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Erard J, Batailler C, Swan J, Sappey-Marinier E, Servien E, Lustig S. Lateral approach total knee arthroplasty achieves equivalent patellar tracking in severe valgus deformity compared to mild valgus deformity. Knee Surg Sports Traumatol Arthrosc 2022; 30:740-752. [PMID: 33492408 DOI: 10.1007/s00167-021-06451-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Patellar tracking problems represent 2-10% of complications of total knee arthroplasties (TKA) in valgus knees. However, there are no studies assessing patellar tracking according to the severity of the valgus deformity. The hypothesis was that lateral approach TKA in severe valgus deformity provides equivalent patellar tracking to that in knees with mild valgus deformity. METHODS Between 1988 and 2016, 77 TKAs were performed via a lateral approach on a severe valgus deformity (HKA > 195°). Forty-three TKAs performed without tibial tubercle osteotomy and with complete radiological data were included in this study. These were compared with 86 matched TKAs performed via a lateral approach with a mild valgus deformity (HKA between 181° and 190°). Patellar tilt and patellar position were assessed by axial view radiographs at the last follow-up. Complications and clinical outcomes were also evaluated. RESULTS The follow-up was mean 52 ± 21 months in the severe valgus group. No significant differences were found between the severe valgus deformity group and the mild valgus deformity groups in patellar tilt (1.6° ± 6.6° versus 1.9° ± 3.2°, respectively) or patellar subluxation. There were complications in 12% (n = 5) and 11% (n = 9) of the severe valgus group and the mild valgus group respectively, without significant difference. There was no significant difference in extensor mechanism complication rate (2.3% versus 4.7%, respectively). CONCLUSION Lateral parapatellar approach, without tibial tubercle osteotomy, for TKA in severe valgus deformity results in good patellar tracking. With this approach, the extensor mechanism complication rate in severe valgus deformity was not higher than for mild valgus deformity. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Julien Erard
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon North University Hospital, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Cécile Batailler
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon North University Hospital, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. .,Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622, Lyon, France.
| | - John Swan
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon North University Hospital, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Elliot Sappey-Marinier
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon North University Hospital, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Elvire Servien
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon North University Hospital, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,LIBM-EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University, Lyon, France
| | - Sébastien Lustig
- Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon North University Hospital, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Univ Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406, 69622, Lyon, France
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Yang D, Zhou Y, Shao H, Deng W. Different Deformity Origins and Morphological Features in Subtypes of Valgus Knees: A Radiological Classification System. Orthop Surg 2022; 14:96-103. [PMID: 34870368 PMCID: PMC8755874 DOI: 10.1111/os.13178] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To analyze the deformity origins and distribution among valgus knees to individualize their morphological features. METHODS Radiographic images of 105 valgus knees were analyzed. Long-film radiographs and computed tomography were collected for every knee. A malalignment test was performed on standing long-film radiographs. The hip-knee-ankle angle (HKA), the anatomical lateral distal femoral angle (aLDFA), and the anatomical medial proximal tibial angle (aMPTA) were measured on long-film radiographs. The distal condylar angle and posterior condylar angle on distal femur were further measured on computed tomography scans. The tibial bone varus angle was measured on long-film radiographs as well. All the valgus knees were sorted into different subtypes according to the origins of bony deformity, and the prevalence of each subtype was reported. Finally, to examine the inter-observer reproducibility of this classification system, two observers measured the deformities and did the classification for all the 105 knees independently and then the intraclass correlation coefficient (ICC) was calculated. RESULTS Among the 105 knees, 48 knees (45.7%) had apparent deformity from the tibial plateau, and 62 knees (59.0%) had apparent deformity from the supracondylar region of the femur. Eighteen knees (17.1%) had distal condylar angle >7°, among which 11 knees had posterior condylar angle >3° simultaneously. Valgus knees had five subtypes of bone deformity origins-the supracondylar part of the femur, the distal aspect of the lateral femoral condyle, both distal and posterior aspects of the lateral femoral condyle, the tibial plateau, or the metaphyseal segment of the tibia. A valgus knee could be labeled as only one subtype, or a combination of two or more subtypes. Labeling 105 knees with origin of the most severe deformity, the prevalence of each subtype was 40.0%, 5.7%, 9.5%, 28.6%, and 16.2%, respectively. The intra-observer and inter-observer ICC of this classification system was 0.992 and 0.976, respectively. CONCLUSIONS Valgus knees can be classified into different subtypes according to deformity origins. This radiological classification system has satisfactory reproducibility. It helps surgeons better individualize morphological features of valgus knees.
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Affiliation(s)
- Dejin Yang
- Department of Orthopaedic SurgeryBeijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua UniversityBeijingChina
| | - Yixin Zhou
- Department of Orthopaedic SurgeryBeijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua UniversityBeijingChina
| | - Hongyi Shao
- Department of Orthopaedic SurgeryBeijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua UniversityBeijingChina
| | - Wang Deng
- Department of Orthopaedic SurgeryBeijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua UniversityBeijingChina
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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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Intelligent analysis of coronal alignment in lower limbs based on radiographic image with convolutional neural network. Comput Biol Med 2020; 120:103732. [DOI: 10.1016/j.compbiomed.2020.103732] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 11/19/2022]
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Unconstrained total knee arthroplasty in significant valgus deformity: a modified surgical technique to balance the knee and avoid instability. Knee Surg Sports Traumatol Arthrosc 2017; 25:2825-2834. [PMID: 26615591 DOI: 10.1007/s00167-015-3881-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 11/12/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE Correction of valgus deformity in total knee arthroplasty (TKA) is technically challenging and has produced variable results. A modified surgical technique involving adapting the distal femoral cut with minimal soft tissue release is proposed. The authors hypothesise that using this technique would result in satisfactory radiological and functional outcome. METHODS The technique involves balancing the knee in extension by changing the distal femoral resection angle and confining soft tissue release to only the posterolateral capsule if required. Retrospective analysis of 276 consecutive TKAs performed using this technique under the care of a single surgeon in patients with valgus knee deformity ≥10° was undertaken. An unconstrained mobile bearing implant was used in all knees with a medial para-patellar approach, and outcome scores were collected prospectively. Seventy-five percent of the knees were cementless. [corrected] RESULTS Mean coronal alignment of the lower limb was corrected from 15.6° (±5.7°) to 3.8° (±2.5°). 97.8 % knees had their coronal alignment restored to ≤7°. Seventy-eight knees (28 %) were balanced by only changing the distal femoral resection angle. One hundred and ninety-eight knees (72 %) had release of the posterolateral capsule. Sixteen knees (5.8 %) also had release of iliotibial band. Lateral patellar release was performed in 39 knees (14 %). 93.1 % had central patello-femoral alignment. At between 5.8 and 10.5 year follow-up, there has been one spinout, managed by closed reduction, and one revision of tibial tray for subsidence. The mean American Knee Society clinical score improved from 19.1 to 86.5 (±12.2). CONCLUSION Adequate correction of valgus knee deformity was successfully achieved using this modified technique with satisfactory medium-term outcome and avoidance of instability.
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Ferreira MC, Franciozi CES, Kubota MS, Priore RD, Ingham SJM, Abdalla RJ. Is the Use of Spreaders an Accurate Method for Ligament Balancing? J Arthroplasty 2017; 32:2262-2267. [PMID: 28283428 DOI: 10.1016/j.arth.2017.01.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To analyze 2 methods of manual spreader gap assessment accuracy, visual vs blinded, compared with a controlled tensioner in total knee arthroplasty. METHODS Twenty-two fresh frozen cadaver knees were used to perform total knee arthroplasty by 22 surgeons. Extension and flexion gaps were measured with empirical manual force application with spreaders in 2 different manners: (1) surgeons were blinded to gap geometry formation-blind method group (BM) and (2) surgeons viewed them-viewing method group (VM). A tensioner was used to measure the corresponding ligament tension applied during spreader measurements and to measure the extension and flexion gaps with standard force of 100 and 80 N (tensioner method [TM]) in each femorotibial compartment. RESULTS All measurements with spreaders (VM and BM) presented extension and flexion gaps oversized and asymmetric (P < .0001), when compared with the same gaps measured with the tensioner. Approximately 63% (P = <0.001) and 77.3% (P = .161) of the VM group and 68.2% (P = .018) and 77.3% (P = .161) of the BM group demonstrated asymmetry for extension and flexion gaps up to 3 mm to the TM. Gaps measured in the VM group presented results with slightly less oversizing and asymmetries than the measurements in the BM group compared with TM, although significantly different (P < .0001). CONCLUSION The assessment of extension and flexion gaps with empirical manual applied force spreaders produced oversized and asymmetric gaps compared with the use of tensioner. No visual influence was observed during the spreader applied empirical manual force compared with the blinded assessment.
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Affiliation(s)
- Marcio C Ferreira
- Department of Orthopedics and Traumatology, Knee Surgery, Heart Hospital, São Paulo, SP, Brazil
| | - Carlos Eduardo S Franciozi
- Department of Orthopedics and Traumatology, Knee Surgery, Heart Hospital, São Paulo, SP, Brazil; Knee Surgery Department, Federal University of São Paulo, Medicine School, São Paulo, Brazil
| | - Marcelo S Kubota
- Knee Surgery Department, Federal University of São Paulo, Medicine School, São Paulo, Brazil
| | - Ricardo D Priore
- Department of Orthopedics and Traumatology, Knee Surgery, Alvorada Hospital, São Paulo, SP, Brazil
| | - Sheila J M Ingham
- Department of Orthopedics and Traumatology, Knee Surgery, Heart Hospital, São Paulo, SP, Brazil
| | - Rene J Abdalla
- Department of Orthopedics and Traumatology, Knee Surgery, Heart Hospital, São Paulo, SP, Brazil; Department of Orthopedics and Traumatology, Knee Surgery, Alvorada Hospital, São Paulo, SP, Brazil
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Nikolopoulos D, Michos I, Safos G, Safos P. Current surgical strategies for total arthroplasty in valgus knee. World J Orthop 2015; 6:469-482. [PMID: 26191494 PMCID: PMC4501933 DOI: 10.5312/wjo.v6.i6.469] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 04/23/2015] [Accepted: 05/18/2015] [Indexed: 02/06/2023] Open
Abstract
The majority of orthopaedic surgeons even currently agree that primary total arthroplasty in valgus knees with a deformity of more than ten degrees may prove challenging. The unique sets of bone and soft tissue abnormalities that must be addressed at the time of the operation make accurate axis restoration, component orientation and joint stability attainment a difficult task. Understanding the specific pathologic anatomic changes associated with the valgus knee is a prerequisite so as to select the proper surgical method, to optimize component position and restore soft-tissue balance. The purpose of this article is to review the valgus knee anatomical variations, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. It will also be underlying the up-to-date main approaches and surgical techniques be proposed in the English literature both for bone cuts and soft tissue management of valgus knees.
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8
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Huang TW, Kuo LT, Peng KT, Lee MS, Hsu RWW. Computed tomography evaluation in total knee arthroplasty: computer-assisted navigation versus conventional instrumentation in patients with advanced valgus arthritic knees. J Arthroplasty 2014; 29:2363-8. [PMID: 24439997 DOI: 10.1016/j.arth.2013.12.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/11/2013] [Accepted: 12/11/2013] [Indexed: 02/01/2023] Open
Abstract
Arthritic knees with advanced valgus deformity present with soft tissue and osseous anomalies that make total knee arthroplasty (TKA) difficult. We conducted a retrospective chart review of 41 patients (51 knees) to determine whether computer-assisted surgery-TKA (CAS-TKA) is superior to TKA using conventional guiding systems. A significantly higher rate of lateral retinaculum release as well as outlier of sagittal mechanical axes and position of the femoral component (femoral flexion and femoral rotational angle) was recorded in the conventional TKA group versus the CAS-TKA group. Both groups had significant postoperative improvement in clinical performance, but results did not differ significantly between groups. Despite its radiographic benefit, CAS-TKA showed no significant benefit over TKA in short-term clinical functional outcomes when performed by an experienced surgeon.
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Affiliation(s)
- Tsan-Wen Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Liang-Tseng Kuo
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kuo-Ti Peng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Mel S Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Robert Wen-Wei Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University, Taoyuan, Taiwan
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Ang CL, Fook S, Chia SL, Chin PL, Lo NN, Yeo SJ. Unconstrained arthroplasty in type II valgus knees: posterior stabilized or cruciate retaining? Knee Surg Sports Traumatol Arthrosc 2014; 22:666-73. [PMID: 24057422 DOI: 10.1007/s00167-013-2677-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 09/05/2013] [Indexed: 01/15/2023]
Abstract
PURPOSE Type II valgus knees are defined by medial collateral ligament laxity. This paper studies the results of posterior stabilized (PS) and cruciate retaining (CR) knee implants in type II valgus knees. METHODS From 1999 to 2009, there were 100 type II valgus knees in 95 patients eligible for study (63 PS, 37 CR). Patients had prospectively collected clinical data up to 2 years after surgery. RESULTS At 24 months after surgery, the CR group had reduced range of motion (PS: median 126.0°, CR: median 114°; n.s.) and a marginally but statistically significant increased valgus alignment (PS: median 5°, CR: median 6°; p = 0.011). Despite this, both groups produced equal and marked improvements in SF-36, function score and knee score of the Knee Society score, and Oxford knee score. CONCLUSIONS Overall, both PS and CR implants performed equally well in type II valgus knees at 24 months post-operatively. Further longer-term studies would be warranted to assess for late instability. LEVEL OF EVIDENCE Retrospective, Level III.
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Affiliation(s)
- Chia Liang Ang
- Department of Orthopaedic Surgery, Singapore General Hospital, 20 College Road, Level 4, Singapore, 169856, Singapore,
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Chou WY, Siu KK, Ko JY, Chen JM, Wang CJ, Wang FS, Wong T. Preoperative templating and computer-assisted total knee arthroplasty for arthritic valgus knee. J Arthroplasty 2013; 28:1781-7. [PMID: 23518428 DOI: 10.1016/j.arth.2012.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 09/05/2012] [Accepted: 09/23/2012] [Indexed: 02/01/2023] Open
Abstract
We reported the functional outcomes, component alignment and optimal thickness of the tibial inserts and joint line changes of 21 arthritic valgus knee deformities using preoperative templating and computer-assisted total knee arthroplasty(TKA). The osseous cut was modified using a novel preoperative templating technique. Soft tissue balance and component implantation were implemented with the aid of a computed tomography-free navigation system. The arthritic valgus knees had clinical, and functional improvement of the knee Society scores and Lysholm scores postoperatively, at an average of 37.8 ± 7.2 months. The mean anatomic axis (15.2° ± 4.5° vs. 6.1° ± 1.4°) and mechanical axis (8.3° ± 5.2° vs. 0.28° ± 1.6°) were also significantly improved postoperatively. The mean thickness of tibial inserts and joint line changes was 10.7 ± 1.46 mm and 0.1 ± 1.4 mm. This computer-assisted technique with preoperative radiographic templating is an alternative strategy to improve TKA results in arthritic valgus knees.
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Affiliation(s)
- Wen-Yi Chou
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Graduate Institute of Clinical Medical Science, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Jia Y, Gou W, Geng L, Wang Y, Chen J. Anatomic proximity of the peroneal nerve to the posterolateral corner of the knee determined by MR imaging. Knee 2012; 19:766-8. [PMID: 22424689 DOI: 10.1016/j.knee.2012.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 12/25/2011] [Accepted: 01/30/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND The pie crusting technique has been extensively used to release the lateral soft tissue in total knee arthroplasty. However, it may place the peroneal nerve at direct injury risk when performed in a valgus knee. The aim of this study was to determine the anatomic proximity of the peroneal nerve to the posterolateral corner of the knee. METHODS One hundred knees were measured on axial MR images for the proximity of peroneal nerve to the closest edge of the inner surface of joint capsule or the posterolateral corner of proximal tibia at the level of the joint line and the level of the tibial cut respectively. RESULTS The distance between the peroneal nerve and the closest edge of the inner surface of joint capsule at the level of the joint line was 15.0 ± 2.6mm (range, 8.5-22.3mm), and the distance between the peroneal nerve and the posterolateral corner of proximal tibia was 14.0 ± 2.7 mm (range, 8.0-23.2mm). These distances were correlated with the anteroposterior diameter of the soft tissue of the knee, but not correlated with the size of the tibia. CONCLUSIONS These results suggest that it is safe enough providing that the scalpel blade does not pierce more than 8mm deep. However, patients with smaller legs are at greater risk of direct peroneal nerve injury.
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Affiliation(s)
- Yanhui Jia
- Department of Orthopedics, Chinese PLA General Hospital, No.28 Fuxing Road, Haidian District, Beijing 100853, China
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Bremer D, Orth BC, Fitzek JG, Knutsen A. [Briard's sagittal sliding osteotomy of the lateral condyle in total knee arthoplasty of the severe valgus knee]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:95-108. [PMID: 22526171 DOI: 10.1007/s00064-011-0064-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Distalization of the insertion of the lateral collateral ligament and popliteus tendon by sliding osteotomy of the lateral femur condyle in order to correct a residual contracture in extension in total knee arthroplasty (TKA) of the severe valgus deformity. INDICATIONS Genuine and other valgus deformity of the knee. CONTRAINDICATIONS Severe laxity of the medial collateral ligament; common contraindications of joint replacement. SURGICAL TECHNIQUE Lateral parapatellar approach and stepwise osteotomy of the tubercle of the tibia, subperiostal release of the lateral contracted structures such as iliotibial band (ITB) and lateral collateral ligament (LCL) in flexion. Tibia first technique, verification of a balanced and stable flexion gap parallel to the epicondylar line. Posterior cruciate ligament (PCL) is preserved. Referencing of the distal femoral cut by a spacer filled only in the medial extension gap. Finishing femoral chamfer cuts. If extension gap remains trapezoidal, further release of the residual lateral contracted structures in extension by means of sliding osteotomy of the lateral condyle and subperiostal release of the capsule and the lateral septum intermusculare is required. Termporary fixation of the lateral condyle by K-wires, resection of the bony excess, trial of test components, definite screw fixation. POSTOPERATIVE MANAGEMENT Comparable to TKA in varus deformities by a medioparapatellar approach. RESULTS A total of 79 patients (61 women, 18 men, average age 71 years at the time of surgery) with fixed valgus deformities were operated between June 2001 and December 2010 using TKA and sliding osteotomy of the lateral femoral condyle. The preoperative valgus angle under defined valgus and varus stress was 19.5° (8-40), postoperative 4.7° (2-11). Mean medial angle (valgus stress) of the follow-up was 2.1° (0.5-5°), lateral angle (varus stress) 2.3° (0.5-5°). A total of 35 patients were followed-up, at a mean of 73.3 month (24-109 months). The postoperative Knee Society Score was 95 points (56-100 points), while the postoperative Function Score was 90 points (55-100 points) postoperatively. The Oxford Score improved from 22 points (3-43 points) preoperatively to 45 points (21-48 points) postoperatively. One knee had to be revised due to infection, one knee due to non-union of the tibial tubercle. Finally, there were 3 cases with complications associated with the procedure due to the sliding osteotomy of the lateral femoral condyle; all were revised successfully. No conversion to a semi-constrained or constrained knee prosthesis was necessary.
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Affiliation(s)
- D Bremer
- Klinik für Orthopädie im Zentrum für Orthopädie und Unfallchirurgie, Kreiskrankenhaus Mechernich, Lehrkrankenhaus der Universität Bonn, St. Elisabeth Str. 2-6, 53894, Mechernich, Deutschland.
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Babazadeh S, Stoney JD, Lim K, Choong PFM. The relevance of ligament balancing in total knee arthroplasty: how important is it? A systematic review of the literature. Orthop Rev (Pavia) 2011; 1:e26. [PMID: 21808688 PMCID: PMC3143981 DOI: 10.4081/or.2009.e26] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 10/20/2009] [Indexed: 12/13/2022] Open
Abstract
Ligament balancing affects many of the postoperative criteria for a successful knee replacement. A balanced knee contributes to improved alignment and stability. Ligament balancing helps reduce wear and loosening of the joint. A patient with a balanced knee is more likely to have increased range of motion and proprioception, and decreased pain. All these factors help minimize the need for revision surgery. Complications associated with ligament balancing can include instability caused by over-balancing and the possibility of neurovascular damage during or as a result of ligament balancing. This article attempts to summarize the literature, to define a balanced knee, and outline the benefits and possible complications of ligament balancing. Different techniques, sequences, and tools used in ligament balancing, and their relevance in correcting various deformities are reviewed.
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Total knee arthroplasty in severe valgus knee deformity: comparison of a standard medial parapatellar approach combined with tibial tubercle osteotomy. Knee Surg Sports Traumatol Arthrosc 2011; 19:1834-42. [PMID: 21484391 DOI: 10.1007/s00167-011-1474-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Accepted: 02/24/2011] [Indexed: 01/14/2023]
Abstract
PURPOSE Primary TKA in valgus knees with a deformity of more than ten degrees may prove challenging, since bone and soft tissue abnormalities make accurate axis restoration, component orientation and joint stability attainment a difficult task. The purpose of this study was to determine which approach is optimal in these patients, by comparing the standard medial parapatellar approach to a lateral parapatellar combined with a tibial tubercle osteotomy (TTO). METHODS Forty-four valgus knees--with an axis deviation ranging from 15 to 36 degrees (mean 24°)--were dealt with primary TKA and followed up for a minimum period of 7 years. Lateral parapatellar arthrotomy combined with TTO was performed in 22 individuals (Group A) and a standard medial parapatellar capsulotomy in the remaining patients (Group B). The International Knee Society System Score (IKSS) was used for clinical evaluation. Radiological assessment was performed yearly postoperatively using long films for assessment of the anatomical axis. RESULTS The postoperative IKSS scores showed no significant statistical difference between groups A and B (P < 0.05). In the alignment parameter, however, residual valgus deviation occurred in 9% of patients from Group A and in 32% from Group B. No late-onset instability was displayed. CONCLUSION Lateral parapatellar approach combined with TTO may prove highly beneficial in significant valgus deformities, as the anatomical axis is restored accurately and soft tissue release of the lateral contracted structures facilitated to an important extent.
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Rajgopal A, Dahiya V, Vasdev A, Kochhar H, Tyagi V. Long-term results of total knee arthroplasty for valgus knees: soft-tissue release technique and implant selection. J Orthop Surg (Hong Kong) 2011; 19:60-3. [PMID: 21519079 DOI: 10.1177/230949901101900114] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To report long-term results of total knee arthroplasty (TKA) for valgus knees. METHODS 34 women and 19 men aged 39 to 84 (mean, 74) years with valgus knees underwent primary TKA by a senior surgeon. Of the 78 knees, 43, 29, and 6 had type-I, type-II, and type-III valgus deformities, respectively. A preliminary lateral soft-tissue release was performed, and the tibia and femur were prepared. The tight lateral structures were released using the pie-crusting technique. In 92% of the knees, cruciate-retaining implants were used. In knees with severe deformity and medial collateral ligament insufficiency, the posterior cruciate ligament was sacrificed and constrained implants were used. The Hospital for Special Surgery (HSS) knee score was assessed, as were tibiofemoral alignment, range of motion, stability, and evidence of loosening or osteolysis. RESULTS Patients were followed up for 8 to 14 (mean, 10) years. All knees had a good patellar position and were clinically stable in both mediolateral and anteroposterior planes. No radiolucency was noted. The mean HSS knee score improved from 48 to 91 (p<0.001). The mean tibiofemoral alignment improved from valgus 20 to 5 degrees (p<0.001). The mean range of motion improved from 65 to 110 degrees (p<0.001). One patient developed a deep infection at year 4, and 2 had periprosthetic fractures at years 6 and 8. CONCLUSION Adequate lateral soft-tissue release is the key to successful TKAs in valgus knees. The choice of implant depends on the severity of the valgus deformity and the extent of soft-tissue release needed to obtain a stable, balanced flexion and extension gap, in order to achieve minimal constraint with maximum stability.
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Affiliation(s)
- Ashok Rajgopal
- Medanta Bone and Joint Institute, Medanta-The Medicity, Gurgaon, India.
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Sampath SAC, Voon SH, Sangster M, Davies H. The statistical relationship between varus deformity, surgeon's experience, BMI and tourniquet time for computer assisted total knee replacements. Knee 2009; 16:121-4. [PMID: 19013071 DOI: 10.1016/j.knee.2008.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 09/18/2008] [Accepted: 09/26/2008] [Indexed: 02/02/2023]
Abstract
The outcome of total knee arthroplasty (TKA) with severe pre-operative varus deformity is significantly worse than in well aligned knees. Computer navigated TKA has addressed some of the problems by ensuring accurate post-operative alignment. Our aims were to see if navigation could reproducibly correct a varus deformity to 3 degrees of the mechanical axis and to investigate the relationships between the tourniquet time and severity of the preoperative deformity, BMI and a surgeon's experience. The 172 e.motion floating platform TKA's were implanted using the OrthoPilot Navigation system (B Braun-Aesculap, Tuttlingen, Germany). Pre-operative deformity and post-operative alignment were measured by the software. Tourniquet times were recorded automatically. All knees were corrected to within 3 degrees of the neutral axis (mean 0.48 degrees ). Statistically significant relationships between tourniquet time (TT) and degree of pre-operative varus (p<0.001), total number of previous e.motion TKA's performed (p<0.001), and body mass index (p=0.013) were found. A linear relationship between the variables can be expressed as a statistical formula: TT=49.5+PreOp Varus+0.6(BMI)-0.1(total previous). Tourniquet time is measured in minutes and preoperative varus is measured in degrees from the mechanical axis. Total previous is the total number of navigated TKA's implanted by the surgeon. Tourniquet time is increased with larger pre-operative deformities and high BMI and decreased with surgical experience. The formula may give us a method of predicting the length of a procedure for a particular surgical team and may allow us to plan operating lists more accurately.
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Affiliation(s)
- Shameem A C Sampath
- Bluespot Knee Clinic, Classic Fylde Coast Hospital, St Walburgas Road, Blackpool, FY3 8BP, UK.
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Hadjicostas PT, Soucacos PN, Thielemann FW. Computer-assisted osteotomy of the lateral femoral condyle with non-constrained total knee replacement in severe valgus knees. ACTA ACUST UNITED AC 2008; 90:1441-5. [PMID: 18978262 DOI: 10.1302/0301-620x.90b11.20092] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
We describe the mid-term results of a prospective study of total knee replacement in severe valgus knees using an osteotomy of the lateral femoral condyle and computer navigation. There were 15 knees with a mean valgus deformity of 21 degrees (17 degrees to 27 degrees) and a mean follow-up of 28 months (24 to 60). A cemented, non-constrained fixed bearing, posterior-cruciate-retaining knee prosthesis of the same design was used in all cases (Columbus-B. Braun; Aesculap, Tuttlingen, Germany). All the knees were corrected to a mean of 0.5 degrees of valgus (0 degrees to 2 degrees). Flexion of the knee had been limited to a mean of 85 degrees (75 degrees to 110 degrees) pre-operatively and improved to a mean of 105 degrees (90 degrees to 130 degrees) after operation. The mean Knee Society score improved from 37 (30 to 44) to 90 points (86 to 94). Osteotomy of the lateral femoral condyle combined with computer-assisted surgery gave an excellent mid-term outcome in patients undergoing total knee replacement in the presence of severe valgus deformity.
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Affiliation(s)
- P T Hadjicostas
- Department of Trauma and Reconstructive Surgery, Schwarzwald-Baar Clinic, Teaching Hospital, University of Freiburg, Rontgen Strasse 20, D 78054 Villingen Schenningen, Germany.
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McAuley JP, Collier MB, Hamilton WG, Tabaraee E, Engh GA. Posterior cruciate-retaining total knee arthroplasty for valgus osteoarthritis. Clin Orthop Relat Res 2008; 466:2644-9. [PMID: 18712454 PMCID: PMC2565016 DOI: 10.1007/s11999-008-0436-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 07/18/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED The valgus, osteoarthritic knee is challenging technically and it is unknown whether and how technical and implant variables influence outcomes. We therefore determined the influence of surgical technique of soft tissue balancing and patient and implant factors from 100 unselected cruciate-retaining TKAs for valgus osteoarthritis in patients younger than 75 years of age. From 1987 to 1990, lateral soft tissue balancing was done with an outside-in progression in which the lateral collateral ligament and popliteus were typically released from the femur. From 1991 to 1994, an inside-out technique was use in which the lateral collateral ligament and/or popliteus were typically preserved. The minimum followup was 0.1 year (mean, 8.2 years; range, 0.1-18.2 years). Fourteen of 16 revisions were for wear and/or instability. Popliteus release, lateral collateral ligament release, or greater polyethylene shelf age increased the risk of revision. At 10 postoperative years, survival (end point, revision) was 89% (100 knees), 94% when the shelf age was less than 1 year (n = 73 knees), 97% when the popliteus or lateral collateral ligament was not released (n = 57 knees), and 100% when both conditions were met (n = 39 knees). Cruciate-retaining implants can be successfully used in knees with any degree of valgus osteoarthritis and survival is improved when the surgeon preserves at least one of the structures providing lateral stability in flexion and uses polyethylene with a short shelf life. LEVEL OF EVIDENCE Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James P McAuley
- Division of Orthopaedic Surgery, University of Western Ontario, London Health Sciences Center, University Hospital, London, ON, Canada.
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Abstract
UNLABELLED Valgus deformity correction with total knee arthroplasty is challenging. We hypothesized selective release of the tight lateral structures (pie-crusting technique), and of the lateral retinaculum in case of patellar maltracking, would obtain and maintain correction of the frontal plane deformity, restore patellar tracking and function, and avoid the complications of the extensive releases, including lateral condyle avascularity and residual lateral instability. We followed 48 patients with 53 valgus knees who underwent TKA and were followed a minimum of 5 years (mean, 8 years; range, 5-12 years). Soft tissue balancing of the lateral structures was performed with the pie-crusting technique. We employed either a fixed posterior stabilized or a mobile implant. A lateral release was performed in 67% of the cases. We observed one postoperative complication, a transient postoperative peroneal nerve palsy that spontaneously completely recovered. In 51 of the 53 knees (96%) we achieved alignment within 5 degrees from neutral. One patient had varus instability in extension. No component was revised. The pie-crusting technique reliably corrects moderate to severe fixed valgus deformities with a low complication rate and reasonable mid-term results. The multiple punctures allow gradual stretching of the lateral soft tissues and preservation of the popliteus tendon reducing the risk of posterolateral instability. LEVEL OF EVIDENCE Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.
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Sorrells RB, Murphy JA, Sheridan KC, Wasielewski RC. The effect of varus and valgus deformity on results of cementless mobile bearing TKA. Knee 2007; 14:284-8. [PMID: 17561401 DOI: 10.1016/j.knee.2007.04.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Revised: 04/10/2007] [Accepted: 04/16/2007] [Indexed: 02/02/2023]
Abstract
We aimed to determine whether preoperative angular deformity affects survivorship or postoperative alignment after cementless mobile bearing total knee arthroplasty. Nine hundred seventeen knees were grouped according to preoperative mechanical alignment: normal, 0-5 degrees ; abnormal, 6-10 degrees ; severely abnormal, >10 degrees. Ten-year survival estimates were 89.7% for the severely abnormal alignment group, 95.5% for the abnormal alignment group, and 94.9% for the normal alignment group. Postoperatively, normal alignment was restored in 95.6% of knees in the severely abnormal group and 94.5% of knees in the abnormal group. For the normal alignment group, 99.2% of knees remained normally aligned after TKA. These differences in postoperative alignment may explain the severely abnormal alignment group's inferior survivorship outcome. This study shows that cementless mobile bearing implants can be successfully used in a wide range of angulated deformed knees, although preoperatively deformed knees did not do as well as preoperatively undeformed knees.
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Affiliation(s)
- R Barry Sorrells
- The Joint Replacement Clinic, 17 Rubra Court, Little Rock, AR 72223, United States.
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Stensdotter AK, Holmgren C, Dalén T, Häger-Ross C. The role of M. popliteus in unpredictable and in self-initiated balance provocations. J Orthop Res 2006; 24:524-30. [PMID: 16456827 DOI: 10.1002/jor.20057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to determine whether m. popliteus (POP) activity would contribute to the control of knee joint position in unpredictable and in self-initiated provocations of standing balance. Ten healthy women (age 25.2 +/- 4.5 years, means and SD) without known knee pathology were tested for postural reactions (1) to unpredictable support surface translations in anterior and posterior directions, and (2) in self-initiated balance provocations in a reaction time (RT) forward reach-and-grip task. Electromyographic activity was recorded from POP and other leg muscles plus the deltoid muscle. Three-dimensional kinematics were captured for the knee joint and the body centre of mass was calculated. POP was active first of all the muscles recorded, regardless of translation direction, and knee joint movements elicited were either knee extension or external rotation of the tibia. In the RT task, the POP was active after initiation of reaching movement, and there was little consistency in the kinematic response. POP activity was not direction specific in response to support surface translation, but appeared triggered from reactive knee joint movement. The response to the support-surface translation suggests that POP served to control knee joint position rather than posture. In the RT task, we could not deduce whether POP activity was attributed to knee joint control or to postural control.
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Affiliation(s)
- Ann-Katrin Stensdotter
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, S-901-87, Umeå, Sweden.
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