One-Stage Total Knee Arthroplasty Plus Corrective Osteotomy for Osteoarthritis Associated With Severe Extra-articular Deformity

Navigation-Assisted One-Stage Total Knee Arthroplasty With Extra-Articular Corrective Osteotomy for Knee Osteoarthritis With Femoral and Tibial Extra-Articular Deformity: A Case Report

Background: Knee osteoarthritis (OA) with extra-articular deformity (EAD) is a rare condition for which achieving accurate alignment with total knee arthroplasty (TKA) is difficult. Extra-articular corrective osteotomy may be necessary for severe deformities. Case Presentation: A 76-year-old man underwent TKA for knee OA with EAD due to malunion after fractures of the femur and tibia. The femoral varus and the tibial valgus/recurvatum deformities were mild and corrected by intra-articular osteotomy using navigation (i.e., navigation-assisted standard TKA). However, the femoral antecurvatum deformity was severe, and we performed extra-articular corrective osteotomy simultaneously with TKA. Navigation was used not only for TKA but also for extra-articular corrective osteotomies. The osteotomy site was fixed with a cemented stem and metaphyseal sleeve. The postoperative hip-knee-ankle angle was 1° varus, the femoral implant was implanted at 0.5° varus/0.5° flexion, and the tibial implant was implanted at 0.5° varus/0° posterior slope. Two years after surgery, improvements were obtained in the range of motion from 15°-95° to 0°-110°, the Knee Society Score from 39 to 92 points, and the functional score from 35 to 100 points. Conclusions: One-stage TKA with extra-articular corrective osteotomy achieved good clinical results due to accurate alignment using navigation and firm fixation of the osteotomy site using cemented-stem and metaphyseal sleeve without any fixation devices.

Staged Extra-Articular Deformity Correction in the Setting of Total Knee Arthroplasty

Background

Extra-articular lower-leg deformities mandate unique considerations when planning total knee arthroplasty (TKA). Poor limb alignment may increase perioperative complications and cause early implant failure. This study reports on the safety and efficacy of staged, extra-articular deformity correction about the knee in the setting of osteoarthritis and TKA.

Methods

A retrospective review was conducted from December 2007 to December 2019 identifying 30 deformities in 27 patients (average age: 52.7 years; range 31-74) who underwent staged surgical correction of extra-articular deformity in preparation for TKA. Patient demographics, surgical details, clinical and radiographic measurements, severity of knee arthritis, and complications were collected.

Results

There were 17 femur and 12 tibia deformities. There was an average improvement of 14.7° of deformity measured in the coronal plane and 12.7° of deformity in the sagittal plane in the femur and 13.5° in the coronal plane and 10.3° in the sagittal plane in the tibia. Leg length discrepancies improved by 26 mm on average (1-100 mm). After an average 3.1-year follow-up, 12 out of 27 patients proceeded with primary or revision TKA. There were no cases of blood transfusion, nerve palsy, or compartment syndrome, and all patients achieved bony union.

Conclusions

Staged, extra-articular deformity correction is a safe and effective approach to improve limb alignment in the setting of knee osteoarthritis and TKA.

[Effectiveness analysis of lateral condyle sliding osteotomy in total knee arthroplasty for the treatment of lateral femoral bowing deformity]

OBJECTIVE

To investigate the effectiveness of lateral condyle sliding osteotomy (LCSO) in total knee arthroplasty (TKA) for the treatment of lateral femoral bowing deformity.

METHODS

The clinical data of 17 patients with lateral femoral bowing deformity treated by LCSO during TKA between July 2018 and July 2020 was retrospectively analysed. There were 3 males and 14 females, with an average of 63.2 years (range, 58-68 years). The etiology of lateral femoral bowing deformity included 12 cases of femoral developmental deformity and 5 cases of femoral fracture malunion. Kellgren-Lawrence classification of knee osteoarthritis was 4 cases of grade Ⅲ and 13 cases of grade Ⅳ. The preoperative hip-knee shaft was 9.5°-12.5° (mean, 10.94°). The disease duration was 3-25 years (mean, 15.1 years). The mechanical lateral distal femur angle (mLDFA), hip-knee-ankle angle (HKA), and mechanical axis deviation (MAD) of the distal femur were measured before operation and at last follow-up to evaluate the correction of extra-articular deformities in the joints and the recovery of mechanical force lines of the lower extremities. The knee society score (KSS) knee score and function score, visual analogue scale (VAS) score, knee joint range of motion (ROM) were used to evaluate effectiveness. The knee varus/valgus stress test and osteotomy healing by X-ray films were performed to evaluate the joint stability and the safety of LCSO.

RESULTS

All incisions of the patients healed by first intention after operation, and there was no early postoperative complication such as infection of the incision and deep vein thrombosis of the lower extremities. All 17 patients were followed up 12-36 months, with an average of 23.9 months. The osteotomy slices all achieved bony healing, and the healing time was 2-5 months, with an average of 3.1 months. After operation, the knee varus/valgus stress tests were negative, and there was no relaxation and rupture of the lateral collateral ligament, instability of the knee joint, loosening, revision and infection of the prosthesis occurred. At last follow-up, mLDFA, HKA, MAD, knee ROM, VAS score, KSS knee score and function score significantly improved when compared with preoperative ones ( P<0.05).

CONCLUSION

LCSO is effective and safe in TKA with lateral femoral bowing deformity. Extra-articular deformities are corrected intra-articularly. The mechanical force line and joint balance of the lower extremities can be restored simultaneously in an operation.

Single-stage total knee arthroplasty and femoral osteotomy for osteoarthritis with severe supracondylar deformity

Background

Knee osteoarthritis associated with extra-articular deformity (EAD) can confront the arthroplasty surgeons with challenges of bone resection and soft tissue balancing. The aim of this study was to describe a single-stage procedure associating corrective osteotomy with total knee arthroplasty (TKA), and to determine the outcome at mid- to long-term follow-up.

Methods

A total of seven patients (seven knees) with knee osteoarthritis and supracondylar deformity were included in this study. Six patients were female, and one was male, with the median age of 62 years (range, 37-76 years). All patients were treated with single-stage TKA and femoral osteotomy. Osteotomy was fixed with long cemented stem. Hospital of Special Surgery (HSS) scores, collateral ligament laxity, and range of motion (ROM) were clinically evaluated preoperatively and at each follow-up. Radiographic parameters including the mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), mechanical proximal tibial angle (mMPTA), and joint line congruence angle (JLCA) were also measured. The occurrence of perioperative complications was recorded.

Results

The median follow-up time was 91 months (range, 38-104 months). At the last follow-up, all components were stable and no patients required revision. Nonunion of the osteotomy occurred in one patient. In all patients, the lower limb mechanical alignment improved greatly. The mean angle of MAD was restored from 10.49±6.05 cm preoperatively to 1.11±4.97 cm postoperatively. The 90° mLDFA was almost acquired in all cases, with the postoperative value of 90.79±2.40°. After operation, the mMPTA improved from 84.18±6.13° to 91.33±3.13°. The JLCA changed from 2.94±1.61° to −0.71±3.50°. The median HSS score improved from 45 (range, 34-56) preoperatively to 90 (range, 82-97) postoperatively, with the outcome of all patients rated good to excellent. The median ROM improved from 70° (range 0–110°) preoperatively to 105° (range 90–125°) postoperatively. No instability of knee joint was observed. Complications included an intraoperative split fracture of distal femur and one case of wound exudation resulting from fat liquefaction.

Conclusions

For knee osteoarthritis with femoral supracondylar deformity, single-stage TKA and corrective osteotomy was feasible but technically demanding. The use of long cemented stem for osteotomy fixation can provide reliable rotational control of the bone segments.