New Knee Society Score System (NEW-KSS) at 1 day before operation and 1, 6, and 12 months after operation were recorded and compared. Results The novel technique group was significantly better than the conventional group in controlling lateral tibial component angle (LTC) (P < 0.001), and the novel technique group had lower percentages of hip-knee-ankle angle (HKA) outliers (P < 0.001) and overcorrection (P = 0.003). The operation time, tourniquet time, and hospital stay of the novel technique group was shorter (P < 0.05). In 1 month after the operation, the novel technique group achieved a significantly better VAS score (P < 0.05), but a similar NEW-KSS score (P > 0.05) when compared with the conventional group. But in 6 and 12 months after surgery, no statistical differences were seen in the above two scores (P > 0.05). Conclusion The novel technique of CT-based patient-specific 3D preoperative design combined with conventional instruments can improve the accuracy of osteotomy in primary total knee arthroplasty, with benefits of significantly reducing pain and rapid recovery during the early postoperative period, but having no obvious effect on outcome after a 1-year follow-up.
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Affiliation(s)
- Kai Lei
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Li Ming Liu
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Yi Xiang
- Department of Orthopaedics, Logistic Support Forces of the Chinese PLA 985 Hospital, No. 30 Qiaodong Street, Taiyuan, 030001, Shanxi, China
| | - Xin Chen
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Hua Quan Fan
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Yang Peng
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Jiang Ming Luo
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China
| | - Lin Guo
- Center for Joint Surgery, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing, 400036, China.
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Cheng W, Li Z, Zhang J, Cao Q, Yu H, Qi L, Yao F, Jing J. A lateral parapatellar approach with iliotibial band dissection from the Gerdy tubercle for total knee arthroplasty of the valgus knee. Exp Ther Med 2020; 21:38. [PMID: 33273968 DOI: 10.3892/etm.2020.9470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 09/11/2020] [Indexed: 01/14/2023] Open
Abstract
Valgus knee, which causes severe dysfunction and seriously affects the quality of life of patients, is a condition affecting 10% of patients who undergo total knee arthroplasty (TKA). The best choice of surgical approach and the method of release of soft tissue, however, is still unclear. Therefore, the aim of the present study was to investigate the clinical efficacy of a lateral parapatellar approach with iliotibial band (ITB) dissection from the Gerdy tubercle for TKA in valgus knees. In total, 56 patients (25 males and 31 females) who underwent surgery via a lateral parapatellar approach with ITB dissection from the Gerdy tubercle for TKA due to valgus knee, with at least one-year follow-up, were retrospectively analyzed. Operation duration, length of time leg was raised post-surgery, prosthetic position, lower limb force line, visual analogue score for pain (VAS), range of movement (ROM), and Knee Society Scores (KSS; including knee score and functional score) were reviewed and analyzed. The data indicated that VAS, ROM and KSS were significantly improved after surgery compared with those before surgery. Additionally, no patient had a deviation in prosthetic position or limb alignment greater than 5˚. These results suggest that a lateral parapatellar approach with ITB dissection from the Gerdy tubercle for TKA is an effective technique to treat valgus knee, which can significantly improve pain and function without deviation of the lower limb mechanical axis or prosthesis position.
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Affiliation(s)
- Wendan Cheng
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Ziyu Li
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Jisen Zhang
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Qiliang Cao
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Haoran Yu
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Lei Qi
- Department of Orthopedic Surgery, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, P.R. China
| | - Fei Yao
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
| | - Juehua Jing
- Department of Orthopedic Surgery, Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230000, P.R. China
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Incidence of Soft-Tissue Releases, Clinical and Radiological Outcomes of Lateral Parapatellar Approach for Valgus Arthritic Knees: A 4-year Follow-up Study with A Review of Literature. Indian J Orthop 2020; 55:38-45. [PMID: 34122753 PMCID: PMC8149535 DOI: 10.1007/s43465-020-00294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To analyse the incidence of additional soft tissue releases with the lateral parapatellar approach, and the clinical and radiological outcomes of total knee arthroplasties performed using the lateral parapatellar approach for valgus arthritic knees. A review of the existing literature on valgus arthritic knees undergoing knee replacement was performed and our results compared. MATERIALS AND METHODS This is a prospective cohort study of 50 patients operated by this approach. Operation and clinical records were assessed to determine the number and sequence of soft tissue releases. Functional outcome was measured using the Oxford Knee Score. Radiological assessment included measurement of alignment and implant positioning. RESULTS 46 patients included. Mean follow-up of 4 years. Additional lateral releases were performed in 11 (24%) cases. Mean valgus alignment corrected from 13.1 degrees pre-operatively to 5.7 degrees post-operatively. Oxford Knee Score improved from a mean pre-operative score of 11.9 to a mean post-operative score of 38.3 at final follow-up. Radiographs revealed lateralisation of the tibial component in 4 patients. No immediate or late post-operative wound complications, late instabilities or revisions were observed. CONCLUSION Lateral parapatellar approach is highly effective in correcting the valgus deformity with a low incidence of additional soft tissue releases. Medium-term results indicate an excellent functional outcome with no complications.
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Novoa-Parra CD, Sanjuan-Cerveró R, de la Iglesia NH, Franco-Ferrando N, Larrainzar-Garijo R, Lizaur-Utrilla A. Importance of the gender and preoperative knee sagittal alignment to avoid unnecessary tibial resection in TKR. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:333-340. [PMID: 32886248 DOI: 10.1007/s00590-020-02773-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Standard resections according to the TKR manufacturers can lead to unnecessary bone resections in some patients. The objective of this study was to determine in which patients is recommended to perform a minimal tibial resection (MTR) that could restore the joint line height (JLH). METHODS Navigation records of 108 consecutive posterior cruciate-substituting TKR performed by one surgeon were analyzed. Optimal tibial resection depth to restore the JLH (0 mm) was calculated by an algorithm. Postoperatively, the knees were distributed in two groups: those in which a MTR (depth ≤ 8 mm) would have been enough to restore the JLH and those in which a standard resection depth would have been necessary. ROC curves and Youden index were used to determine the cutoff point of the coronal and sagittal mechanical axis that predicted a MTR restoring the JLH. Multivariate analysis was used to identify independent factors associated with requiring an MTR. RESULTS A MTR could be required in 20 (18.5%) knees. In the ROC curve analyses, the cutoff points that best discriminated between minimal and standard tibial resection was ≤ 3° of varus and < 2° of flexion preoperative deformity. Multivariate analysis showed that female gender and preoperative flexion < 2° were significant predictors of requiring a MTR to restore JLH. CONCLUSION A MTR with the JLH restoration could be possible in female patients with a preoperative sagittal deformity less than 2° of flexion. Preoperative coronal alignment had no influence to discriminate when a MTR is required.
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Affiliation(s)
- Carlos Daniel Novoa-Parra
- Orthopaedic and Traumatology Department, Denia Hospital, Partida Beniadla S/N, 03700, Alicante, Spain.
| | - R Sanjuan-Cerveró
- Orthopaedic and Traumatology Department, Denia Hospital, Partida Beniadla S/N, 03700, Alicante, Spain
| | - N H de la Iglesia
- Orthopaedic and Traumatology Department, Denia Hospital, Partida Beniadla S/N, 03700, Alicante, Spain
| | - N Franco-Ferrando
- Orthopaedic and Traumatology Department, Denia Hospital, Partida Beniadla S/N, 03700, Alicante, Spain
| | - R Larrainzar-Garijo
- Orthopaedic and Traumatology Department, Infanta Leonor University Hospital, Madrid, Spain
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Raut V, Matar HE, Singh A. Satisfactory medium-term outcomes with lateral condylar sliver osteotomy to correct valgus deformity in total knee replacements. Knee Surg Sports Traumatol Arthrosc 2020; 28:1394-1399. [PMID: 30887065 DOI: 10.1007/s00167-019-05488-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/13/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe a surgical technique in correcting valgus deformity during total knee replacement and evaluate medium-term clinical outcomes. METHODS This was a retrospective consecutive series of total knee replacement for severe valgus deformity of patients who underwent a lateral ligament complex release with a sliver osteotomy of the lateral femoral condyle with a minimum 1-year follow-up and recording objective and patient-reported outcome measures. RESULTS Twenty-three patients (25 knees) were included with median follow-up of 5 years (range 1-15 years) and average age 67.7 years (range 43-87). The primary diagnosis was osteoarthritis in 14 patients (61%) and inflammatory arthritis in 9 patients (39%). At final follow-up, the median mechanical tibiofemoral angle was restored to 4° (range 2-7) compared with a median valgus of 20° (range 13-30) preoperatively. This was statistically significant (P < 0.00001). Median Oxford Knee Score at final follow-up was 43 (range 36-48) indicating satisfactory outcomes. There were no revisions for any cause with a mean arc range of movement 110° (range 85-120). CONCLUSION This study shows that a technique utilising the familiar medial parapatellar approach, staged soft tissue releases, and a novel sliver lateral femoral condylar osteotomy with intact periosteum to release the lateral ligament complex leads to satisfactory medium-term outcomes, improved range of movement and patients' reported outcome measures. Sliver osteotomy is a useful technique in correcting valgus deformity in total knee replacements at medium-term follow-up. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Videshnandan Raut
- Wrightington and Lancashire Teaching Hospitals, Edge Hill University, Wigan, WN6 9EP, UK
| | - Hosam E Matar
- Centre for Hip Surgery, Wrightington Hospital, Wigan, WN6 9EP, UK.
| | - Amit Singh
- Trauma and Orthopaedics, Royal Lancaster Infirmary, Ashton Road, Lancaster, LA1 4RP, UK
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Völlner F, Herl F, Greimel F, Benditz A, Renkawitz T, Grifka J, Craiovan B, Weber M. The effects of soft tissue lateral release on the stability of the ligament complex of the knee. Arch Orthop Trauma Surg 2020; 140:933-940. [PMID: 32232619 PMCID: PMC7295728 DOI: 10.1007/s00402-020-03422-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Indexed: 01/08/2023]
Abstract
PURPOSE Valgus deformity presents a particular challenge in total knee arthroplasty. This condition regularly leads to contractures of the lateral capsular ligament complex and to overstretching of the medial ligamentous complex. Reconstruction of the knee joint kinematics and anatomy often requires lateral release. However, data on how such release weakens the stability of the knee are missing in the literature. This study investigated the effects of sequential lateral release on the collateral stability of the ligament complex of the knee in vitro. METHODS Ten knee prostheses were implanted in 10 healthy cadaveric knee joints using a navigation device. Soft tissue lateral release consisted of five release steps, and stiffness and stability were determined at 0, 30, 60 and 90° flexion after each step. RESULTS Soft tissue lateral release increasingly weakened the ligament complex of the lateral compartment. Because of the large muscular parts, the release of the iliotibial band and the M. popliteus had little effect on the stability of the lateral and medial compartment, but release of the lateral ligament significantly decreased the stability in the lateral compartment over the entire range of motion. Stability in the medial compartment was hardly affected. Conversely, further release of the posterolateral capsule and the posterior cruciate ligament led to the loss of stability in the lateral compartment only in deep flexion, whereas stability decreased significantly in the medial compartment. CONCLUSION Our study shows for the first time the association between sequential lateral release and stability of the ligamentous complex of the knee. To maintain the stability, knee surgeons should avoid releasing the entire lateral collateral ligament, which would significantly decrease stability in the lateral compartment.
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Affiliation(s)
- Florian Völlner
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Florian Herl
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Felix Greimel
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Achim Benditz
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Tobias Renkawitz
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Joachim Grifka
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Benjamin Craiovan
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
| | - Markus Weber
- Department of Orthopaedic Surgery, Regensburg University Medical Centre, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077 Bad Abbach, Germany
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Wang B, Xing D, Li JJ, Zhu Y, Dong S, Zhao B. Lateral or medial approach for valgus knee in total knee arthroplasty - which one is better? A systematic review. J Int Med Res 2019; 47:5400-5413. [PMID: 31642382 PMCID: PMC6862885 DOI: 10.1177/0300060519882208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To identify whether the medial or lateral approach is superior for patients with valgus knees undergoing primary total knee arthroplasty (TKA). Methods Studies evaluating the 2 approaches were sourced from the PUBMED, EMBASE, Web of Science, and OVID databases. The quality of included studies was assessed using a modified quality evaluation method, and differences between approaches were systematically reviewed. Results Seventeen observational studies were included. The studies were published between 1991 and 2016, and included 5 retrospective studies and 12 prospective studies. Sixteen evaluation methods for the study outcomes were identified. Twelve and eight complication types were identified by studies reporting the lateral and medial approaches for valgus knee, respectively. Several studies showed that pain scores and knee function were superior using a lateral approach. Conclusion The lateral approach (combined with a tibial tubercle osteotomy or proximal quadriceps snip) was more useful and safer than the medial approach in the treatment of severe uncorrectable valgus knee deformity in patients undergoing TKA. Most of the available evidence supports the use of a lateral approach provided that the surgeon is familiar with the pathological anatomy of the valgus knee.
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Affiliation(s)
- Bin Wang
- Orthopedic Department, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Dan Xing
- Arthritis Clinic & Research Center, Peking University People's Hospital, Peking University, Beijing, China
| | - Jiao Jiao Li
- Kolling Institute, University of Sydney, Sydney, Australia
| | - Yuanyuan Zhu
- Pharmaceutical Department, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Shengjie Dong
- Orthopedic Department, Yantaishan Hospital, Yantai, Shandong, China
| | - Bin Zhao
- Orthopedic Department, Second Hospital of Shanxi Medical University, Taiyuan, China
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Mazzotti A, Perna F, Golinelli D, Quattrini I, Stea S, Bordini B, Faldini C. Preoperative valgus deformity has twice the risk of failure as compared to varus deformity after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:3041-3047. [PMID: 30539306 DOI: 10.1007/s00167-018-5331-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/07/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE The aim of this study was to assess whether preoperative valgus or varus deformity affected survivorship after total knee arthroplasty (TKA) and to quantify the risk factors for implant failure in a registry-based population. METHODS The Emilia-Romagna Registry of Prosthetic Orthopedic Implants was examined regarding TKAs performed on patients with a preoperative diagnosis of valgus or varus deformity. Demographics, implant characteristic and survivorships were investigated and compared. A total of 2327 TKA procedures performed from 2000 to 2016 were included in the study. Six hundred and forty primary TKAs with a diagnosis of valgus deformity were evaluated with a median follow-up of 3.3 years; 1687 primary TKAs with a diagnosis of varus deformity were evaluated with a median follow-up of 2.5 years. RESULTS Bi-compartmental, cemented posterior stabilised fixed-bearing implants were preferred. For both diagnoses, the implant survivorship rate was greater than 98% in the first year. However, the survival curve of the TKAs implanted for valgus deformity showed a greater slope in the first 3 years as compared to the survival curve of those implanted for varus deformity. Valgus deformity had a 2.1-fold higher risk for revision as compared with varus deformity. Infection was a major cause of implant failure in TKAs for varus deformity, 9/24 (37.5%), while its incidence was lower for valgus deformity, 1/21 (4.8%). CONCLUSIONS Preoperative valgus alignment showed a twofold risk of failure as compared to varus alignment after TKA. This should be considered in daily practice, and surgeons are called on to pay more attention when performing TKAs on such patients. Prospective randomised controlled trials are, therefore, necessary to better understand the role of preoperative coronal knee deformity in implant failure. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Antonio Mazzotti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Fabrizio Perna
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Davide Golinelli
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Via San Giacomo 12, 40126, Bologna, Italy.
| | - Irene Quattrini
- IRCCS Istituto Ortopedico Rizzoli, via di Barbiano 1/10, 40136, Bologna, Italy
| | - Susanna Stea
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano 1/10, 40136, Bologna, Italy
| | - Barbara Bordini
- Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano 1/10, 40136, Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
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Li F, Liu N, Li Z, Wood KB, Tian H. Abnormally high dislocation rate following constrained condylar knee arthroplasty for valgus knee: a case-control study. J Orthop Surg Res 2019; 14:268. [PMID: 31443664 PMCID: PMC6708210 DOI: 10.1186/s13018-019-1325-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/18/2019] [Indexed: 11/24/2022] Open
Abstract
Background With the use of constrained condylar knee (CCK) prostheses, dislocation of the knee following total knee arthroplasty (TKA) with valgus deformity is rare. In our practice with such patients, however, an abnormally high dislocation rate was noted. It appeared to be associated with the extent of soft-tissue release which varied among surgeons following different sequences of release. We asked in CCK TKA with valgus deformity is releasing both the lateral collateral ligament (LCL) and popliteus tendon (PT) associated with the occurrence of dislocation. Methods This is a case-control study of consecutive patients with valgus deformity who underwent primary CCK TKA between July 2008 and October 2015. The cases and controls were patients with and without postoperative dislocation of the knee, respectively. The extent of the release of lateral soft-tissue structures was compared between the two groups. Other patient characteristics including age, body mass index, pre- and post-operative valgus deformity, preoperative flexion-contracture, and height of the polyethylene insert were compared as well to reduce confounding. Results Forty-three consecutive patients with a minimum 2-year follow-up were enrolled. 9.3% (4/43) of the patients had postoperative dislocation of the knee. While the dislocated patients did not significantly differ from the controls on most characteristics, they were more likely to have both the LCL and PT released together during the surgery [100% (4/4) vs. 2.6% (1/39), P < 0.001]. Conclusion Releasing both LCL and PT in CCK TKA with valgus deformity may increase the risk of dislocation, and need to be performed with some caution.
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Affiliation(s)
- Feng Li
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Garden Road, Beijing, 100191, China
| | - Ning Liu
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Redwood City, CA, 94063, USA
| | - Zijian Li
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Garden Road, Beijing, 100191, China
| | - Kirkham B Wood
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Redwood City, CA, 94063, USA
| | - Hua Tian
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Garden Road, Beijing, 100191, China.
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Brand J, Tyagi V, Rubin L. Total knee arthroplasty in osteogenesis imperfecta. Arthroplast Today 2019; 5:176-180. [PMID: 31286040 PMCID: PMC6588802 DOI: 10.1016/j.artd.2018.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/14/2018] [Accepted: 09/15/2018] [Indexed: 11/28/2022] Open
Abstract
Osteogenesis imperfecta is a genetic disease resulting in abnormal collagen formation, with multiple clinical manifestations. Advancements in medical and surgical treatments have prolonged the life expectancy of these patients in recent decades. As a result, orthopedic surgeons are likely to be faced with the challenge of performing arthroplasty in these patients on a more frequent basis. Here, we describe a patient with osteogenesis imperfecta and subsequent severe osteoarthritis prompting primary total knee arthroplasty. This rare case presents an opportunity to explore special considerations unique to this patient population, including comorbid bone defects, the need for using extramedullary guides, careful alignment of prostheses to accommodate abnormalities in limb axes, and equipment utilization.
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Affiliation(s)
| | | | - Lee Rubin
- Yale New Haven Hospital New Haven, CT, USA
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Mou P, Zeng Y, Pei F, Zhou Z, Shen B, Kang P, Yang J. Medial femoral epicondyle upsliding osteotomy with posterior stabilized arthroplasty provided good clinical outcomes such as constrained arthroplasty in primary total knee arthroplasty with severe valgus deformity. Knee Surg Sports Traumatol Arthrosc 2019; 27:2266-2275. [PMID: 30430221 DOI: 10.1007/s00167-018-5292-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/09/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE A modified technique referred to as a medial femoral epicondyle upsliding osteotomy was proposed to address severe valgus deformity with unconstrained posterior stabilized (PS) arthroplasty. The study compared the effectiveness of the technique and PS arthroplasty with constrained arthroplasty during primary total knee arthroplasty (TKA). METHODS Fifty-three patients presenting with valgus knees with a mean valgus angle (VA) greater than 30° were prospectively randomized and divided into two groups, and both groups received primary TKA. Upsliding osteotomy with PS arthroplasty was performed on the knees of 27 patients (group A), while the remaining 26 patients (group B) received a constrained arthroplasty. The Knee Society function score (KSF), Hospital for Special Surgery knee score (HSS), range of motion (ROM), mediolateral stability and hospitalization expenses were recorded. The hip-knee-ankle angle (HKA), femorotibial angle (FTA) and VA were analysed. Complications were also recorded. RESULTS The patients received follow-up care for more than 50 months. The postoperative KSF, HSS and ROM showed marked improvement in both groups (p < 0.05). Radiological assessments showed that HKA, FTA and VA for group A were restored to (179.9 ± 3.0)°, (173.0 ± 2.4)° and (7.0 ± 2.4)°, respectively. For group B, the HKA, FTA and VA were restored to (181.5 ± 2.3)°, (172.5 ± 2.3)° and (7.5 ± 2.3)°, respectively. Only two patients from group A demonstrated mild medial laxity in their knees, and the remaining patients from both groups were stable medially and laterally. However, the total hospitalization expenses and material expenses of group A were less than those of group B because of the more expensive constrained prosthesis and stems. No late-onset loosening or recurrent valgus deformity was displayed. CONCLUSIONS Both medial femoral epicondyle upsliding osteotomy with PS arthroplasty and constrained arthroplasty showed good outcomes for the restoration of neutral limb alignment and soft tissue balance, which are demonstrated to be safe and effective techniques for correcting severely valgus knees. Therefore, the clinically important finding of this study is that medial femoral epicondyle upsliding osteotomy with PS arthroplasty can be an alternative method for correcting severe valgus knees. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Ping Mou
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yi Zeng
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Fuxing Pei
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zongke Zhou
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Bin Shen
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Pengde Kang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jing Yang
- Department of Orthopedic Surgery, West China Hospital, West China Medical School, Sichuan University, #37 Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
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Distal femoral osteotomy in a young symptomatic population: Outcomes correlate to concomitant pathology. J Orthop 2019; 16:283-288. [PMID: 31193264 DOI: 10.1016/j.jor.2019.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/15/2019] [Indexed: 11/21/2022] Open
Abstract
Background There is a paucity of literature describing distal femoral osteotomies (DFO) in regards to complications and outcomes with previously studied cohorts containing primarily older, arthritic subjects. There has been no study to date focusing on younger, pre-arthritic patients. Methods All service members indicated for distal femoral osteotomy for coronal plane malalignment were isolated from military treatment centers between 2007 and 2013. Demographic and surgical variables were extracted, and perioperative complications, clinical course, and return to military function were extracted using clinical notes and radiographs. Results A total of 22 knees in 19 patients were identified at an average 3.2 year follow-up, with the exclusion of 16 individuals. Statistical analysis revealed worse outcomes associated with smoking, over correction, breach of the medial cortex, and prior surgeries. Overall 58% of patients left the military as the result of knee dysfunction despite an average improvement in visual analog scores (VAS) from 4.0 to 1.9 (p = 0.004). Conclusions While offloading the lateral compartment improves symptoms at short to midterm follow-up preventing progression to arthroplasty, young active duty military members have suboptimal return to duty rates.
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A simple method for determining ligament stiffness during total knee arthroplasty in vivo. Sci Rep 2019; 9:5261. [PMID: 30918309 PMCID: PMC6437197 DOI: 10.1038/s41598-019-41732-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 03/14/2019] [Indexed: 12/12/2022] Open
Abstract
A key requirement in both native knee joints and total knee arthroplasty is a stable capsular ligament complex. However, knee stability is highly individual and ranges from clinically loose to tight. So far, hardly any in vivo data on the intrinsic mechanical of the knee are available. This study investigated if stiffness of the native ligament complex may be determined in vivo using a standard knee balancer. Measurements were obtained with a commercially available knee balancer, which was initially calibrated in vitro. 5 patients underwent reconstruction of the force-displacement curves of the ligament complex. Stiffness of the medial and lateral compartments were calculated to measure the stability of the capsular ligament complex. All force-displacement curves consisted of a non-linear section at the beginning and of a linear section from about 80 N onwards. The medial compartment showed values of 28.4 ± 1.2 N/mm for minimum stiffness and of 39.9 ± 1.1 N/mm for maximum stiffness; the respective values for the lateral compartment were 19.9 ± 0.9 N/mm and 46.6 ± 0.8 N/mm. A commercially available knee balancer may be calibrated for measuring stiffness of knee ligament complex in vivo, which may contribute to a better understanding of the intrinsic mechanical behaviour of knee joints.
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Lateral femoral sliding osteotomy in total knee arthroplasty with valgus deformity greater than twenty degrees. INTERNATIONAL ORTHOPAEDICS 2019; 43:2511-2517. [PMID: 30659318 DOI: 10.1007/s00264-019-04295-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/06/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Lateral femoral sliding osteotomy has been reported as an effective technique for total knee arthroplasty (TKA) with significant valgus deformity. This study aims to investigate its utility in TKA with valgus deformity greater than 20°, for which few studies have examined. METHODS Consecutive TKA patients with valgus deformity treated with the sliding osteotomy at our institution were retrospectively studied. Constraint implants were not used. Radiological and clinical parameters at follow-ups were compared with those pre-operatively. Radiological parameters included the hip-knee-ankle angle (HKA), the anatomical lateral distal femoral angle (aLDFA), the anatomical lateral plateau ankle angle (aLPTA), and the angle between the femoral mechanical axis and transepicondylar line (femoral transepicondylar angle, FTEA) which was used to reflect concurrent extra-articular valgus and corresponding local alignment. Clinical outcome measures included the Knee Society Score and Functional Score. RESULTS Twenty-five patients operated on between July 2011 and February 2017 were enrolled. The average follow-up time was 3.3 (1.5~7.9) years. The pre-operative HKA of 202.7 ± 2.3° (equivalent to valgus of 22.7 ± 2.3°) was reduced to 180.4 ± 2.3° at final follow-ups (P < 0.001). The aLFDA, aLPTA, and FTEA were all significantly improved, with the last one increased from 84.2 ± 1.8° to 89.6 ± 1.6° (t = - 11.35, P < 0.001). All clinical scores were significantly improved without major complications. CONCLUSIONS Lateral femoral sliding osteotomy can be effective and safe for TKA with severe valgus deformity greater than 20°.
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Utomo DN, Mahyudin F, Yanuar A, Widhiyanto L, Hernugrahanto KD. Correction of severe valgus deformity of knee osteoarthritis with non-constrained total knee arthroplasty implant: A case report. Int J Surg Case Rep 2018; 53:218-222. [PMID: 30428435 PMCID: PMC6232595 DOI: 10.1016/j.ijscr.2018.10.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/19/2018] [Accepted: 10/29/2018] [Indexed: 12/01/2022] Open
Abstract
Knee osteoarthritis with severe valgus deformity is a challenging case. The correction usually requires the use of high-cost constrained knee implant. Non-constrained implant with ligament adjustment provide good outcome. Introduction Knee osteoarthritis with valgus deformity presents a surgical challenge that must be solved during total knee arthroplasty (TKA). In some case whereby ligament imbalance is found, constrained implant should be used. Unfortunately, the implant is not always readily accessible in some developing countries. The objective of this paper is to provide alternative solution to such case. Presentation of case We reported a 71-year-old female patient with a painful and fixed valgus deformity of her right knee. Preoperatively, the patient’s right knee range of motion (ROM) was 10–145° of flexion with a 32° fixed valgus deformity. A constrained implant was not accessible. To balance the ligament, Medial Collateral Ligament (MCL) origin was shifted to superior and anterior. A non-constrained implant was used. The valgus deformity was corrected intraoperatively and ROM achieved 0–140° of flexion. Discussion It is crucial that attention is given not only to the restoration of proper bony alignment but even more importantly to soft tissue balancing. By using the non-constrained implant, the cost can also be reduced and suitable for developing countries with limited coverage of state insurance. Conclusion Three months after the surgery, the patient achieved stable and painless knee with 10–90° of flexion and complete correction of her valgus deformity.
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Affiliation(s)
- Dwikora Novembri Utomo
- Orthopedic and Traumatology Department, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, Indonesia.
| | - Ferdiansyah Mahyudin
- Orthopedic and Traumatology Department, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, Indonesia.
| | | | - Lukas Widhiyanto
- Orthopedic and Traumatology Department, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, Indonesia.
| | - Kukuh Dwiputra Hernugrahanto
- Orthopedic and Traumatology Department, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, Indonesia.
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