Lateral parapatellar approach with tibial tubercle osteotomy for the treatment of non-correctable valgus knee osteoarthritis: a retrospective clinical study

Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study

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.

Osteotomies and Total Knee Arthroplasty: Systematic Review and Meta-Analysis

Total knee replacement (TKA) is a frequent modality performed in patients with osteoarthritis. Specific circumstances can make it much more difficult to execute successfully, and additional procedures such as osteotomy may be required. The aim of this study was to perform a meta-analysis and systematic review of osteotomies combined with TKA. Methods: In June 2022, a search PubMed, Embase, Cochrane, and Clinicaltrials was undertaken, adhering to PRISMA guidelines. The search included the terms “osteotomy” and “total knee arthroplasty”. Results: Two subgroups (tibial tubercle osteotomy and medial femoral condyle osteotomy) were included in the meta-analysis. Further subgroups were described as a narrative review. The primary outcome showed no significant difference in favor to TTO. Secondary outcomes showed improved results in all presented subgroups compared to preoperative status. Conclusion: This study showed a significant deficit of randomized control trials treated with osteotomies, in addition to TKA, and a lack of evidence-based surgical guidelines for the treatment of patients with OA in special conditions: posttraumatic deformities, stiff knee, severe varus, and valgus axis or patella disorders.

A lateral parapatellar approach with iliotibial band dissection from the Gerdy tubercle for total knee arthroplasty of the valgus knee

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.

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

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.

Total Knee Arthroplasty for Valgus Deformity via a Lateral Approach: Clinical Results, Comparison to Medial Approach, and Review of Recent Literature

BACKGROUND

Total knee arthroplasty (TKA) for valgus deformity is a challenge. The standard medial parapatellar approach may not be universally useful for this. We have adopted the lateral approach to valgus knees. Here we describe our experience with this approach, present early results, and compare them to the medial approach.

METHODS

Our institutional registry was queried for all patients with valgus deformity who underwent a TKA via a lateral approach between 2013 and 2016. The registry was also queried for patients with valgus deformity who underwent a TKA through a medial approach in previous years and this data was compared to the study group.

RESULTS

Seventy-nine valgus knees in 72 patients were operated through a lateral approach. Deformity was corrected by 10.8°, from 16.2° to 5.4° (P < .001). Patellar tilt improved from -2.3° to 0.3° (P = .037). Seven implants (9%) were constrained. Mean operating time was 87 minutes (range 53-137). Twenty-five knees in 23 patients were operated via the medial approach. Deformity was corrected by 7.3°, from 13.2° to 5.9° (P < .001). Mean operating time was 137 minutes (range 90-230). Constrained implants were used in 16% of cases. The lateral approach allowed better correction of valgus deformity (10.8 vs 7.3, P = .03) and shorter operative times (87 vs 137 minutes, P < .001).

CONCLUSION

A lateral approach TKA for valgus deformity improves knee alignment and patellar tilt. Compared to the medial approach, it allows better correction of the deformity, shorter operating times, and perhaps less use of constrained implants.

Lateral subvastus approach: A cadaveric examination of its potential for total knee arthroplasty

BACKGROUND

Lateral approaches to total knee arthroplasty (TKA) provide good surgical exposure and may provide greater ease of soft tissue balancing in patients with a valgus deformity; however, little is known about the versatility in non-valgus knees. The present study evaluated if a lateral subvastus approach can achieve adequate surgical exposure while maintaining less soft tissue damage compared with the medial parapatellar approach in knees without any significant deformity.

METHODS

Using paired fresh-frozen cadaveric knees, the present study provides the first specimen-matched, side-by-side comparison of the lateral subvastus approach to the standard medial parapatellar approach to TKA. Ten knees were selected to undergo a lateral subvastus approach; the contralateral knee had a medial parapatellar approach as control. Incision length, surgical exposure and iatrogenic soft tissue damage were compared between the two approaches.

RESULTS

The lateral subvastus approach was successfully performed using an incision length that was not different from that used in the medial parapatellar approach (p > 0.05). The resultant surgical exposure was comparable between approaches (p > 0.05). The risk of the approach included tearing of the vastus lateralis fibers, and/or abrasion of the iliotibial tract/patellar ligament.

CONCLUSIONS

The lateral subvastus approach to TKA provided a comparable method to the standard medial parapatellar approach. Despite adequate exposure, the approach did risk soft tissue injury. Caution needs to be exercised to reduce the risk of iatrogenic injury to the vastus lateralis and surrounding ligaments. The successful implementation in this cadaveric study substantiates the need for further consideration of this approach in clinical practice.

The lateral and medial approach in total arthroplasty for valgus knee: a meta-analysis of current literature

Aim: To compare the lateral and medial approaches of total knee arthroplasty (TKA) in the valgus knee. Materials & methods: An electronic search from the PubMed, Embase, Web of Science and Cochrane library was performed according to 'TKA', 'valgus', 'knee' and 'approach'. Subsequently, manual search was conducted from the reference lists in the identified studies. Results: Four randomized controlled trials and five cohorts were included. Better knee society score and function was noticed in patients after lateral approach. Similar postoperative valgus deformity, operative time, blood loss, Western Ontario and McMaster Universities Osteoarthritis Index, range of motion, pain and total complications in both groups. Conclusion: Compared with the medial approach for TKA in valgus knee, current data shows superior results after TKA by the lateral approach.

Lateral or medial approach for valgus knee in total knee arthroplasty - which one is better? A systematic review

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.

Total knee replacement on more than 20° valgus: A case control study

INTRODUCTION

Lower-limb valgus deformity exceeding 20° is a particular case, with few publications assessing the impact of the severity of the valgus. The present retrospective case control study compared a series of>20° valgus versus a series of 10-20° valgus, assessing (1) operative data [approach, type of total knee replacement (TKR)], (2) complications and implant survival, and (3) clinical and radiological results.

HYPOTHESIS

Severe valgus deformity requires TKR with greater constraint, incurring a higher rate of complications and poorer implant survival.

MATERIAL AND METHOD

A multicenter retrospective study for the period January 2006 to December 2010 included 53 patients, with a mean age of 72±10 years, presenting>20° valgus. The study series was matched for age and gender with a series of 53 cases of 10-20° valgus. Convexity laxity was greater in the>20° group (p=0.004).

RESULTS

There was no significant inter-group difference in approach (p=0.13). Greater constraint was more frequent in the>20° group (7/53 versus 1/53; p=0.03), independently of convexity laxity or Krackow grade (p=0.14). There were 7 complications (13.2%) in the>20° group and 7 in the 10-20° group (NS). Eight-year survivorship was 95.12% in the>20° group and 94.9% in the 10-20° group (p=0.63). There were no significant differences in Oxford score (p=0.30) or HKA angle (p=0.78) at last follow-up.

CONCLUSION

The study hypothesis was partially confirmed: greater constraint was more frequent in>20° valgus. The number of complications was low, and survival was identical to that of a control group with less severe deformity.

LEVEL OF EVIDENCE

III, retrospectivecase controlstudy.

Short-term and mid-term results of lateral condyle sliding osteotomy in the treatment of valgus total knee arthroplasty: A successful therapy option in Grade 2 valgus total knee arthroplasty

BACKGROUND

Different methods exist for deformity correction and ligament balancing in total knee arthroplasty (TKA) of valgus knees, the sliding osteotomy being one of them. The objective of the current study was to analyze the clinical and radiological short-term and mid-term results of this technique in a larger series.

METHODS

Between June 2007 and May 2014, 98 patients were treated with 98 TKAs and a simultaneous sliding osteotomy. All of them had a Grade 2 fixed valgus deformity (between 10° and 20°). All patients received a mobile-bearing, non-constrained (CR) implant. After prospective inclusion (T1), patients were clinically assessed after one (T2) and 4.5years (±2.1years) (T3), and radiological and Oxford Knee Score (OKS), Knee Society Knee Score (KSS) and the Knee Society Function Score (KSF) were obtained.

RESULTS

All knees were corrected to a mechanical leg alignment within three degrees. Significant improvement of all scores could be measured at T2 and T3. Seven revisions needed to be performed; three of them were procedure-related. In two of them, a problem of capsular closure occurred, while in one the slided epicondyle dislocated after three months. All other revisions were performed because of non-procedure-related problems (e.g. infection).

CONCLUSIONS

Sliding osteotomy of the lateral condyle is a successful option for the treatment of Grade 2 fixed valgus deformity. Due to this technique, higher constraint could be avoided. The results stayed constant over time. The procedure-related complications need to be kept in mind. Long-term results still need to be awaited.

Tibial tubercle osteotomy (TTO) in total knee arthroplasty, is it worth it? A review of the literature

INTRODUCTION

Tibial tubercle osteotomy (TTO) is a well-established extensile approach to improve joint visualization and implant removal. Despite this, TTO is a challenging technique with a long learning curve and potential pitfalls. Complications are not infrequent, even if performing the correct surgical steps. Aim of this paper is to review the current literature about TTO, its safeness and reliability, and finally the complications rate.

MATERIALS AND METHODS

We performed a systematic review of the available English literature, considering the outcomes and the complications of TTO. The combinations of keyword were "tibial tubercle osteotomy", "total knee arthroplasty", "total knee revision", "outcomes", "complication" and "surgical approach".

RESULTS

From the starting 322 papers available, 26 manuscripts were finally included. Most of the papers show significant improvements in clinical outcomes, both in primary and in revision procedures. Radiographic fragment healing is close to 100%. Related complications can range from 3.8-20%.

CONCLUSION

TTO may be necessary to correct pathological tuberosity position or patella tracking. However, TTO is a challenging technique to improve the surgical approach during total knee arthroplasty. A strict surgical technique can lead to better results and to minimize complications. However, it is not clear if the improved outcome can outweigh the longer surgery and the higher risk of pitfalls.

Total Knee Arthroplasty in Severe Valgus Osteoarthritis Excellent Early Results in a 90-Year-Old Patient with a Valgus Deformity of 47°

Grade III valgus deformity (tibiofemoral alignment > 20°) is present in only 0.5% of patients receiving total knee arthroplasty. Furthermore, cases with a valgus deformity exceeding 40° are even rarer. Since they mostly affect elderly, polymorbid patients, successful outcome means a great challenge. We report on a case of a 90-year-old patient with a valgus deformity of 47°. The patient was preoperatively restricted to a wheel chair, unable to walk, and only able to stand for a few seconds. The maximal knee flexion was 100°, and there was an extension deficit of 15°. The WOMAC score was 91; the EQ-5D-5L Index was 0.048. She was treated with a constrained hinged prosthesis. Postoperatively, the axis was 6° valgus. After 3 months of rehabilitation, she was independent using a wheeled walker. The maximal flexion of the knee was 110° and there was no extension deficit. The WOMAC score was 45; the EQ-5D-5L Index was 0.813. This case demonstrates the possibility of a satisfactory result and an improvement in quality of life and mobility with a plausible timetable and with reasonable use of resources even in advanced age and severe valgus deformity.

Keblish's lateral surgical approach enhances patellar tilt in valgus knee arthroplasty

Objective

To compare the clinical and radiological outcomes of conventional medial and lateral approaches for total knee replacement in the valgus osteoarthritic knee.

Methods

In this randomized controlled trial, 21 patients with valgus knee osteoarthritis were randomized to total knee replacement through medial or lateral approach. The primary outcome was radiographic patellar tilt. Secondary outcomes were visual analog scale of pain, postoperative levels of hemoglobin, and clinical aspect of the operative wound.

Results

There were no differences between the groups regarding other clinical variables. Mean lateral tilt of the patella was 3.1 degrees (SD ± 5.3) in the lateral approach group and 18 degrees (SD ± 10.2) in the medial approach group (p = 0.02). There were no differences regarding the secondary outcomes.

Conclusion

Lateral approach provided better patellar tilt following total knee replacement in valgus osteoarthritic knee.

Current surgical strategies for total arthroplasty in valgus knee

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.

Equivalent results of medial and lateral parapatellar approach for total knee arthroplasty in mild valgus deformities

PURPOSE

When performing total knee arthroplasty (TKA) in valgus knee deformities, a medial or lateral parapatellar approach can be performed, but the lateral approach is often considered technically more difficult. The purpose of this study was to compare intra-operative, early clinical and radiological outcomes of medial and lateral parapatellar approaches for TKA in the setting of moderate knee valgus (<10°).

METHODS

We prospectively analysed 424 knees with pre-operative valgus deformity between 3° and 10° that underwent TKA over an 18-year period; 109 were treated with a medial approach and 315 with a lateral approach. Intra- and post-operative outcomes and complication rates after a minimum follow-up of one year were compared.

RESULTS

Tourniquet (p = 0.25) and surgical (p = 0.62) time were similar between groups. The popliteus tendon was released more frequently in the medial-approach group (p = 0.04), while the iliotibial band was released more frequently in the lateral-approach group (p < 0.001). A tibial tuberosity osteotomy was performed more frequently in the lateral- than medial-approach group (p = 0.003). No significant differences in limb alignment (p = 0.78), or Knee Society Score (KSS) knee (p = 0.32) and function (p = 0.47) results were noted based on surgical approach, and complication rates were similar between groups (p = 0.53).

CONCLUSIONS

Lateral parapatellar approach is a safe and effective surgical technique for performing TKA in moderately valgus knees. These equivalent early results are encouraging for systematic use of the lateral approach in moderately valgus knees.