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Wan JJY, Yow LPS, Cheong NK, Koh DTS, Soong J, Lee KH, Bin Abd Razak HR. Femoral and tibial phenotypes of varus alignment in a Southeast Asian arthritic population: a descriptive study. Singapore Med J 2024:00077293-990000000-00150. [PMID: 39287500 DOI: 10.4103/singaporemedj.smj-2023-174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 02/19/2024] [Indexed: 09/19/2024]
Abstract
INTRODUCTION Knowledge of femoral and tibial morphology is important for patient-specific surgery in both joint reconstruction and preservation procedures. Studies evaluating morphological variance in femoral and tibial alignments in Asian populations are scarce. This is the first descriptive study evaluating the femoral and tibial phenotypes of varus alignment in a Southeast Asian population. METHODS Long-leg coronal standing radiographs of 2021 limbs were obtained, and the hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle and joint line convergence angle were measured. Joint line obliquity was calculated, and the knees were classified according to the Coronal Plane Alignment of Knee (CPAK) classification. Descriptive analyses on alignment parameters and demographic data (age, gender, ethnicity and body mass index [BMI]) were performed and entered into a linear regression model. RESULTS The highest frequency of limb alignment in the population was found to be CPAK type I (52.71%, n = 1003). Tibial varus was the largest contributor of varus malignment. Of the varus knees (n = 1247), varus deformity was found solely in the tibia (68.60%), solely in the femur (2.07%) and was contributed by both the femur and the tibia (4.97%). In the linear regression model, BMI was found to be a strong determinant for femoral varus (P = 0.004) and joint line incongruence (P < 0.001). CONCLUSION The findings of this study will be important to surgeons during planning for joint preservation procedures (such as corrective osteotomies) and joint arthroplasties to restore alignment.
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Affiliation(s)
| | - Lina Pei Shi Yow
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore
| | - Nian Kai Cheong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Junwei Soong
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Kong Hwee Lee
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Lan S, Li J. Assessment of preoperative planning and intraoperative accuracy of the AIKNEE system for total knee arthroplasty. BMC Musculoskelet Disord 2024; 25:562. [PMID: 39030596 PMCID: PMC11264798 DOI: 10.1186/s12891-024-07645-1] [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: 08/02/2023] [Accepted: 07/01/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND The aim of this retrospective study was to evaluate the effectiveness and accuracy of the AIKNEE system in preoperative planning and intraoperative alignment for total knee arthroplasty (TKA). METHODS A total of 64 patients were planned preoperatively by the AIKNEE system, including the measurement of mechanical femorotibial angle (mFTA), lateral distal femoral angle (LDFA), and medial proximal tibial angle (MPTA) using three-dimensional reconstructed images. Intraoperatively, the actual prosthesis size and alignment were compared to the planned parameters. Postoperative outcomes, including pain levels, range of motion (ROM), and Knee Scoring System (KSS) scores, were assessed after surgery. Statistical analyses were performed to evaluate the correlation between alignment deviations and postoperative function. RESULTS The AIKNEE system accurately predicted the prosthesis size in thirty-one of femoral cases (48%) and forty-seven of tibial cases (73%). Deviations of mFTA, LDFA, and MPTA from the target value were within 3° in 88%, 92%, and 95% of cases, respectively. A significant improvement was observed in postoperative pain, ROM, and KSS scores (p < 0.001). Correlation analysis revealed that greater deviations in mFTA and LDFA were associated with increased pain (p = 0.004, 0.047) and lower KSS scores (p = 0.027). CONCLUSION The AIKNEE system demonstrated promising results in predicting prosthesis size and achieved alignment within the desired range in a majority of cases. Postoperative outcomes, including pain levels and functional improvement, were favorable.
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Affiliation(s)
- Saijiao Lan
- Department of Sports Medicine, Fujian Province Second People's Hospital, No.282, Wusi Road, Gu Lou District, Fuzhou, 350001, Fujian, China
- Department of Sports Medicine, The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, 350001, Fujian, China
| | - Jian Li
- Department of Sports Medicine, Fujian Province Second People's Hospital, No.282, Wusi Road, Gu Lou District, Fuzhou, 350001, Fujian, China.
- Department of Sports Medicine, The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, 350001, Fujian, China.
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Berk AN, Cregar WM, Wang S, Habet NA, Ifarraguerri AM, Trofa DP, Piasecki DP, Fleischli JE, Saltzman BM. The Effect of Lower Limb Alignment on Tibiofemoral Joint Contact Biomechanics after Medial Meniscus Posterior Root Repair: A Finite-Element Analysis. J Am Acad Orthop Surg 2024; 32:e558-e567. [PMID: 38669669 DOI: 10.5435/jaaos-d-23-00702] [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] [Received: 07/28/2023] [Accepted: 02/25/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION The purpose of this study was to determine how variations in lower limb alignment affect tibiofemoral joint contact biomechanics in the setting of medial meniscus posterior root tear (MMPRT) and associated root repair. METHODS A finite-element model of an intact knee joint was developed. Limb alignments ranging from 4° valgus to 8° varus were simulated under a 1,000 N compression load applied to the femoral head. For the intact, MMPRT, and root repair conditions, the peak contact pressure (PCP), total contact area, mean and maximum local contact pressure (LCP) elevation, and total area of LCP elevation of the medial tibiofemoral compartment were quantified. RESULTS The PCP and total contact area of the medial compartment in the intact knee increased from 2.43 MPa and 361 mm 2 at 4° valgus to 9.09 MPa and 508 mm 2 at 8° of varus. Compared with the intact state, in the MMPRT condition, medial compartment PCP was greater and the total contact area smaller for all alignment conditions. Root repair roughly restored PCPs in the medial compartment; however, this ability was compromised in knees with increasing varus alignment. Specifically, elevations in PCP relative to the intact state increased with increasing varus, as did the total contact area with LCP elevation. After root repair, medial compartment PCP remained elevated above the intact state at all degrees tested, ranging from 0.05 MPa at 4° valgus to 0.27 MPa at 8° of varus, with overall PCP values increasing from 2.48 to 9.09 MPa. For varus alignment greater than 4°, root repair failed to reduce the total contact area with LCP elevation relative to the MMPRT state. DISCUSSION Greater PCPs and areas of LCP elevation in varus knees may reduce the clinical effectiveness of root repair in delaying or preventing the development of tibiofemoral osteoarthritis.
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Affiliation(s)
- Alexander N Berk
- From the OrthoCarolina-Sports Medicine Center, Charlotte, NC (Berk, Cregar, Ifarraguerri, Piasecki, Fleischli, and Saltzman), the OrthoCarolina Research Institute, Charlotte, NC (Berk, Cregar, Ifarraguerri, Piasecki, Fleischli, and Saltzman), the Atrium Health-Musculoskeletal Institute, Charlotte, NC (Berk, Cregar, Wang, Habet, Ifarraguerri, Piasecki, Fleischli, and Saltzman), and the Columbia University Medical Center-Department of Orthopaedics, New York Presbyterian, New York, NY (Trofa)
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Ichiyanagi K, Kuriyama S, Sakai S, Maeda T, Yamawaki Y, Nishitani K, Nakamura S, Matsuda S. Small medial proximal tibial angle is a radiographic finding strongly associated with less coronal alignment correction under valgus stress in medial knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2024; 32:645-655. [PMID: 38409922 DOI: 10.1002/ksa.12095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE The degree to which varus knees can be corrected manually is important when considering total versus unicompartmental knee arthroplasty (UKA). The primary aim was to clarify the relationship between the degree of coronal alignment correction and radiographic parameters involved in UKA prognosis using preoperative full-length lower extremity valgus stress radiography. The secondary aim was to identify the factors affecting alignment correction. METHODS This retrospective observational study included 115 knees with medial osteoarthritis that underwent knee osteotomy or arthroplasty. Percent mechanical axis without valgus stress (%MA: neutral, 50%; varus, <50% and valgus, >50%), mechanical lateral distal femoral angle, lateral bowing femoral angle, medial proximal tibial angle (MPTA), joint line convergence angle, medial and lateral joint space width (LJSW) and medial femoral and tibial joint osteophyte size were measured using preoperative full-length weight-bearing radiographs. Correlation and multiple linear regression analyses were used to assess associations between parameters and %MA with valgus stress or amount of %MA change (%MA with valgus stress minus %MA without valgus stress). RESULTS %MA with valgus stress was correlated with all radiographic parameters. %MA change was correlated with parameters except for MPTA and LJSW. Multiple regression analyses showed that %MA without valgus stress and MPTA were associated with both %MA with valgus stress and %MA change. When %MA with valgus stress was set at 30%, 40% and 50%, MPTA cutoff values were 81.6°, 83.5° and 84.9°, and cutoffs for %MA without valgus stress were 10.7%, 17.1% and 25.1%, respectively. CONCLUSION Small MPTA is strongly associated with less alignment correction under valgus stress in varus knees. The finding is useful in surgical planning, especially to avoid undercorrection with UKA when valgus stress radiographs are unavailable. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kazuki Ichiyanagi
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Kuriyama
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sayako Sakai
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Maeda
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yusuke Yamawaki
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kohei Nishitani
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Nakamura
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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He L, Wu C, Lang J, Chen L, Wu P. The main cause of tibial prosthesis malalignment after total knee arthroplasty in Southern Chinese population. Heliyon 2024; 10:e25447. [PMID: 38322978 PMCID: PMC10844569 DOI: 10.1016/j.heliyon.2024.e25447] [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: 08/11/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/08/2024] Open
Abstract
Objectives This study aimed to determine the occurrence rate of malalignment of tibial prosthesis and explore the influencing factors. Methods 296 patients from Southern China who underwent total knee arthroplasty (TKA) were selected as the research objects. Their general demographic data were recorded. The tibial bowing angle (TBA), tibial length, medial proximal tibial angle (MPTA), tibial plateau shift angle (TPSA), tibial bone loss, lateral distal tibial angle, and overall width of tibial plateau and widths of medial and lateral tibial plateau were measured before TKA. The tibial component coronal alignment angle (TCCA) was measured after the operation. Malalignment of the tibial prosthesis was defined as TCCA <87° or TCCA >93°. Tibial bowing was indicated by TBA >2°, and lateral bowing was recorded as +. The correlations of TCCA with demographic data and pre-operation imaging measurement parameters were statistically analyzed. Results Bivariate correlation analysis revealed negative correlations between TCCA and TBA (r = -0.602, P < 0.001) and TPSA (r = -0.304, P < 0.001), and a positive correlation with MPTA (r = -0.318, P < 0.001). Multivariate linear regression analysis demonstrated a significant negative correlation between TCCA and TBA (P < 0.001). The occurrence rate of malalignment of tibial prosthesis was 12.37 %. The occurrence rates of malalignment were 22.54 % in the tibial bowing group and 6.87 % in the non-tibial bowing group, showing statistical differences (P < 0.001). Conclusion The malalignment rate of tibial prosthesis among Southern Chinese patients is relatively high, possibly attributed to the tibial anatomy anomalies, particularly the tibial bowing. The entry point should be determined based on tibial morphology.
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Affiliation(s)
- Lili He
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Congcong Wu
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Junzhe Lang
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Lei Chen
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
| | - Peng Wu
- The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang street, Ouhai district, Wenzhou city, Zhejiang province, 325200, China
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Jiang X, Xie K, Chen H, Zhang K, Hu Y, Kan T, Sun L, Ai S, Zhu X, Zhang L, Yan M, Wang L. A Radiographic Analysis of Coronal Morphological Parameters of Lower Limbs in Chinese Non-knee Osteoarthritis Populations. Orthop Surg 2024; 16:452-461. [PMID: 38088238 PMCID: PMC10834221 DOI: 10.1111/os.13952] [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: 06/15/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES Analyzing the lower limb coronal morphological parameters in populations without knee osteoarthritis (KOA) holds significant value in predicting, diagnosing, and formulating surgical strategies for KOA. This study aimed to comprehensively analyze the variability in these parameters among Chinese non-KOA populations, employing a substantial sample size. METHODS A cross-sectional retrospective analysis was performed on the Chinese non-KOA populations (n = 407; 49.9% females). The study employed an in-house developed artificial intelligence software to meticulously assess the coronal morphological parameters of all 814 lower limbs. The parameters evaluated included the hip-knee-ankle angle (HKAA), weight-bearing line ratio (WBLR), joint line convergence angle (JLCA), mechanical lateral-proximal-femoral angle (mLPFA), mechanical lateral-distal-femoral angle (mLDFA), mechanical medial-proximal-tibial angle (mMPTA), and mechanical lateral-distal-tibial angle (mLDTA). Differences in these parameters were compared between left and right limbs, different genders, and different age groups (with 50 years as the cut-off point). RESULTS HKAA and JLCA exhibited left-right differences (left vs. right: 178.2° ± 3.0° vs. 178.6° ± 2.9° for HKAA, p = 0.001; and 1.8° ± 1.5° vs. 1.4° ± 1.6° for JLCA, p < 0.001); except for the mLPFA, all other parameters show gender-related differences (male vs. female: 177.9° ± 2.8° vs. 179.0° ± 3.0° for HKAA, p < 0.001; 1.5° ± 1.5° vs. 1.8° ± 1.7° for JLCA, p = 0.003; 87.1° ± 2.1° vs. 88.1° ± 2.1° for mMPTA, p < 0.001; 90.2° ± 4.0° vs. 91.1° ± 3.2° for mLDTA, p < 0.001; 38.7% ± 12.9% vs. 43.6% ± 14.1% for WBLR, p < 0.001; and 87.7° ± 2.3° vs. 87.4° ± 2.7° for mLDTA, p = 0.045); mLPFA increase with age (younger vs. older: 90.1° ± 7.2° vs. 93.4° ± 4.9° for mLPFA, p < 0.001), while no statistical difference exists for other parameters. CONCLUSIONS There were differences in lower limb coronal morphological parameters among Chinese non-KOA populations between left and right sides, different genders, and age.
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Affiliation(s)
- Xu Jiang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Kai Xie
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Hongyu Chen
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Kai Zhang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Yuqi Hu
- School of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Tianyou Kan
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Lin Sun
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Songtao Ai
- Department of RadiologyShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Xianping Zhu
- Department of Orthopaedic SurgeryTaizhou Central HospitalTaizhouChina
| | - Lichi Zhang
- School of Biomedical EngineeringShanghai Jiao Tong UniversityShanghaiChina
| | - Mengning Yan
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
| | - Liao Wang
- Shanghai Frontiers Science Center of Degeneration and Regeneration in Skeletal System, Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic SurgeryShanghai Jiao Tong University of Medicine affiliated Ninth People's HospitalShanghaiChina
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Palmer J, Getgood A, Lobenhoffer P, Nakamura R, Monk P. Medial opening wedge high tibial osteotomy for the treatment of medial unicompartmental knee osteoarthritis: A state-of-the-art review. J ISAKOS 2024; 9:39-52. [PMID: 37839705 DOI: 10.1016/j.jisako.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/13/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023]
Abstract
Medial unicompartmental knee osteoarthritis is a common condition that is frequently associated with significant pain and dysfunction. Medial opening wedge high tibial osteotomy (MOWHTO) offers a unique opportunity to preserve the knee joint and potentially alter the course of the degenerative process. Recent advances in this field of surgery have enabled surgeons to perform a MOWHTO in a safe, reliable and reproducible manner. This state-of-the-art review highlights the most important advances in the field of MOWHTO. Key concepts related to patient selection, pre-operative planning, surgical accuracy and patient outcome are considered. The importance of an individualized approach is emphasized and its influence on the future direction of the procedure is discussed.
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Affiliation(s)
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada, N6A 3K7
| | | | - Ryuichi Nakamura
- Joint Preservation and Sports Orthopaedic Center, Harue Hospital, Sakai, 919-0476, Japan
| | - Paul Monk
- Unisports Orthopaedics, Auckland, 1072, New Zealand; Department of Trauma and Orthopaedics, Auckland City Hospital, Auckland, 1023, New Zealand.
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Ishikawa M, Ishikawa M, Nagashima H, Ishizuka S, Michishita K, Soda Y, Hiranaka T. Effects of Unrestricted Kinematically Aligned Total Knee Arthroplasty with a Modified Soft-Tissue Respecting Technique on the Deformity of Limb Alignment in Japanese Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1969. [PMID: 38004019 PMCID: PMC10673030 DOI: 10.3390/medicina59111969] [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: 10/08/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Unrestricted kinematic alignment total knee arthroplasty (KA-TKA) with a soft-tissue respecting technique (STRT) is a soft-tissue-dependent tibial resection entailing the restoration of the original soft-tissue tension using ligamentotaxis after resurfacing the femur, based on the concept of restoring the native or pre-osteoarthritis alignment in each patient. However, there is no consensus on the indications of unrestricted KA-TKA with the STRT. We modified the STRT, followed by an investigation of the effects of surgery on the postoperative hip-knee-ankle angle (HKAA). Materials and Methods: We retrospectively analyzed the clinical background data, including the preoperative and postoperative HKAA, of 87 patients who underwent unrestricted KA-TKA with the modified STRT. Univariate and multivariate analyses were performed to determine the factors affecting the postoperative HKAA. A receiver operating characteristic (ROC) curve was plotted to investigate the change in the cut-off values of preoperative HKAA with respect to the safe zone of the postoperative HKAA. We generated two regression models, the linear regression model and generalized additive model (GAM) using machine learning, to predict the postoperative HKAA. Results: Univariate and multivariate analyses revealed the preoperative HKAA as the factor most relevant to the postoperative HKAA. ROC analysis revealed that the preoperative HKAA exhibited a high predictive utility, with a cut-off value of -10°, when the safe range of postoperative HKAA was set at ±5°. The GAM was the superior machine learning model, indicating a non-linear association between the preoperative and postoperative HKAA. Patients with preoperative HKAAs ranging from -18° to 4° were more likely to fall within the ±5° safe range of the postoperative HKAA. Conclusions: The preoperative HKAA influences the postoperative HKAA in unrestricted KA-TKA with the modified STRT. Machine learning using the GAM may contribute to the selection of patients eligible for the surgical approach.
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Affiliation(s)
- Masahiro Ishikawa
- Department of Orthopedic Surgery, Nagahama Red Cross Hospital, Miyamae Nagahama, Nagahama 526-0053, Shiga, Japan;
| | - Masaaki Ishikawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwachou, Amagasaki 660-8550, Hyogo, Japan
| | - Hideaki Nagashima
- Department of Orthopedic Surgery, Nagahama Red Cross Hospital, Miyamae Nagahama, Nagahama 526-0053, Shiga, Japan;
| | - Shinya Ishizuka
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho Shouwaku Nagoya, Nagoya 466-8550, Aichi, Japan;
| | - Kazuhiko Michishita
- Department of Orthopedic Surgery, Japan Community Healthcare Organization, Yugawara Hospital, Yugawara 259-0396, Kanagawa, Japan;
| | - Yoshinori Soda
- Department of Joint Reconstruction and Arthroscopy Center, Midorii Orthopedics, 6-35-1 Midorii, Asaminami-ku, Hiroshima City 731-0103, Hiroshima, Japan;
| | - Takafumi Hiranaka
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Osaka 569-1192, Osaka, Japan;
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Moon HH, Seo YG, Kim WM, Yu JH, Lee HL, Park YJ. Effect of Combined Exercise Program on Lower Extremity Alignment and Knee Pain in Patients with Genu Varum. Healthcare (Basel) 2022; 11:healthcare11010122. [PMID: 36611582 PMCID: PMC9819428 DOI: 10.3390/healthcare11010122] [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: 11/22/2022] [Revised: 12/24/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023] Open
Abstract
This study aimed to assess the effect of a combined exercise program on lower-extremity alignment and knee pain in patients with genu varum. Forty-seven middle-aged women with knee pain and genu varum were randomly divided into the exercise (EG, n = 24) and control (CG, n = 23) groups. The exercise group underwent a combined exercise program lasting 60 min in one session, three times a week for 12 weeks. Knee-to-knee length (KTKL), hip-knee-ankle angle (HKAA), hip inclination angle (HIA), and medial proximal tibial angle (MPTA) were assessed to evaluate lower-extremity alignment. To evaluate knee pain, the short form-McGill Pain Questionnaire (SF-MPQ) were used. There was a significant difference between the groups, and a decrease of 16% in KTKL (from 6.48 ± 1.26 cm to 5.47 ± 1.21 cm) was shown in EG. Other variables, including HKAA, HIA, and MPTA on the right side, showed significant differences between pre- and post-intervention in EG (p < 0.01, p < 0.01, and p < 0.01, respectively). SF-MPQ score improved with 45% from 18.75 ± 1.64 to 10.33 ± 2.47 after exercise intervention in EG. These results suggest that the combined exercise program, including strength and neuromuscular exercises, is an effective intervention for improving lower-extremity alignment and knee pain in middle-aged women with genu varum.
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Affiliation(s)
- Hyung-Hoon Moon
- Department of Sports Medicine, Cha University, Gyeonggi-do, Pocheon-Si 11160, Republic of Korea
| | - Yong-Gon Seo
- Samsung Medical Center, Department of Orthopedic Surgery, Division of Sports Medicine, Seoul 06351, Republic of Korea
| | - Won-Moon Kim
- Department of Sports Science, Dongguk University, Gyeongju-si 38066, Republic of Korea
| | - Jae-Ho Yu
- Department of Physical Therapy, Sunmoon University, Asan 31460, Republic of Korea
| | - Hae-Lim Lee
- Department of Sports Medicine, Cha University, Gyeonggi-do, Pocheon-Si 11160, Republic of Korea
| | - Yun-Jin Park
- Division of Health Rehabilitation, Osan University, 45, Cheonghak-ro, Osan-si 18119, Republic of Korea
- Correspondence: ; Tel.: +82-31-370-2771
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Fixed 6° distal femoral cut consistently achieves neutral alignment for Asians, Caucasians, and Native Hawaiian/Pacific Islanders. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04673-1. [PMID: 36326872 DOI: 10.1007/s00402-022-04673-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/23/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Restoration of a neutral mechanical axis (MA) is important to the success of total knee arthroplasty (TKA). While known differences are present between Asians and Caucasians regarding native knee alignment, it is unknown whether such differences exist amongst Native Hawaiian/Other Pacific Islanders (NHPI) or if utilizing a fixed distal femoral cut of 6° can consistently achieve a neutral MA in these minority racial groups. This study examines the preoperative deformities presented by Asians, Caucasians, and NHPI, and the resulting knee alignment achieved following TKA when a fixed 6° distal femoral cut is targeted for all patients. METHODS Preoperative and postoperative MA was measured from 835 Asian, 447 Caucasian, and 163 NHPI hip-to-ankle radiographs. All patients underwent TKA in which a standard distal femoral cut of 6° valgus was targeted for all patients. Data were evaluated as continuous variables and by groupings of varus (MA < - 3°), valgus (MA > 3°), and neutral (- 3° ≤ MA ≤ 3°) alignment. RESULTS Preoperative deformity ranged from 38° varus to 29° valgus. The proportion of Asian and NHPI presenting with varus alignment prior to surgery was significantly greater than Caucasian patients in both males (Asians: 80.6%; Caucasians: 67.0%; NHPI: 79.0%, p = 0.001) and females (Asians: 66.1%; Caucasians: 45.7%; NHPI: 63.2%, p < 0.001). There was no difference in the proportion of patients (72-79%) achieving a neutral MA amongst all three racial groups. CONCLUSION NHPI appear to have similar preoperative deformities to Asians with both groups having significantly more varus alignment than Caucasians. Despite a wide range of preoperative deformity, application of a fixed distal femoral cut of 6° valgus successfully established a neutral MA equally in the majority of patients across all three racial groups.
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Zhu F, Jiao J, Huang Y, Xiao F, Zuo W, Chen M, Wang X, Wang J. A preliminary study of the surgical approach for posterior tibial plateau fractures: Based on posterior fragment segment classification. Injury 2022; 53:3820-3827. [PMID: 36116959 DOI: 10.1016/j.injury.2022.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The optimal surgical approach for the posterior tibial plateau fractures (PTPFs) remains controversial. This study aims to establish a method for posterior fragment segment classification to guide the choice of surgical approach and to reveal the outcome of their early reduction and health status. METHODS The medical records of 42 PTPFs patients treated with the strategy were collected retrospectively from December 2017 to December 2021. The posterior cortex of the tibial plateau was classified into postero-medial (PM), postero-central (PC), and postero-lateral (PL) segments. A posteromedial inverted L-shaped approach was adopted when the fractures involved the PM segment in the presence or absence of PC. The Frosch approach was performed when the PL segment was concerned. Fractures containing both PM and PL segments were treated by combined approaches. Four factors were measured to evaluate the reduction effect, including medial proximal tibial angle (MPTA), lateral posterior slope angle (LPSA), medial posterior slope angle (MPSA), and articular step-off. The Short Form 36 (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were completed at the last follow-up to assess health status and the degree of osteoarthritis. RESULTS A posteromedial inverted L-shaped approach was adopted in 16 PTPFs patients, a Frosch approach was adopted in 14 PTPFs patients, and a combined approach was adopted in 12 PTPFs patients. Immediate radiographic results indicated a promising fixation performance with this treatment strategy. The results of SF-36 and WOMAC scores reported good health status in all patients with a mean follow-up time of 34.50 (23-50) months. Two patients developed superficial wound infections, and one patient had liquefaction necrosis in adipose tissue. Although skin numbness occurred in 4 patients, they recovered within 6 months. CONCLUSION PTPFs patients treated under the guidance of posterior fragment segment classification achieved encouraging levels of immediate fixation and health status.
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Affiliation(s)
- Fukang Zhu
- Department of Orthopedics, Third People's Hospital of Hubei Province, Wuhan 430000, China
| | - Jing Jiao
- Department of Orthopedic Trauma, Wuhan Fourth Hospital, Wuhan 430000, China
| | - Yucheng Huang
- Department of Orthopedic Trauma, Wuhan Fourth Hospital, Wuhan 430000, China
| | - Fei Xiao
- Department of Orthopedic Trauma, Wuhan Fourth Hospital, Wuhan 430000, China
| | - Wei Zuo
- Department of Orthopedic Trauma, Wuhan Fourth Hospital, Wuhan 430000, China
| | - Ming Chen
- Department of Orthopedic Trauma, Wuhan Fourth Hospital, Wuhan 430000, China
| | - Xianxun Wang
- Department of Orthopedics, Third People's Hospital of Hubei Province, Wuhan 430000, China
| | - Junwen Wang
- Department of Orthopedic Trauma, Wuhan Fourth Hospital, Wuhan 430000, China.
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Butarbutar JCP, Mandagi T, Siahaan LD, Suginawan ET, Elson, Irvan. Prevalence of proximal tibia vara in Indonesian population with knee osteoarthritis. J Clin Orthop Trauma 2022; 29:101871. [PMID: 35510147 PMCID: PMC9058951 DOI: 10.1016/j.jcot.2022.101871] [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: 08/02/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Proximal tibia vara has drawn interest since the concept of constitutional varus was introduced. Proximal tibia vara is a condition where the knee varus tilt the tibia condyle medially and shift the tibial articular surface medially. This condition affects medial proximal tibial angle measurements and the placement of the tibial implant in knee replacement surgery. Thus, it challenged the neutral knee arthroplasty alignment target because some people may present a proximal tibia vara. This study assesses the prevalence of the proximal tibia vara and the correlation to knee osteoarthritis grade. METHODS This retrospective study was carried out from January 2021 to June 2021. Eighty-five limbs were included with the following inclusion criteria: knee osteoarthritis patients who received a long view lower extremity radiograph. The exclusions criteria were (1) patients who had undergone arthroplasty and lower extremity surgery before and (2) valgus knee deformity. The outcomes in this study were HKAA, MAD, TAD, MPTA, PTRP, LDFA, and PTS. Intraclass correlation (ICC) using two-way mixed was used to assess the reproducibility of the radiographic parameters. Multiple logistic regression was used to evaluate the correlation between knee osteoarthritis grade and radiographs parameters (MAD and TAD). RESULT A total 85 limbs from 52 patients were assessed in this study. Proximal tibia vara was found in 18 knees (21%.). The logistic regression was performed to assess the correlation between the severity of the knee osteoarthritis and radiographic parameters (MAD, TAD, LDFA, and PTS) with an overall p-value < 0.001 and pseudo-R2 = 0.29. CONCLUSION A significant portion of patients with knee osteoarthritis have proximal tibia vara, and it is a pre-existing condition. Since the pre-existing proximal tibia vara affects preoperative measurements, a long-standing lower extremity x-ray is recommended to be obtained as part of knee replacement preparation.
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Shin KH, Jang KM, Han SB. Residual varus alignment can reduce joint awareness, restore joint parallelism, and preserve the soft tissue envelope during total knee arthroplasty for varus osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2022; 30:507-516. [PMID: 32743784 DOI: 10.1007/s00167-020-06201-3] [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: 06/16/2020] [Accepted: 07/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The objectives were to compare the coronal joint configuration of the knee joints, coronal gap imbalances requiring substantial medial release, and patient-reported outcomes, including the forgotten joint score, between knees in which residual varus alignment was intentionally allowed according to an individualised lower limb analysis and those with mechanical alignment in total knee arthroplasty for varus osteoarthritis. METHODS Consecutive primary navigated total knee arthroplasty procedures for varus osteoarthritis were retrospectively reviewed. The study cohort was stratified based on whether residual varus alignment was intentionally allowed. Propensity-score matching was performed based on the baseline characteristics, including demographic characteristics, preoperative radiological measurements, and the Western Ontario and McMaster University Osteoarthritis Index (mechanical alignment group vs residual varus group). The patient-reported outcomes and coronal joint line orientation of the knee (relative to the ground) and ankle were evaluated. Coronal gap differences and coronal gap imbalances were analysed using intraoperative gap measurements. RESULTS Relative to the ground and ankle, the postoperative knee joint line orientation slanted down laterally in the mechanical alignment group (- 3.05˚ ± 1.62, relative to the ground; - 2.65˚ ± 1.56, relative to the ankle joint), but was parallel in the residual varus group (- 0.75˚ ± 1.59, relative to the ground; - 0.95˚ ± 1.71, relative to the ankle joint). Coronal gap differences at extension and the proportion of coronal gap imbalances requiring substantial medial release were 1.27 ± 1.53 and 6% in the residual varus group and 2.32 ± 1.24 and 15% in the mechanical alignment group. Postoperatively, the residual varus group showed higher Western Ontario and McMaster University Osteoarthritis Index scores and total forgotten joint scores than the mechanical alignment group (6.97 ± 4.75 vs. 10.31 ± 5.74 and 56.42 ± 12.85 vs. 45.69 ± 14.49, respectively). CONCLUSION Intentionally allowed residual varus alignment with individualised analysis of lower limb alignment restored the parallel joint line of the knees, preserved the soft tissue envelope, and reduced joint awareness after total knee arthroplasty for varus osteoarthritis. LEVEL OF EVIDENCE Therapeutic, Level III retrospective case-control study.
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Affiliation(s)
- Kyun-Ho Shin
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Sungbuk-gu, Seoul, 02841, South Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Sungbuk-gu, Seoul, 02841, South Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, 73 Inchon-ro, Sungbuk-gu, Seoul, 02841, South Korea.
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Ethnical Differences in Knee Phenotypes Indicate the Need for a More Individualized Approach in Knee Arthroplasty: A Comparison of 80 Asian Knees with 308 Caucasian Knees. J Pers Med 2022; 12:jpm12010121. [PMID: 35055436 PMCID: PMC8779125 DOI: 10.3390/jpm12010121] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 11/30/2022] Open
Abstract
The purpose of this study was to determine the distribution of functional knee phenotypes in a non-osteoarthritic Asian population. The Stryker Orthopaedic Modeling and Analytics (SOMA) database was searched for CT scans of the lower limb meeting the following inclusion criteria: patient age at time of image >18 and <46 years, no signs of fractures and/or previous surgery and/or degenerative changes, Asian ethnicity. A total of 80 CT scans of 40 patients were included (24 males, 16 females). The hip-knee-ankle angle (HKA), femoral mechanical angle (FMA) and tibial mechanical angle (TMA) were measured. Based on these measurements, each limb was phenotyped according to the previously introduced functional knee phenotype concept. All angles and phenotypes of the present study were compared with previously published data of a non-osteoarthritic Caucasian population (308 legs of 160 patients, 102 males, 58 females). Asian knees had a significantly lower TMA (both genders p < 0.001) but a higher FMA (males p < 0.05, females p < 0.001) than Caucasian knees but showed no difference in the HKA. Asian knees differed significantly with regard to femoral and tibial phenotypes (p < 0.01), but not with regard to limb phenotypes. The high variability of all coronal alignment parameters highlights the importance of a detailed analysis prior to TKA. Ethnical differences underline the need for a more individualized approach in TKA.
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Lahoti O. Non-arthroplasty options for hip, knee and ankle arthritis in adults. J Clin Orthop Trauma 2022; 24:101727. [PMID: 34938648 PMCID: PMC8654618 DOI: 10.1016/j.jcot.2021.101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Om Lahoti
- British Limb Reconstruction Society, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
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Wan XF, Yang Y, Wang D, Xu H, Huang C, Zhou ZK, Xu J. Comparison of Outcomes After Total Knee Arthroplasty Involving Postoperative Neutral or Residual Mild Varus Alignment: A Systematic Review and Meta-analysis. Orthop Surg 2021; 14:177-189. [PMID: 34898039 PMCID: PMC8867439 DOI: 10.1111/os.13155] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 09/08/2021] [Accepted: 09/15/2021] [Indexed: 02/05/2023] Open
Abstract
Comparing mainly clinical and functional outcomes as well as prosthesis survival with neutral and residual mild varus alignment, we searched PubMed, Embase, Cochrane Library and Web of Science databases from 1 January 1974 to 18 December 2020 to identify studies comparing clinical and functional outcomes as well as prosthesis survival in the presence of different alignments after total knee arthroplasty (TKA) for varus knees. The included studies were assessed by two researchers according to the Newcastle–Ottawa Scale (NOS). Postoperative neutral alignment (0° ± 3°) was compared to residual mild varus (3°–6°) and residual severe varus (>6°). Meta‐analysis was performed using Review Manager 5.3. The odds ratios (OR) and mean differences (MD) were used to compare dichotomous and continuous variables. The fixed‐effect model and random‐effect model were used to meta‐analyze the data. Nine studies were included in the meta‐analysis with 1410 cases of postoperative neutral alignment, 564 of residual mild varus alignment and 175 of residual severe varus alignment following TKA, all of which were published after 2013. Three studies scored 7 points on the NOS, while the remaining studies scored 8 points, suggesting high quality. The pooled mean differences (MDs) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were 1.07 [95% confidence interval (CI) −1.06 to 3.20; P = 0.32; I2 = 79%]. The meta‐analysis showed that neutral alignment and mild varus alignment were associated with similar the Oxford Knee Score (OKS), Knee Society Knee Score (KS‐KS), and Knee Society Function Score (KS‐FS), while neutral alignment was associated with lower Forgotten Joint Score (FJS) [mean difference −6.0, 95% confidence interval (CI) −9.37 to −2.64, P = 0.0005]. Neutral alignment was associated with higher KS‐KS than severe alignment (M 2.98, 95% CI 1.42 to 4.55, P = 0.0002; I2 = 0%) as well as higher KS‐FS (M 8.20, 95% CI 4.58 to 11.82, P < 0.00001; I2 = 0%). Neutral alignment was associated with similar rate of survival as mild varus alignment (95% CI 0.36 to 9.10; P = 0.48; I2 = 65%) or severe varus alignment (95% CI 0.94 to 37.90; P = 0.06; I2 = 61%). There was no statistical difference in others. Residual mild varus alignment after TKA may lead to similar or superior outcomes than neutral alignment in patients with preoperative varus knees, yet the available evidence appears to be insufficient to replace the current gold standard of neutral alignment. Severe varus alignment should be avoided.
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Affiliation(s)
- Xu-Feng Wan
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Yang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Duan Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Xu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Chao Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Zong-Ke Zhou
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Xu
- Tianjin Hospital, Tianjin, China
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Ranade AS, Oka GA, Ardawatia G, Goyal N. Lower Limb Alignment in Indian Children: A Radiographic Analysis of Coronal Plane Parameters. Indian J Orthop 2021; 56:639-645. [PMID: 35342532 PMCID: PMC8921369 DOI: 10.1007/s43465-021-00548-6] [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: 07/25/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Indian children are known to have variations in the tibiofemoral angle as compared to children of other ethnicities. There is no study describing radiographic angles in coronal plane in Indian children. Our aim was to evaluate coronal plane alignment in Indian children. METHODS Database of radiographs between January 2011 and December 2019 was searched. Full-length standing radiographs of patients younger than 16 years with unilateral congenital or post-traumatic or post-infective deformity were included. The radiographs were measured for mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), tibiofemoral angle (TFA), hip-knee-ankle (HKA) angle, lateral distal tibial angle, mechanical axis deviation (MAD), and mechanical lateral proximal femoral angle. RESULTS Analysis of 221 lower limbs of 177 children is presented. There were 103 (58.2%) boys and 74 (41.8%) girls. Mean age was 8 years, 6 months (range: 2 years, 1 month to 15 years, 11 months). The mean mLDFA remained constant between 87° and 88° after the age of 5 years. The mean MPTA remained around 88° after 8 years of age. The mean MAD remained within 4 mm of the midpoint of the knee after the age of 8 years. The adult value of TFA was achieved after 8 years of age. The mLDFA, MPTA, and mLPFA are significant predictors of change in the TFA. CONCLUSION The development of tibiofemoral angle in Indian children is slightly different than children of other ethnicities. We recommend using age-specific values for Indian children younger than 8 years of age.
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Affiliation(s)
- Ashish S. Ranade
- Blooming Buds Centre for Pediatric Orthopaedics, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411004 India
| | - Gauri A. Oka
- Central Research and Publication Unit, Bharati Vidyapeeth University Medical College and Hospital, Pune, 411043 India
| | - Gaurav Ardawatia
- Department of Orthopaedics, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411004 India
| | - Nishant Goyal
- Department of Orthopaedics, Sant Parmanand Hospital and Delhi Institute of Trauma and Orthopaedics, New Delhi, 110054 India
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Singh D, Patel KC, Singh RD. Achieving coronal plane alignment in total knee arthroplasty through modified preoperative planning based on long-leg radiographs: a prospective study. J Exp Orthop 2021; 8:100. [PMID: 34729656 PMCID: PMC8563908 DOI: 10.1186/s40634-021-00418-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose This prospective study was undertaken to examine whether the desired coronal plane alignment of limb and prosthetic components in total knee arthroplasty (TKA) could be achieved precisely using conventional jig-based methods by modifying the preoperative planning of bone resection utilizing long-leg radiographs (LLRs). Methods The study included consecutive 245 TKA procedures. Pre- and postoperative radiological variables, i.e., the mechanical axis (hip-knee-ankle [HKA] axis), mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle (MPTA), and their outliers were evaluated. Statistical analysis was performed using SPSS version 21.0. Results The mean postoperative HKA axis, mLDFA and MPTA was 179.80 ± 1.81° (p < 0.01; 95% CI: 8.09–9.67), 90.35 ± 1.54° (p < 0.01; 95% CI: 1.33–2.02), and 90.26 ± 1.25° (p < 0.01; 95% CI: 4.41–5.20), respectively. The postoperative HKA axis on the coronal plane was 180 ± 3° in 235 knees (95.92%, 4.08% outliers). Femoral and tibial components were implanted in an acceptable position, withing 90 ± 3° of the mechanical axis of the femur and tibia on the coronal plane in 238 (97.14%, 2.86% outliers) and 243 (99.18%, 0.8% outliers) knees, respectively. Conclusion Modified preoperative planning for TKA on LLRs is a reliable and consistent method to achieve the desired limb and component alignment on the coronal plane without adding financial or logistical costs. Level of evidence II
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Affiliation(s)
- Daria Singh
- Zydus Hospitals, Ahmedabad, Gujarat, 380059, India.
| | | | - Ragini D Singh
- Zydus Hospitals, Ahmedabad, Gujarat, 380059, India.,Department of Biochemistry, All India Institute of Medical Sciences, Khanderi, Rajkot, Gujarat, India
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Outcomes of Kinematically Aligned Total Knee Arthroplasty in Indian Population-Case Series with Three Year Clinical Results. Indian J Orthop 2021; 55:1118-1126. [PMID: 34824711 PMCID: PMC8586312 DOI: 10.1007/s43465-021-00521-3] [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: 05/17/2021] [Accepted: 09/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Kinematic total knee arthroplasty (KA) is emerging as an alternative for conventional mechanically aligned (MA) total knee arthroplasty (TKA) for treating patients with osteoarthritis (OA) knee. Since its introduction, concerns remain about the reproducibility and outcomes in different ethnic groups. This study was undertaken to analyse patient-reported outcomes of kinematically aligned total knee arthroplasty using Oxford Knee Score (OKS) in Indian population. METHODS A total of 104 consecutive patients (75 females and 29 males) who underwent total knee arthroplasty between February 2016 and February 2018 were included in this prospective study. Only patients with primary OA knee were included, those with rheumatoid arthritis, previous knee surgery were excluded. All surgeries were done by a single surgeon using the same type of cruciate-retaining prosthesis (Vanguard, Zimmer Biomet, Indiana, United States) with the conventional instruments. The principles of kinematic knee alignment were followed. Preoperative and postoperative OKS were recorded. Secondary outcome variables such as Haemoglobin (Hb) drop and blood transfusion rate were noted. RESULTS The mean age of this group of patients was 65.28 years (range 54-83 years). 96 patients (108 knees) were available for final review. The average preoperative OKS was 15.71 whereas the average OKS at 2 years follow-up improved to 42.07. The mean Hb drop was 1.18 g/dl and none of the patients required blood transfusion. CONCLUSION This study demonstrates that kinematic alignment TKA provides excellent to good patient satisfaction in Indian population. There were no catastrophic failures in three years of follow-up in this series. The results of KA TKA were not compared to MA TKA in this study and our sample size is not big enough to make recommendations on routine use of this technique. Larger randomised trials in Indian patients are needed to propose solid recommendations. Our pilot data can be useful in calculating sample size for such studies.
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Iizawa N, Oshima Y, Kataoka T, Watanabe H, Majima T, Takai S. The relationship between severity of varus osteoarthritic knees and contracture of the medial structures. J NIPPON MED SCH 2021; 89:108-113. [PMID: 34526449 DOI: 10.1272/jnms.jnms.2022_89-113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Severe varus osteoarthritic knee has possibility of medial structure contracture. There is no report concerning the relationship between severity of varus deformity and contracture of medial structure. We aimed to reveal a threshold angle that could be corrected in proportion to the width of medial osteophyte removal, and to examine correction differences between larger and smaller than the threshold angle in total knee arthroplasty. METHODS This study included 27 varus osteoarthritic knees scheduled for total knee arthroplasty (TKA). Each knee was measured the hip-knee-ankle angles (HKA) using a navigation system, at maximum extension, 30˚ and 60˚ flexion before and after osteophyte removal, with and without external 10 N-m valgus torque loads. Subsequently, resected osteophyte widths were measured. Mean correction angle per 1 mm osteophyte removal was calculated, and the threshold angle was calculated using the receiver operating characteristic curve. HKA differences were compared against larger and smaller deformity than the threshold angle. RESULTS Mean osteophyte width was 7.1±2.20 mm. Osteophyte removal produced a mean 3.1° correction, which equaled a 0.4° correction per 1 mm osteophyte width removal. The varus deformity threshold angle was 9.5°, however, when comparing the groups larger and smaller than the threshold, there were no significant differences in HKA differences between each step and flexion angle. CONCLUSIONS The threshold angle for expected correction with medial osteophyte removal was 9.5˚. However, with no differences in correction between those with larger or smaller than this angle, medial structure contracture seemed to be unrelated to severity of deformity.
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Affiliation(s)
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, Nippon Medical School
| | | | | | | | - Shinro Takai
- Department of Orthopaedic Surgery, Nippon Medical School
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Ho JPY, Merican AM, Ayob KA, Sulaiman SH, Hashim MS. Tibia vara in Asians: Myth or fact? Verification with three-dimensional computed tomography. J Orthop Surg (Hong Kong) 2021; 29:2309499021992618. [PMID: 33632009 DOI: 10.1177/2309499021992618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is a common perception among surgeons that Asian tibiae are significantly more varus compared to non-Asians, contributed both by an acute medial tibial proximal angle (MPTA) and diaphyseal bowing. Insight into the normative morphology of the tibia allows generation of knowledge towards disease processes and subsequently planning for corrective surgeries. METHODS Computed tomography (CT) scans of 100 normal adult knees, aged 18 years and above, were analysed using a 3-dimensional (3D) analysis software. All tibiae were first aligned to a standard frame of reference and then rotationally aligned to the tibial centroid axis (TCAx) and the transmalleolar axis (tmAx). MPTA was measured from best-fit planes on the surface of the proximal tibia for each rotational alignment. Diaphyseal bowing was assessed by dividing the shaft to three equal portions and establishing the angle between the proximal and distal segments. RESULTS The mean MPTA was 87.0° ± 2.2° (mean ± SD) when rotationally aligned to TCAx and 91.6° ± 2.7° when aligned to tmAx. The mean diaphyseal bowing was 0.1° ± 1.9° varus when rotationally aligned to TCAx and 0.3° ± 1.6° valgus when aligned to tmAx. The mean difference when the MPTA was measured with two different rotational alignments (TCAx and tmAx) was 4.6° ± 2.3°. No statistically significant differences were observed between males and females. Post hoc tests revealed statistically significant difference in MPTA between different ethnic sub-groups. CONCLUSION The morphology of the proximal tibiae in the disease-free Asian knee is inherently varus but not more so than other reported populations. The varus profile is contributed by the MPTA, with negligible diaphyseal bowing. These implications are relevant to surgical planning and prosthesis design.
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Affiliation(s)
- Jade Pei Yuik Ho
- Department of Orthopaedic Surgery, Sarawak General Hospital, Kuching, Malaysia
| | - Azhar Mahmood Merican
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khairul Anwar Ayob
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shahrul-Hisham Sulaiman
- Department of Orthopaedic Surgery, Faculty of Medicine, University Teknologi MARA, Sungai Buloh, Malaysia
| | - Muhammad Sufian Hashim
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Osteotomy around the knee is planned toward an anatomical bone correction in less than half of patients. Orthop Traumatol Surg Res 2021; 107:102897. [PMID: 33753267 DOI: 10.1016/j.otsr.2021.102897] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In cases where the femur or tibial deformity is not correctly analysed, the corrective osteotomies may result in an oblique joint line. The aim of this study was to assess the preoperative deformity of patients due to undergo corrective osteotomy and the resulting abnormal tibial and femoral morphologies after the planned correction using 3D software. METHODS CT scans of 327 patients undergoing corrective osteotomy were retrospectively included. Each patient was planned using a software application and the simulated correction was validated by the surgeon. Following the virtual osteotomy, tibial and femoral coronal angular values were considered abnormal if the values were outside 97.5% confidence intervals for non-osteoarthritis knees. After virtual osteotomy, morphological abnormalities were split into two types. Type 1 was an under/overcorrection at the site of the osteotomy resulting in abnormal bone morphology. A type 2 was defined as an error in the site of the correction, resulting in an uncorrected abnormal bone morphology. RESULTS The global rate of planned abnormalities after tibial virtual osteotomy was 50.7% (166/327) with abnormalities type 1 in 44% and type 2 in 6.7%. After femoral virtual osteotomy the global rate was 6.7% (22/327) with only abnormalities type 1. A lower preoperative HKA was significantly associated with a non-anatomical correction (R2=0.12, p<0.001) for both femoral (R2=0.06, p<0.001) and tibial (R2=0.07, p<0.001) abnormalities. CONCLUSION Non-anatomical correction was found in more than half the cases analysed more frequently for preoperative global varus alignment. These results suggest that surgeons should considered anatomical angular values to avoid joint line obliquity. LEVEL OF EVIDENCE III; retrospective cohort study.
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Griffiths-Jones W, Chen DB, Harris IA, Bellemans J, MacDessi SJ. Arithmetic hip-knee-ankle angle (aHKA): An algorithm for estimating constitutional lower limb alignment in the arthritic patient population. Bone Jt Open 2021; 2:351-358. [PMID: 34042492 PMCID: PMC8168548 DOI: 10.1302/2633-1462.25.bjo-2021-0028.r1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aims Once knee arthritis and deformity have occurred, it is currently not known how to determine a patient’s constitutional (pre-arthritic) limb alignment. The purpose of this study was to describe and validate the arithmetic hip-knee-ankle (aHKA) algorithm as a straightforward method for preoperative planning and intraoperative restoration of the constitutional limb alignment in total knee arthroplasty (TKA). Methods A comparative cross-sectional, radiological study was undertaken of 500 normal knees and 500 arthritic knees undergoing TKA. By definition, the aHKA algorithm subtracts the lateral distal femoral angle (LDFA) from the medial proximal tibial angle (MPTA). The mechanical HKA (mHKA) of the normal group was compared to the mHKA of the arthritic group to examine the difference, specifically related to deformity in the latter. The mHKA and aHKA were then compared in the normal group to assess for differences related to joint line convergence. Lastly, the aHKA of both the normal and arthritic groups were compared to test the hypothesis that the aHKA can estimate the constitutional alignment of the limb by sharing a similar centrality and distribution with the normal population. Results There was a significant difference in means and distributions of the mHKA of the normal group compared to the arthritic group (mean -1.33° (SD 2.34°) vs mean -2.88° (SD 7.39°) respectively; p < 0.001). However, there was no significant difference between normal and arthritic groups using the aHKA (mean -0.87° (SD 2.54°) vs mean -0.77° (SD 2.84°) respectively; p = 0.550). There was no significant difference in the MPTA and LDFA between the normal and arthritic groups. Conclusion The arithmetic HKA effectively estimated the constitutional alignment of the lower limb after the onset of arthritis in this cross-sectional population-based analysis. This finding is of significant importance to surgeons aiming to restore the constitutional alignment of the lower limb during TKA. Cite this article: Bone Jt Open 2021;2(5):351–358.
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Affiliation(s)
- William Griffiths-Jones
- CPAK Research Group, Kogarah, New South Wales, Australia.,North Devon District Hospital, Barnstaple, UK
| | - Darren B Chen
- CPAK Research Group, Kogarah, New South Wales, Australia.,Sydney Knee Specialists, Kogarah, New South Wales, Australia.,St George Private Hospital, Kogarah, New South Wales, Australia
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Johan Bellemans
- CPAK Research Group, Kogarah, New South Wales, Australia.,Hasselt University, Department of Orthopaedic Surgery, ZOL Hospitals, Genk, ArthroClinic Leuven, Belgium
| | - Samuel J MacDessi
- CPAK Research Group, Kogarah, New South Wales, Australia.,Sydney Knee Specialists, Kogarah, New South Wales, Australia.,St George Private Hospital, Kogarah, New South Wales, Australia.,St George & Sutherland Clinical School, University of New South Wales, Kogarah, New South Wales, Australia
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24
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Bini SA, Chung CC, Wu SA, Hansen EN. Tibial Mechanical Axis Is Nonorthogonal to the Floor in Varus Knee Alignment. Arthroplast Today 2021; 8:237-242. [PMID: 33937465 PMCID: PMC8079331 DOI: 10.1016/j.artd.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/03/2021] [Accepted: 03/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background Classical models of the knee assume the joint line is parallel to the floor and the tibial mechanical axis (TMA) is orthogonal to the floor. Our study characterizes the angle subtended by the TMA and floor during bipedal stance, called the tibial axis orientation angle (TAOA), and tests the assumption that the TMA should be orthogonal to the floor. Methods We reviewed the nonoperative knee on full-length, standing radiographs in patients undergoing total knee arthroplasty between 2013 and 2017. Radiographic measurements were obtained for hip-knee-ankle axis, medial proximal tibial angle (MPTA), joint line orientation angle, and TAOA and correlated by regression analysis. The cohort was stratified by hip-knee-ankle axis alignment to determine statistical differences in knee angle values. Demographic data were collected to assess associations with knee angles. Results Our cohort included 68 patients, with 56% female and average age of 62.3 years. Varus knees comprised 56% of the cohort, with 7% neutral and 37% valgus. The cohort demonstrated an MPTA of 3.06°, TAOA of 2.67°, and joint line orientation angle of 0.36°. Varus knees had a higher MPTA (4.26°) and TAOA (4.74°) than valgus knees (P < .001). MPTA and TAOA were correlated on regression analysis (r2 = 0.465), and all angles were statistically different between sexes. Conclusion The angle between the TMA and floor, called TAOA, is not orthogonal in normal knees, contrary to assumptions in classical biomechanics. Knee angles vary significantly between varus and valgus cohorts, and the distinction between these cohorts should be noted when evaluating normal joint line angles.
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Affiliation(s)
- Stefano A. Bini
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher C. Chung
- University of Virginia School of Medicine, Charlottesville, VA, USA
- Corresponding author. 500 Parnassus Avenue MU 323-W San Francisco CA 94143, USA. Tel.: +1 415 476 3320.
| | - Scott A. Wu
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Erik N. Hansen
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
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Micicoi G, Jacquet C, Sharma A, LiArno S, Faizan A, Kley K, Parratte S, Ollivier M. Neutral alignment resulting from tibial vara and opposite femoral valgus is the main morphologic pattern in healthy middle-aged patients: an exploration of a 3D-CT database. Knee Surg Sports Traumatol Arthrosc 2021; 29:849-858. [PMID: 32372282 DOI: 10.1007/s00167-020-06030-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Given the goal of achieving optimal correction and alignment after knee arthroplasty or high tibial osteotomy, literature focusing on the inter-individual variability of the native knee, tibia and femur with regards to the coronal or sagittal alignment is lacking. The aim of this study was to analyse normal angular values in the healthy middle-aged population and determine differences of angular values according to inter-individual features. The first hypothesis was that common morphological patterns may be identified in the healthy middle-aged non-osteoarthritic population. The second hypothesis was that high inter-individual variability exists with regards to gender, ethnicity and alignment phenotype. METHODS A CT scan-based modelling and analysis system was used to examine the lower limb of 758 normal healthy patients (390 men, 368 women; mean age 58.5 ± 16.4 years) with available data concerning angular values and retrieved from the SOMA database. The hip-knee-ankle angle (HKA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), posterior distal femoral angle (PDFA), posterior proximal tibial angle (PPTA) and non weight-bearing joint line convergence angle (nwJLCA) were then measured for each patient. Results were analysed for the entire cohort and based on gender, ethnicity and phenotype. RESULTS The mean HKA was 179.4° ± 2.6°, LDFA: 85.8° ± 2.0°, MPTA: 85.6° ± 2.4°, PDFA: 85.2° ± 1.5°, PPTA: 83.8° ± 2.9° and nwJLCA: 1.09° ± 0.9°. Gender was associated with higher LDFA and lower HKA for men. Ethnicity was associated with greater proximal tibial vara and distal femoral valgus for Asian patients. Patients with an overall global varus alignment had more tibia vara and less femoral valgus than patients with an overall valgus alignment. CONCLUSION Even if significant differences were found based on subgroup analysis (gender, ethnicity or phenotype), this study demonstrated that neutral alignment is the main morphological pattern in the healthy middle-aged population. This neutrality is the result from tibia vara compensated by an ipsilateral femoral valgus. LEVEL OF CLINICAL EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Grégoire Micicoi
- iULS-University Institute for Locomotion and Sports, Pasteur 2 Hospital, University Côte d'Azur, Nice, France.,Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Christophe Jacquet
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | - Akash Sharma
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France
| | | | | | - Kristian Kley
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,The London clinic, 20 Devonshire Pl, Marylebone, London, W1G 6BW, UK
| | - Sébastien Parratte
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France.,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France.,Adult Reconstructive Surgery, International Knee and Joint Centre, Abu Dhabi, United Arab Emirates
| | - Matthieu Ollivier
- Aix Marseille Univ, APHM, CNRS, ISM, Sainte-Marguerite Hospital, Institute for Locomotion, Department of Orthopedics and Traumatology, Marseille, France. .,Department of Orthopedics and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, 270 Boulevard Sainte Marguerite, BP 29, 13274, Marseille, France.
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Moon HS, Choi CH, Yoo JH, Jung M, Lee TH, Jeon BH, Kim SH. Mild to Moderate Varus Alignment in Relation to Surgical Repair of a Medial Meniscus Root Tear: A Matched-Cohort Controlled Study With 2 Years of Follow-up. Am J Sports Med 2021; 49:1005-1016. [PMID: 33600226 DOI: 10.1177/0363546520988072] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Increased varus alignment of the lower extremity is known to be a poor prognostic factor for the surgical repair for a medial meniscus root tear (MMRT). However, given the concept of constitutional varus, which is present in a substantial portion of the normal population, the generally accepted surgical indication for MMRT concerning a varus alignment of 5° may be unnecessarily narrow. PURPOSE To compare the surgical outcomes of arthroscopic transtibial pullout repair of MMRT according to the degree of varus alignment of the lower extremity. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who underwent isolated arthroscopic transtibial pullout repair of MMRT between January 2010 and July 2017 at one institution and had a minimum follow-up of 2 years were included in this study. Patients were classified into 1 of 2 groups: the experimental group (n = 22) included patients with a preoperative hip-knee-ankle angle between 5° and 10° varus (mild to moderate varus alignment) and the control group (n = 51) included those with a preoperative hip-knee-ankle angle <5° varus (neutral alignment). Clinical scores and radiographic parameters were compared between the groups to assess surgical outcomes, which were statistically matched for potential confounders (age, body mass index, the severity of cartilage lesion) by use of the inverse probability of treatment weighting. A noninferiority trial was performed comparing the experimental and control groups in terms of subjective outcomes (International Knee Documentation Committee subjective and Lysholm scores) and objective outcomes (postoperative medial meniscal extrusion and the rate of osteoarthritis progression). RESULTS There were no statistically significant differences in surgical outcomes between the groups in subjective and objective aspects, which were consistent before and after inverse probability of treatment weighting. Apart from the clinical improvement observed in both groups, overall degenerative changes in the knee were found, although progression rates did not differ between the groups. In terms of the noninferiority trial, the overall surgical outcomes in the experimental group were not inferior to those in the control group. CONCLUSION The short-term surgical outcomes of arthroscopic transtibial pullout repair for MMRT of patients with mild to moderate varus alignment were not inferior to but rather comparable with those with neutral alignment in terms of subjective and objective aspects. Therefore, it would be inappropriate to exclude patients with a diagnosis of MMRT from being indicated for the surgery simply because of mild to moderate varus alignment.
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Affiliation(s)
- Hyun-Soo Moon
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Chong-Hyuk Choi
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Je-Hyun Yoo
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Min Jung
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Ho Lee
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Hun Jeon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Nayak M, Kumar V, Yadav R, Srivastava DN, Pandit H, Malhotra R. Lateral Coronal Bowing of Femur and/or Tibia Amplifies the Varus Malalignment of Lower Limb as well as Increases Functional Disability in Patients with Knee Osteoarthritis. Indian J Orthop 2020; 55:88-96. [PMID: 34122760 PMCID: PMC8149558 DOI: 10.1007/s43465-020-00303-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/24/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE In the present study, we aimed at assessing the effect of femoral and tibial coronal bowing on varus malalignment and Oxford knee score (OKS) at different grades of knee osteoarthritis (OA). MATERIALS AND METHODS This prospective observational study was conducted at a tertiary referral centre in New Delhi, India. Consecutive patients presenting to the "knee OA" outpatient clinics were invited to take part in the study conducted over a 12-month period. All consented patients underwent long-leg standing alignment radiographs using standardised technique and patient reported knee pain and function were recorded using Oxford knee score. The following radiological parameters were measured from weight-bearing long-leg radiographs of 824 varus aligned limbs via a morphometric software (Matlab R2009a) (1) hip-knee-ankle angle (HKAA), (2) femoral bowing, (3) tibial bowing. The knees were graded according to Kellegren and Lawrence grade (K&L) and OKS was recorded. 3 groups of HKAA were made based on the angle, A (0° to - 3°), B (- 3° to - 10°) and C (< - 10°). Both the femoral and tibial bow were also categorized into three groups depending upon the angle; in-range (- 2° to + 2°), varus (< - 2°), valgus (> + 2°). RESULTS The mean (± SD) of HKAA, femoral bow and tibial bow of the whole cohort was - 6.97° ± 5.64°, - 1.54° ± 4.31° and - 1.96° ± 3.5°, respectively. An increase in the lateral bow of both femur and tibia was seen with an increase in the severity of OA. A consequent increase in the varus malalignment was observed with an increase in the lateral bow of both femur as well as the tibia at all grades of OA, with significant correlation observed between HKAA with Femoral bowing and HKAA with tibial bowing. The mean OKS for femoral bow, in-range, varus and valgus was 30.6 ± 11.5, 21.3 ± 11.5 and 35.3 ± 11.4, respectively, and for tibial bow, in-range, varus and valgus was 27.6 ± 11.5, 26. ± 11.5 and 28 ± 11.4, respectively. The difference in the mean OKS was observed to be significant when the varus bow group was compared to in range as well as valgus group (p < 0.01) for both femur and tibia for all the grades of OA. CONCLUSION The present study shows a significant correlation between varus malalignment and the bowing of extremities. Varus coronal bowing of both femur and tibia were seen to have significantly lower mean OKS as compared to valgus bowing or in-range bowing at all grades of knee OA.
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Affiliation(s)
- Mayur Nayak
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Vijay Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Rahul Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Hemant Pandit
- Chapel Allerton Hospital, University of Leeds, Leeds, UK
| | - Rajesh Malhotra
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
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Mullaji A. Can isolated removal of osteophytes achieve correction of varus deformity and gap-balance in computer-assisted total knee arthroplasty? Bone Joint J 2020; 102-B:49-58. [PMID: 32475289 DOI: 10.1302/0301-620x.102b6.bjj-2019-1597.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aims of this study were to determine the effect of osteophyte excision on deformity correction and soft tissue gap balance in varus knees undergoing computer-assisted total knee arthroplasty (TKA). METHODS A total of 492 consecutive, cemented, cruciate-substituting TKAs performed for varus osteoarthritis were studied. After exposure and excision of both cruciates and menisci, it was noted from operative records the corrective interventions performed in each case. Knees in which no releases after the initial exposure, those which had only osteophyte excision, and those in which further interventions were performed were identified. From recorded navigation data, coronal and sagittal limb alignment, knee flexion range, and medial and lateral gap distances in maximum knee extension and 90° knee flexion with maximal varus and valgus stresses, were established, initially after exposure and excision of both cruciate ligaments, and then also at trialling. Knees were defined as 'aligned' if the hip-knee-ankle axis was between 177° and 180°, (0° to 3° varus) and 'balanced' if medial and lateral gaps in extension and at 90° flexion were within 2 mm of each other. RESULTS Of 50 knees (10%) with no soft tissue releases (other than cruciate ligaments), 90% were aligned, 81% were balanced, and 73% were aligned and balanced. In 288 knees (59%) only osteophyte excision was performed by subperiosteally releasing the deep medial collateral ligament. Of these, 98% were aligned, 80% were balanced, and 79% were aligned and balanced. In 154 knees (31%), additional procedures were performed (reduction osteotomy, posterior capsular release, and semimembranosus release). Of these, 89% were aligned, 68% were balanced, and 66% were aligned and balanced. The superficial medial collateral ligament was not released in any case. CONCLUSION Two-thirds of all knees could be aligned and balanced with release of the cruciate ligaments alone and excision of osteophytes. Excision of osteophytes can be a useful step towards achieving deformity correction and gap balance without having to resort to soft tissue release in varus knees while maintaining classical coronal and sagittal alignment of components. Cite this article: Bone Joint J 2020;102-B(6 Supple A):49-58.
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Affiliation(s)
- Arun Mullaji
- Mullaji Knee Clinic, Breach Candy Hospital, Mumbai, India
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29
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Nayak M, Kumar V, Yadav R, Maredupaka S, Srivastava DN, Malhotra R, Pandit H. Coronal Alignment of the Lower Extremity: A Gender-Based Radio-Graphic Analysis in Indian Patients. Indian J Orthop 2020; 54:504-512. [PMID: 32549966 PMCID: PMC7271308 DOI: 10.1007/s43465-020-00050-5] [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: 11/30/2019] [Accepted: 02/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Variation in the shape of the femur and tibia has been shown to influence hip-kneeankle-axis angle (HKAA) and bears a role in reconstructive surgeries such as total knee arthroplasty (TKA). However, data on the axial alignment of the lower extremity specific to sex largely remains unavailable. Thus, we conducted a study with an aim to measure alignment and calculate differences in both the sexes in Indian population. MATERIALS AND METHODS The following radiological parameters were measured from weight-bearing long leg radiographs of 966 limbs of Indian subjects via a morphometric software (Matlab R2009a) (1) Hip-Knee-Ankle angle (HKAA), (2) femoral bowing, (3) tibial bowing, (4) condylar plateau angle (CPA). The knees were classified according to the Kellegren and Lawrence grading and the differences between both the sexes were calculated with appropriate statistical tests. RESULTS 56.04% of the subjects were female. An increase in the mean age was observed for both the genders with an increase in the severity of OA. Height did not show any significant association with the alignment of the limb. The mean HKAA observed was - 5.88° ± 0.35° in females and - 4.99° ± 0.41° in males. The overall mean femoral bow and tibial bow was - 1.26° ± 0.24°, - 1.60° ± 0.18° in females and - 1.09 ± 0.28, - 1.47° ± 0.21° in males. The mean condylar plateau angle was higher in females - 2.67 ± 0.34 as compared to males - 2.35° ± 0.39°. A greater lateral bow was seen in males at higher grades of OA for femur and at lower grades of OA for tibia. CONCLUSION This study provides gender-based differences in the various axial radio-graphic parameters in a long leg radio-graphs in Indian population which might help in a better understanding of the etiopathogenesis of osteoarthritis and also help planning and execution of reconstructive surgeries such as TKA.
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Affiliation(s)
- Mayur Nayak
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Vijay Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Rahul Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Siddhartha Maredupaka
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Rajesh Malhotra
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Hemant Pandit
- Chapel Allerton Hospital, University of Leeds, Leeds, UK
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30
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Nayak M, Kumar V, Kanojiya G, Mellon S, Srivastava DN, Pandit H, Malhotra R. A radiographic analysis of alignment in 966 lower extremities with knee pain and its association with osteoarthritis in Indian population. J Orthop 2019; 20:207-212. [PMID: 32025151 DOI: 10.1016/j.jor.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/08/2019] [Indexed: 10/25/2022] Open
Abstract
Purpose This study aimed to investigate the alignment based on deformity in knees affected by osteoarthritis (OA) at different stages and evaluate its association with OA. Material and methods The following radiological parameters were measured from weight bearing long leg radiographs of 966 legs in the Indian subjects via a morphometric software (Matlab R2009a) (1)Hip-Knee-Ankle angle (HKAA), (2) Femoral bowing, (3) Tibial Bowing, (4) Condylar Plateau angle (CPA). The knees were classified according to the Kellegren and Lawrence grading and these parameters were evaluated with OA for its association using appropriate statistical tests. Results The mean HKAA angle was 174.5° ±6.5°, 65.8% of the limbs were in found to be in varus (<177°) and 3.8% in valgus (>183°). The mean femoral and tibial bowing was -1.19 ± 4.95° and -1.54 ± 3.58° respectively. 55.8% of femorae and 41.4% of the tibia were observed to have varus bowing while 24.12% of femorae and 12.11% the tibia were observed to have valgus bowing. An increase in odds of disease severity was observed with femoral and tibial bowing >2°. With an increase in the grades of OA a significant increase in the lateral bow of both femur and tibia was observed. The mean condylar plateau angle was observed to be -2.53° ±7.9°. Positive association was seen between the varus CPA, HKA and OA (p < 0.01). Conclusion This study describes the various radiological parameters in Indian patients at different grades of OA and might elucidate the role of these factors in OA initiation and progression.
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Affiliation(s)
- Mayur Nayak
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Vijay Kumar
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Gourav Kanojiya
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Stephen Mellon
- Botnar Research Centre, University of Oxford, Oxford, UK
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
| | - Hemant Pandit
- Orthopaedics and Honorary Consultant, Chapel Allerton Hospital, University of Leeds, UK
| | - Rajesh Malhotra
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
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Radiographic analysis of lower limb alignment in professional football players. Arch Orthop Trauma Surg 2019; 139:1771-1777. [PMID: 31463688 DOI: 10.1007/s00402-019-03266-9] [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] [Indexed: 10/26/2022]
Abstract
INTRODUCTION To radiographically analyze lower limb alignment in adult asymptomatic professional football players and to correlate these values to clinical measurements. MATERIALS AND METHODS Twenty-four asymptomatic players [24.2 (3.6) years] were enrolled. Standard bilateral lower limb anteroposterior weight-bearing radiographs were acquired and clinical measurement of intercondylar/intermalleolar (ICD/IMD) distance was performed. Coronal plane mechanical alignment was assessed by five angles: leg mechanical axis (LMA), lateral proximal femoral angle (LPFA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and lateral distal tibial angle (LDTA). Their values were compared to the reference values for adult population. An inter-individual comparison between right/left and dominant/non-dominant leg was added. The sum of bilateral LMA was correlated against ICD/IMD and against ICD/IMD adjusted for body height. RESULTS Football players presented with ICD/IMD of 46.5 (19.8) mm. Two, out of five, lower leg coronal angles showed significant differences (p < 0.001) compared to reference data from literature: LMA 5.8 (3.0)º vs.1.2 (2.2)º and MPTA 83.5 (2.6)º vs. 87.2 (1.5)º. No significant differences between left/right leg and dominant/non-dominant leg were established. Summed up bilateral LMA showed a high correlation to IMD/ICD (r = 0.8395; R2 = 0.7048), and even higher to ICD/IMD adjusted for body height (r = 0.8543; R2 = 0.7298). CONCLUSIONS This study was radiographically confirming increased varus of elite football players toward general population. Apex of the varus deformity was located in the proximal tibia. Clinical measurement of ICD/IMD adjusted for body height highly correlated with the radiographic values of coronal alignment; therefore, it may be used in population studies.
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Palanisami D, Jagdishbhai CP, Manohar M, Ramesh P, Natesan R, Shanmuganathan R. Improving the accuracy of tibial component placement during total knee replacement in varus knees with tibial bowing: A prospective randomised controlled study. Knee 2019; 26:1088-1095. [PMID: 31375444 DOI: 10.1016/j.knee.2019.05.010] [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: 04/24/2018] [Revised: 04/02/2019] [Accepted: 05/16/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lateral tibial bowing leads to varus placement of the tibial component during total knee replacement in varus knees. Lateralised tibial jig placement can improve the accuracy of the tibial cut. METHODS A total of 227 patients (300 knees) undergoing total knee replacements were randomised into two groups. In the study group, the point of intersection of the distal tibial diaphyseal line at the tibial plateau drawn on long films was represented by zones. Knees with femoral bowing >5° (28%) were excluded. Tibial jig placement on the proximal tibia was lateralised according to the zones. In the control group, the mid-point of the tibial plateau was taken as a reference. Femoral and tibial bowing, postoperative limb alignment and component placement were assessed. RESULTS Of the 216 knees that were studied, 106 were in the study group and 110 in the control group. Bowing ≥3° had a significant positive correlation with lateralisation of the proximal tibial reference (p < 0.001). The Incidence of tibial bowing ≥3° was 57.33%. The mean postoperative hip-knee-ankle (HKA) angle was 178.31 ± 2.88° and 176.53 ± 2.88° (p < 0.001), whereas the mean medial proximal tibial angle (MPTA) was 89.91 ± 1.42° and 88.79 ± 1.72° (p < 0.001) in the study and control groups, respectively. Considering bowed tibiae alone, HKA angle and MPTA in the study group were 178.08 ± 2.81° and 89.72 ± 1.39° compared with 175.88 ± 2.87° and 88.38 ± 1.38° in the control group (p < 0.001). CONCLUSION There is a high incidence of tibial bowing in varus knees. Lateralised tibial jig placement improved tibial component placement and postoperative limb alignment in total knee arthroplasty in varus knees with tibial bowing.
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Affiliation(s)
| | | | - Mithun Manohar
- Department of Orthopaedic Surgery, Ganga Hospital, Coimbatore, India
| | - Pradeep Ramesh
- Department of Orthopaedic Surgery, Ganga Hospital, Coimbatore, India
| | - Rajkumar Natesan
- Department of Orthopaedic Surgery, Ganga Hospital, Coimbatore, India
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Kuroda Y, Takayama K, Ishida K, Hayashi S, Hashimoto S, Nishida K, Matsushita T, Niikura T, Kuroda R, Matsumoto T. Influence of limb alignment and prosthetic orientation on patient-reported clinical outcomes in total knee arthroplasty. J Orthop Sci 2019; 24:668-673. [PMID: 30553606 DOI: 10.1016/j.jos.2018.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/24/2018] [Accepted: 11/21/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The relationship between postoperative limb alignment and clinical outcomes in primary total knee arthroplasty (TKA) is well reported, but the instruments used to evaluate clinical outcomes of TKA are mainly scoring systems from the physician's viewpoint, not patient-reported outcomes. The purpose of this study was to investigate retrospectively the relationship between postoperative limb alignment and patient-reported clinical outcomes using the 2011 Knee Society Knee Scoring System (2011 KSS). METHODS The present study included 155 knees of patients (median age, 74 years) who underwent primary TKA for varus osteoarthritis, with a mean follow-up period of 46 months. The subjects were divided into three groups based on postoperative limb alignment and femoral and tibial component positioning angle (varus, neutral, and valgus). The 2011 KSS scores were compared among the groups. RESULTS For limb alignment, the postoperative objective knee indicator score was significantly lower in the valgus group than in the varus and neutral groups, whereas no significant differences were observed in any subjective categories of the 2011 KSS. However, for the femoral component angle, functional activity scores were significantly lower in the valgus group than in the varus and neutral groups. CONCLUSIONS The subjective patient-reported score was not affected by the postoperative limb alignment. However, the valgus femoral component angle resulted in lower subjective functional scores. For clinical relevance, postoperative valgus positioning of femoral component should be avoided from patient-reported functional aspects during TKA.
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Affiliation(s)
- Yuichi Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koji Takayama
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazunari Ishida
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Kobe, Japan
| | - Shinya Hayashi
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shingo Hashimoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kyohei Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
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Hirschmann MT, Hess S, Behrend H, Amsler F, Leclercq V, Moser LB. Phenotyping of hip-knee-ankle angle in young non-osteoarthritic knees provides better understanding of native alignment variability. Knee Surg Sports Traumatol Arthrosc 2019; 27:1378-1384. [PMID: 30968238 DOI: 10.1007/s00167-019-05507-1] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/04/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE There is a lack of knowledge about the native coronal knee alignment in 3D. The currently used classification system (neutral, valgus and varus) oversimplifies the coronal knee alignment. The purpose of this study was therefore (1) to investigate the coronal knee alignment in non-osteoarthritic knees using 3D-reconstructed CT images and (2) to introduce a classification system for the overall knee alignment based on phenotypes. METHODS The hospital registry was searched for patients younger than 45 years and older than 16, who received a CT according to the Imperial Knee Protocol. Patients with prosthesis, osteoarthritis, fractures or injury of the collateral ligaments were excluded. Finally, 308 non-osteoarthritic knees of 160 patients remained (102 males and 58 females, mean age ± standard deviation (SD) 30 ± 7 years). The overall lower limb alignment was defined as the hip-knee-ankle angle (HKA), which is formed by lines connecting the centers of the femoral head, the knee and the talus. The angle was measured using a commercially planning software (KneePLAN 3D, Symbios, Yverdon les Bains, Switzerland). Descriptive statistics, such as means, ranges, and measures of variance (e.g., standard deviations) are presented. Based on these results, the currently used classification system was evaluated and a new system, based on phenotypes, was introduced. These phenotypes consist of a phenotype-specific mean value (a HKA value) and cover a range of ± 1.5° from this mean (e.g., 183° ± 1.5°). The mean values represent 3° increments of the angle starting from the overall mean value (mean HKA = 180°; 3° increments = 183° and 177°, 186° and 174°). The distribution of these limb phenotypes was assessed. RESULTS The overall mean HKA was 179.7° ± 2.9° varus and values ranged from 172.6° varus to 187.1° valgus. The mean HKA values for male and female were 179.2° ± 2.8° and 180.5° ± 2.8°, respectively, which implied a significant gender difference (r2 = 0.23). The most common limb phenotype in males was NEUHKA0° (36.4%), followed by VARHKA3° (29.2%) and VALHKA3° (23.1%). The most common limb phenotype in females was NEUHKA0° (36.4%), followed by VALHKA3° (22.1%) and VARHKA3° (15.0%). CONCLUSION The measurements using 3D-reconstructed CT images confirmed the great variability of the overall lower limb alignment in non-osteoarthritic knees. However, the currently used classification system (neutral, varus, valgus) oversimplifies the coronal alignment and therefore the introduced classification system, based on limb phenotypes, should be used. This will help to better understand individual coronal knee alignment. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Silvan Hess
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.,University of Bern, Bern, Switzerland
| | - Henrik Behrend
- Department of Orthopaedic Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | | | | | - Lukas B Moser
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), 4101, Bruderholz, Switzerland.,University of Basel, Basel, Switzerland
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Howell SM. Calipered Kinematically Aligned Total Knee Arthroplasty: An Accurate Technique That Improves Patient Outcomes and Implant Survival. Orthopedics 2019; 42:126-135. [PMID: 31099877 DOI: 10.3928/01477447-20190424-02] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Kinematic alignment performed with caliper measurements and verification checks accurately co-align the femoral and tibial components with the 3 axes and joint lines of the native knee without ligament release and without restrictions on the degree of preoperative varus, valgus, flexion, and extension deformities and the degree of postoperative correction. [Orthopedics. 2019; 42(3):126-135.].
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Native non-osteoarthritic knees have a highly variable coronal alignment: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27:1359-1367. [PMID: 30848310 DOI: 10.1007/s00167-019-05417-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 02/13/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Coronal alignment of the knee is defined by the hip-knee-ankle angle (HKA), the femoral mechanical angle (FMA), the tibial mechanical angle (TMA), and the joint line convergence angle (JLCA). To date, there is still a lack of knowledge about the variability of native coronal knee alignment. The purpose of this paper is to present a systematic review of the current literature about the variability of coronal knee alignment (HKA, FMA, TMA, and JLCA) in non-osteoarthritic knees. METHODS The electronic databases MEDLINE, EMBASE, and Google Scholar were searched from database inception to search date (November 1, 2018) and screened for relevant studies. The PRISMA guidelines were followed. Inclusion criteria were studies that reported the coronal alignment of the native, non-osteoarthritic knee. RESULTS A total of 15 studies met the inclusion criteria. Thirteen studies performed the measurements on weight-bearing long-leg standing radiographs (LLR), one study used MRI, and one study used the EOS imaging system. The mean HKA ranged from 176.7° ± 2.8° (male) to 180.7° (female). The mean FMA ranged from 92.08° ± 1.78° (female) to 97.2° ± 2.7° (female). The mean TMA ranged from 84.6° ± 2.5° (female) to 89.6° (female). The mean JLCA ranged from - 0.47° ± 0.98° (male) to - 1.9° ± 1.4° (female). CONCLUSION This systematic review provides a detailed overview about the variability of the coronal knee alignment in non-osteoarthritic knees. The broad variability of all coronal alignment parameters highlights the necessity for a more anatomic and individualized approach in knee arthroplasty. It also offers the fundament to understand the changes in osteoarthritic knees. LEVEL OF CLINICAL EVIDENCE Systematic review, Level IV.
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The native coronal orientation of tibial plateaus may limit the indications to perform a kinematic aligned total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1442-1449. [PMID: 29947846 DOI: 10.1007/s00167-018-5017-0] [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: 08/07/2017] [Accepted: 06/06/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To investigate the coronal alignment of tibial plateaus in normal and osteoarthritic knees and to simulate the effects of a tibial cut performed in total knee arthroplasty (TKA) using a kinematic alignment technique with standard instrumentation. METHODS The coronal alignment of tibial plateaus was measured in three groups including group 1 (reference group), 50 cadaveric tibiae showing no evidence of degenerative changes of tibial plateaus; group 2, 49 patients who underwent MR of the knee, showing no or mild degenerative changes of the knee joint and, group 3, 54 patients with knee osteoarthritis who underwent computer-assisted total knee arthroplasty. RESULTS The coronal alignment of tibial plateaus averaged 2.4° with no significant differences between groups. The mean coronal orientation of tibial plateaus was 3° ± 2° in men and 1.6° ± 2° in women (p = 0.03). A coronal alignment of tibial plateaus of 3° or more was found in 69 cases (45%) and 5° or more in 23 (14.7%). The simulation of a tibial cut performed with an error of 3° in varus in 15% of the subjects showing a native coronal orientation of tibial plateaus of 3° or more, led to a final tibial cut greater 6° in 13.7% of cases. CONCLUSIONS A coronal alignment of tibial plateaus of 3° or more in varus was found in near half of normal subjects and osteoarthritic patients. A preoperative measurement of the coronal alignment of tibial plateaus is advisable in any patients scheduled for kinematic aligned TKA. As errors in the alignment of the tibial component of 3° or more may occur using standard instrumentations, the results of this study raise questions on performing a kinematic aligned TKA with standard instrumentations. LEVEL OF EVIDENCE IV.
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Kato Y, Yamada S, Hattori S, Takazawa S, Ohuchi H. Combined autologous chondrocyte implantation and meniscus reconstruction for large chondral defect in the lateral compartment due to discoid lateral meniscus tear: A case report. Regen Ther 2018; 10:64-68. [PMID: 30581898 PMCID: PMC6299147 DOI: 10.1016/j.reth.2018.11.002] [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] [Received: 09/26/2018] [Revised: 11/13/2018] [Accepted: 11/16/2018] [Indexed: 01/03/2023] Open
Abstract
Discoid lateral meniscus tear leads to large chondral defect in the lateral compartment of the knee joint. There are few effective treatments for large chondral defect in both the tibial and femoral sides with severe degenerative lateral meniscus. We have developed a combined autologous chondrocyte implantation and meniscus reconstruction technique using hamstring tendon. This technique allows biological reconstruction and avoids knee arthroplasty. Discoid lateral meniscus tear leads to large chondral defect. A combination of autologous chondrocyte implantation and meniscus reconstruction technique using hamstring tendon is introduced. This novel method allows biological reconstruction.
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Affiliation(s)
- Yuki Kato
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Shin Yamada
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Soichi Hattori
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Shuzo Takazawa
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
| | - Hiroshi Ohuchi
- Department of Sports Medicine, Kameda Medical Center, Chiba, Japan
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Wang WJ, Sun MH, Palmer J, Liu F, Bottomley N, Jackson W, Qiu Y, Weng WJ, Price A. Patterns of Compartment Involvement in End-stage Knee Osteoarthritis in a Chinese Orthopedic Center: Implications for Implant Choice. Orthop Surg 2018; 10:227-234. [PMID: 30152607 DOI: 10.1111/os.12395] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 02/04/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Knee osteoarthritis (OA) is a prevalent disease in the elderly, causing pain and contributing to poor quality of life. Surgical intervention, such as knee arthroplasty, can be used in those with end-stage knee OA. Total knee arthroplasty (TKA) is one of the most common surgical procedures for end-stage knee OA, with promising clinical outcomes. However, a large proportion of patients with isolated compartment OA can be treated with unicompartmental knee arthroplasty (UKA) instead. UKA has shown better patient-reported functional outcomes, and lower mortality and major complication rates than TKA. The percentage of UKA in knee arthroplasty varied in different orthopedic centers, and we believed that the requirement for UKA was underestimated in many centers. A retrospective study was carried out on our Chinese patient population presenting for knee arthroplasty; it aimed to identify the proportion of patients that might be suitable for UKA. METHODS A retrospective cross-sectional study of 155 consecutive patients (168 knees) awaiting TKA for end-stage primary OA was performed. The pattern and grade of OA was recorded from preoperative weight-bearing anteroposterior and non-weight-bearing lateral radiographs. The medial, lateral, patellofemoral compartment was given an individual Kellgren-Lawrence grade on the radiographs, and those grade ≥3 were defined as end-stage OA. The compartments involvement was established then. The integrity of the anterior cruciate ligament (ACL) was determined by the modified Keyes classification on lateral radiographs. The applicability for total or partial knee arthroplasty was determined according to the compartments involvement. RESULTS Medial compartment involvement was found in 154 (91.7%) knees, while the involvement of the lateral compartment and patellofemoral joint was found in 54 (32.1%) and 57 (33.9%) knees, respectively. Eighty-one (48.2%) of the knees showed medial compartment OA with or without patellofemoral joint involvement, and modified Keyes classification grade 1, indicating an intact ACL, and, hence, potential suitability for medial UKA. Isolated lateral OA indicating possible suitability for lateral UKA was identified in 11 knees (6.5%). No patients showed isolated patellofemoral joint OA. The other 76 (45.2%) knees could be treated by TKA. CONCLUSIONS The medial compartment was the most commonly affected in our Chinese patients indicated for knee arthroplasty. More than half of the patients in this group could be treated by either medial or lateral UKA.
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Affiliation(s)
- Wei-Jun Wang
- Department of Orthopaedics, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Ming-Hui Sun
- Department of Orthopaedics, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Jonathan Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Fei Liu
- Department of Orthopaedics, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Nicholas Bottomley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - William Jackson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Yong Qiu
- Department of Orthopaedics, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Wen-Jie Weng
- Department of Orthopaedics, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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Ro KH, Heo JW, Lee DH. Bearing Dislocation and Progression of Osteoarthritis After Mobile-bearing Unicompartmental Knee Arthroplasty Vary Between Asian and Western Patients: A Meta-analysis. Clin Orthop Relat Res 2018; 476:946-960. [PMID: 29406457 PMCID: PMC5916611 DOI: 10.1007/s11999.0000000000000205] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Implant survivorship is reported to be lower and complications, particularly bearing dislocation, are reported to be more frequent in Asian than in Western patients with medial knee osteoarthritis (OA) undergoing Oxford® Phase III unicompartmental knee arthroplasty (UKA). To date, however, these complications have not been compared between these groups of patients. QUESTIONS/PURPOSES The purpose of this study was to perform a meta-analysis comparing the standardized incidence rates of (1) all-cause reoperation; (2) reoperation related to bearing dislocation; and (3) reoperation related to progression of lateral compartment arthritis in Asian and Western patients with medial knee OA who underwent Oxford Phase III UKA. METHODS We searched MEDLINE® (January 1, 1976, to May 31, 2017), EMBASE® (January 1, 1985, to May 31, 2017), and the Cochrane Library (January 1, 1987, to May 31, 2017) for studies that reported complications of Oxford Phase III UKAs. Studies were included if they reported reoperation rates attributable to bearing dislocation and/or progression of lateral knee OA after surgery with this implant. Twenty-seven studies were included in this systematic review and 16 studies with followups > 5 years were included in the meta-analysis. These rates were converted to standardized incidence rate (that is, reoperations per 100 observed component years) based on mean followup and number of involved knees in each study. After applying prespecified inclusion and exclusion criteria, the studies were categorized into two groups, Asian and Western, based on hospital location. Twenty-five studies, containing 3152 Asian patients and 5455 Western patients, were evaluated. Study quality was assessed by the modified Coleman Methodology score (MCMS). Although all studies were Level IV, their mean MCMS score was 66.92 (SD, 8.7; 95% confidence interval [CI], 63.5-70.3), indicating fair quality. Because the heterogeneity of all subgroup meta-analyses was high, a random-effects model was used with estimations using the restricted maximum likelihood method. RESULTS There was no difference in the proportion of Asian patients versus Western patients undergoing reoperation for any cause calculated as 100 component observed years (1.022 of 3152 Asian patients; 95% CI, 0.810-1.235 versus 1.300 of 5455 Western patients; 95% CI, 1.067-1.534; odds ratio, 0.7839; 95% CI, 0.5323-1.1545; p = 0.178). The mean reoperation rate attributable to bearing dislocation per 100 observed years was higher in Asian than in Western patients (0.525; 95% CI, 0.407-0.643 versus 0.141; 95% CI, 0.116-0.166; odds ratio, 3.7378; 95% CI, 1.694-8.248; p = 0.001) Conversely, the mean reoperation rate attributable to lateral knee OA per 100 observed years was lower in Asian than in Western patients (0.093; 95% CI, 0.070-0.115 versus 0.298; 95% CI, 0.217-0.379; odds ratio, 0.3114; 95% CI, 0.0986-0.9840; p < 0.001). CONCLUSIONS Although total reoperation rates did not differ in the two populations, reoperation for bearing dislocation was more likely to occur in Asian than in Western patients, whereas reoperation for lateral knee OA progression was more likely to occur in Western than in Asian patients after Oxford Phase III UKA. Although possible explanations for these findings may be hypothesized, additional randomized, prospective comparative studies are needed. However, better survival outcomes after UKA may require consideration of ethnicity and lifestyle choices in addition to traditional surgical technique and perioperative care. LEVEL OF EVIDENCE Level III, therapeutic study.
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Does alignment of the limb and tibial width determine relative narrowing between compartments when planning mechanically aligned TKA? Arch Orthop Trauma Surg 2018; 138:91-97. [PMID: 29071434 DOI: 10.1007/s00402-017-2824-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION We determined (1) the range of the hip-knee-ankle (HKA) angle in the native or pre-arthritic limbs of patients with a contralateral total knee arthroplasty (TKA); and when mechanical alignment is planned (2) the relationships between the HKA angle and the tibial width, and the relative narrowing between the medial and lateral compartments and (3) the effect of tibial width on the range of narrowing. METHODS The HKA angle, distal lateral femoral angle (DLFA), and proximal medial tibial angle (PMTA) were measured on the native limb of 102 subjects (53 female) treated with contralateral TKA. The sine of the angle of the resection gap (PMTA minus 90° subtracted from the DLFA minus 90°) multiplied by the tibial width and by narrow (59 mm), average (75 mm), and wide (91 mm) tibias computed relative narrowing. RESULTS The HKA angle ranged from 8° varus to - 7° valgus; 20% had constitutional varus (≥ 3°) and 11% constitutional valgus (≤ - 3°). The HKA angle strongly predicted (r 2 = 0.87) and tibial width weakly predicted (r 2 = 0.06) relative narrowing. For narrow, average, and wide tibias, the maximum medial narrowing was 9, 11, 14 mm and maximum lateral narrowing was 7, 9, and 11 mm, respectively (p < 0.0001). CONCLUSION When mechanical alignment is planned, there is greater relative narrowing between compartments when the pre-arthritic limb greatly deviates from a 0° HKA angle and the tibia is wide. These limbs may need soft-tissue releases until neutral postoperative limb alignment of 0° and negligible varus-valgus laxity are achieved. LEVEL OF EVIDENCE IV, therapeutic study.
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Sato T, Sato N, Sasaki T, Sato K, Gorniak GC. Patterns of patellofemoral articular cartilage wear in Japanese cadavers. J ANAT SOC INDIA 2017. [DOI: 10.1016/j.jasi.2017.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Koh JH, Myong JP, Yoo J, Lim YW, Lee J, Kwok SK, Park SH, Ju JH. Predisposing factors associated with atypical femur fracture among postmenopausal Korean women receiving bisphosphonate therapy: 8 years' experience in a single center. Osteoporos Int 2017; 28:3251-3259. [PMID: 28748389 DOI: 10.1007/s00198-017-4169-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023]
Abstract
UNLABELLED The risk factors for atypical femur fracture in patients exposed to bisphosphonates for at least 1 year were examined. Prolonged and continuous use of bisphosphonates, long-term use of glucocorticoids, and a higher body mass index were associated with increased risk of atypical femur fracture. INTRODUCTION The purpose of the present study is to determine whether rheumatoid arthritis (RA) and other clinical factors are associated with an increased risk of bisphosphonate (BP)-related atypical femur fracture (AFF). METHODS A retrospective nested case-control study of patients who had taken BPs for at least 1 year was conducted. Patients with AFF were identified by reviewing surgical and radiographic records. Three controls with no history of AFFs were randomly selected and age- and sex-matched to each patient with AFFs. Cox proportional hazard models were used to analyze the independent contribution of risk factors to BP-related AFF. RESULTS Among the 35,104 patients prescribed BPs for at least 1 year, 43 females (mean age, 68 years) suffered AFFs (0.12%). Patients with AFFs were exposed to BPs for a mean of 7.3 years. Patients with AFFs were exposed to BPs for longer than those without AFFs and continued treatment without a drug holiday. More patients with AFF than controls had taken glucocorticoids and disease-modifying anti-rheumatic drugs. Multivariate Cox regression analyses estimated that long-term use of glucocorticoids, prolonged exposure to BP without cessation, and every 1 kg/m2 increase in the body mass index (BMI) increased the hazard ratio for AFFs by 3.0, 5.2, and 1.2, respectively. CONCLUSIONS Prolonged and continuous use of BPs, long-term use of glucocorticoids, and a higher BMI increase the risk of AFFs. Switching long-term BP and glucocorticoid users to other bone-protective agents should be considered.
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Affiliation(s)
- J H Koh
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - J P Myong
- Department of Occupational & Environmental Medicine, Center for Occupational & Environmental Medicine (WHO Collaboratory Center), Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Yoo
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - Y-W Lim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - J Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - S-K Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - S-H Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea
| | - J H Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-040, South Korea.
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Nishida K, Matsumoto T, Takayama K, Ishida K, Nakano N, Matsushita T, Kuroda R, Kurosaka M. Remaining mild varus limb alignment leads to better clinical outcome in total knee arthroplasty for varus osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2017; 25:3488-3494. [PMID: 27506810 DOI: 10.1007/s00167-016-4260-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE Postoperative neutral limb alignment [femorotibial mechanical axis (FTMA) 180° ± 3°] is generally considered to be one of the prerequisites for successful total knee arthroplasty (TKA). However, the influence of residual malalignment on clinical and functional outcomes after TKA is unknown. Therefore, the purpose of this study was to investigate the relationship between postoperative limb alignment and clinical outcomes in Asian patients who underwent primary TKA. METHODS The study included 220 knees with a mean age of 73.5 years who underwent primary TKA for varus-type osteoarthritis; the mean follow-up period was 3.6 years. Patients were divided into four groups based on postoperative FTMA: severe varus (FTMA < 174°, n = 15), mild varus (FTMA >177°and ≤174°, n = 61), neutral (FTMA 180° ± 3°, n = 128), and valgus (FTMA > 183°, n = 16). Knee Society Knee Score (KSKS) and Knee Society Functional Score (KSFS) were compared among the 4 groups. RESULTS KSKS and KSFS showed significant improvement in all groups. There were no statistically significant differences for postoperative KSKS among the four groups. For KSFS, however, the severe varus and valgus groups exhibited significantly lower values compared with the mild varus and neutral groups. CONCLUSION Postoperative mild varus alignment as well as neutral mechanical alignment of the lower limb led to excellent functional outcomes. For the clinical relevance, postoperative mild varus alignment of the lower limb is acceptable following TKA for varus-type osteoarthritis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kyohei Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Koji Takayama
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Kazunari Ishida
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Kobe, Japan
| | - Naoki Nakano
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Masahiro Kurosaka
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Kobe, Japan
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Mullaji AB, Shah S, Shetty GM. Mobile-bearing medial unicompartmental knee arthroplasty restores limb alignment comparable to that of the unaffected contralateral limb. Acta Orthop 2017; 88:70-74. [PMID: 27794622 PMCID: PMC5251267 DOI: 10.1080/17453674.2016.1253327] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Medial unicompartmental knee arthroplasty (UKA) is undertaken in patients with a passively correctable varus deformity. We investigated whether restoration of natural soft tissue tension would result in a lower limb alignment similar to that of the contralateral unaffected lower limb after mobile-bearing medial UKA. Patients and methods - In this retrospective study, hip-knee-ankle (HKA) angle, position of the weight-bearing axis (WBA), and knee joint line obliquity (KJLO) after mobile-bearing medial UKA was compared with that of the unaffected (clinically and radiologically) contralateral lower limb in 123 patients. Results - Postoperatively, HKA angle was restored to within ±3° of the contralateral lower limb in 87% of the patients and the WBA passed within ±1 Kennedy and White's tibial zone of the unaffected contralateral lower limb in 95% of the patients. The mean KJLO in the operated limbs was not significantly different from that in the unaffected lower limbs (p = 0.07) and the KJLO in the operated limb was restored to within ±3° of that in the contralateral lower limb in 96% of the patients. Interpretation - Lower limb alignment and knee joint line obliquity after mobile-bearing medial UKA were comparable to that of the unaffected contralateral limb in most patients. Comparison with the contralateral unaffected lower limb is a reliable method for evaluation and validation of limb mechanical alignment after mobile-bearing medial UKA.
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Affiliation(s)
- Arun B Mullaji
- Department of Orthopedic Surgery, Breach Candy Hospital,Mullaji Knee Clinic, Mumbai, India
| | | | - Gautam M Shetty
- Department of Orthopedic Surgery, Breach Candy Hospital,Mullaji Knee Clinic, Mumbai, India,Correspondence:
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Thienpont E, Parvizi J. A New Classification for the Varus Knee. J Arthroplasty 2016; 31:2156-60. [PMID: 27237965 DOI: 10.1016/j.arth.2016.03.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 03/03/2016] [Accepted: 03/14/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A new classification for osteoarthritis of the knee associated with varus deformity is presented. This classification is derived from the combination of conventional radiographs, stress radiographs (when needed), and clinical examination. METHODS This study included the analysis of coronal alignment on full-leg standing radiographs of 526 patients awaiting knee arthroplasty for varus deformity in a single institution. Various mechanical and anatomic angles were measured, and these findings were combined with a basic clinical examination of patients. The radiographs were measured on 2 separate occasions to determine the intraobserver reliability. Cross-sectional studies such as computed tomography or magnetic resonance imaging were used to further refine observations about different wear patterns. RESULTS Varus deformity can either be intra-articular or extra-articular. Intra-articular deformities can be correctable or fixed. In fixed deformities, the status of the lateral ligament is taken into account. Extra-articular deformity can be metaphyseal or diaphyseal, and the possibility for intra-articular correction will depend on the degree of deformity and its distance from the joint. CONCLUSION This new classification allows for better definition of varus deformity, which can help surgeons during preoperative planning, particularly with their choice of implant and potentially the degree of constraint. The classification can also be a tool for further prospective studies about varus deformity.
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Affiliation(s)
- Emmanuel Thienpont
- Department of Orthopaedic Surgery, University Hospital Saint Luc-UCL, Brussels, Belgium
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, Pennsylvania
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Liu HX, Shang P, Ying XZ, Zhang Y. Shorter survival rate in varus-aligned knees after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2016; 24:2663-71. [PMID: 26377095 DOI: 10.1007/s00167-015-3781-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/08/2015] [Indexed: 01/11/2023]
Abstract
PURPOSE One long-held tenet of total knee arthroplasty (TKA) is that post-operative neutral limb alignment promotes implant durability. Recently, the concept of generic safe zone (0° ± 3°) has been challenged. This meta-analysis aimed to evaluate whether neutral alignment was superior to malalignment in long-term survival of TKAs. METHODS The MEDLINE, Embase, Cochrane Library, China National Knowledge Infrastructure, Wan Fang Chinese Periodical, Google and reference lists of all the included studies were searched. Of the 1512 studies initially identified, ten met the eligibility criteria, including eight case-control studies and two cohort trials. Relative risks of implant failure were compared between post-operative neutrally aligned and malaligned knees. RESULTS Post-operative malalignment showed higher failure rate of knee implants compared with neutral alignment (95 % CI 1.00-1.88, P = 0.05). Failure rate in knees with varus alignment was significantly higher than with neutral alignment (95 % CI 1.07-2.55, P = 0.02). There was no significant difference in the likelihood of implant failure between knees with valgus and neutral alignment (95 % CI 0.78-2.41, n.s.). No significant difference of failure rate was noted between neutral alignment and malalignment for fixed-bearing prothesis (95 % CI 0.94-1.95, n.s.) or rotating-platform prothesis (95 % CI 0.75-2.73, n.s.). There was no significant difference of failure rate between knees with neutral alignment and malalignment for studies with a mean follow-up of more than 10 years (95 % CI 0.81-2.01, n.s.) or studies using long-leg weight-bearing radiographs (95 % CI 0.79-1.79, n.s.). CONCLUSIONS Post-operative varus alignment results in shorter survival rate after TKA. Not only neutral limb alignment but also the valgus alignment promotes implant durability. Neutral or valgus alignment rather than varus alignment is essential to achieve long-term survival of TKAs and patient satisfaction. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hai-Xiao Liu
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi Road, Wenzhou, 325027, China.
| | - Ping Shang
- Department of Rehabilitation, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi Road, Wenzhou, 325027, China
| | - Xiao-Zhou Ying
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi Road, Wenzhou, 325027, China
| | - Yu Zhang
- Department of Orthopaedic Surgery, Second Affiliated Hospital of Wenzhou Medical University, 109, Xueyuanxi Road, Wenzhou, 325027, China
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Koh JH, Myong JP, Jung SM, Lee J, Kwok SK, Park SH, Ju JH. Atypical Femoral Fracture in Rheumatoid Arthritis Patients Treated With Bisphosphonates: A Nested Case-Control Study. Arthritis Rheumatol 2016; 68:77-82. [PMID: 26360133 DOI: 10.1002/art.39429] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 09/03/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the clinical characteristics of atypical femoral fracture (AFF) and to determine the risk factors for and clinical outcomes of AFFs in rheumatoid arthritis (RA) patients treated with bisphosphonates (BPs). METHODS A nested case-control study was conducted using data derived from the medical records of all RA patients treated with BPs at Seoul St. Mary's Hospital, a tertiary rheumatology center, from January 1, 2008 to December 31, 2014. All of the patients with RA and had been treated with BPs for at least 1 year. Ten RA patients with AFF were identified, and each of these patients (cases) was age- and sex-matched with 4 RA patients without AFF (controls). RESULTS Five hundred fifty-two RA patients had BP exposure. Of the 10 with AFF, all were female (mean ± SD age 66.3 ± 8.7 years), and 90% of cases involved fracture of the proximal femur. The mean ± SD length of BP exposure in patients with AFF was 7.4 ± 3.2 years. Compared with controls, patients with AFF had a longer exposure to BPs and more often had a femorotibial angle of <175 degrees (both P < 0.001). There were no differences in RA duration, medications taken during the previous 6 months, and bone mineral density in the femur and lumbar spine between patients with and those without AFF. Multivariate logistic analyses identified longer BP exposure (odds ratio 2.386 [95% confidence interval 1.066-5.343]) as being associated with an increased risk of AFF. CONCLUSION RA patients who have a valgus deformity and are receiving long-term BP treatment are at higher risk of AFF compared with matched control patients with RA. These patients should be carefully followed up with hip radiography or dual x-ray absorptiometry.
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Affiliation(s)
- Jung Hee Koh
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
| | - Jun Pyo Myong
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Min Jung
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
| | - Jennifer Lee
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Ki Kwok
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Park
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Hyeon Ju
- Seoul St. Mary's Hospital and Catholic University of Korea, Seoul, Republic of Korea
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Morin SN, Wall M, Belzile EL, Godbout B, Moser TP, Michou L, Ste-Marie LG, de Guise JA, Rahme E, Brown JP. Assessment of femur geometrical parameters using EOS™ imaging technology in patients with atypical femur fractures; preliminary results. Bone 2016; 83:184-189. [PMID: 26541215 DOI: 10.1016/j.bone.2015.10.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/26/2015] [Accepted: 10/29/2015] [Indexed: 12/12/2022]
Abstract
Atypical femur fractures (AFF) arise in the subtrochanteric and diaphyseal regions. Because of this unique distribution, we hypothesized that patients with AFF demonstrate specific geometrical variations of their lower limb whereby baseline tensile forces applied to the lateral cortex are higher and might favor the appearance of these rare stress fractures, when exposed to bisphosphonates. Using the low irradiation 2D-3D X-ray scanner EOS™ imaging technology we aimed to characterize and compare femur geometric parameters between women who sustained bisphosphonate-associated AFF and those who had experienced similar duration of exposure to bisphosphonates but did not sustain fractures. Conditional logistic regression models were constructed to estimate the association between selected geometric parameters and the occurrence of AFF. We identified 16 Caucasian women with AFF and recruited 16 ethnicity-, sex-, age-, height- and cumulative bisphosphonate exposure-matched controls from local osteoporosis clinics. Compared to controls, those with AFF had more lateral femur bowing (-3.2° SD [3.4] versus -0.8° SD [1.9] p=0.02). In regression analysis, lateral femur bowing was associated with the risk of AFF (aOR 1.54; 95% CI 1.04-2.28, p=0.03). Women who sustained a subtrochanteric AFF demonstrated a lesser femoral neck shaft angle (varus geometry) than those with a fracture at a diaphyseal site (121.9 [3.6]° versus 127.6 [7.2]°, p=0.07), whereas femur bowing was more prominent in those with a diaphyseal fracture compared to those with a subtrochanteric fracture (-4.3 [3.2]° versus -0.9 [2.7]°, p=0.07). Our analyses support that subjects with AFF exhibit femoral geometry parameters that result in higher tensile mechanical load on the lateral femur. This may play a critical role in the pathogenesis of AFF and requires further evaluation in a larger size population.
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Affiliation(s)
- Suzanne N Morin
- McGill University, Montreal, Canada; McGill University Health Center Research Institute, Montreal, Canada.
| | - Michelle Wall
- McGill University Health Center Research Institute, Montreal, Canada
| | - Etienne L Belzile
- Laval University, Quebec City, Canada; CHU de Québec Research Centre, Quebec City, Canada
| | - Benoit Godbout
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Canada
| | - Thomas P Moser
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Canada; Université de Montréal, Montreal, Canada
| | - Laëtitia Michou
- Laval University, Quebec City, Canada; CHU de Québec Research Centre, Quebec City, Canada
| | - Louis-Georges Ste-Marie
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Canada; Université de Montréal, Montreal, Canada
| | - Jacques A de Guise
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Canada; Université de Montréal, Montreal, Canada
| | - Elham Rahme
- McGill University, Montreal, Canada; McGill University Health Center Research Institute, Montreal, Canada
| | - Jacques P Brown
- Laval University, Quebec City, Canada; CHU de Québec Research Centre, Quebec City, Canada
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Kim DK, Seo MC, Song SJ, Kim KI. Are Korean Patients Different from Other Ethnic Groups in Total Knee Arthroplasty? Knee Surg Relat Res 2015; 27:199-206. [PMID: 26675374 PMCID: PMC4678240 DOI: 10.5792/ksrr.2015.27.4.199] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 01/14/2023] Open
Abstract
Most of the implants used for total knee arthroplasty (TKA) in Asian patients have been produced based on anthropometry of Western people. Since anatomic features and life styles are different between Western and Eastern people, there would be ethnic differences in terms of conformity of implants to the patient's anatomy or clinical results after TKA. Therefore, surgeons in Asia are particularly interested in related surgical techniques and implant designs used in TKA for improved clinical results and patient satisfaction. In this review, we investigated the anthropometric differences of Koreans from Westerners. Koreans are of shorter stature, less weight, and smaller skeletal structure and have a higher incidence of constitutional varus alignment of the lower extremity. Moreover, compared to Westerner TKA populations, the proportion of female patients was large and primary osteoarthritis was prevalent in preoperative diagnosis in Korean TKA patients. Culturally, Koreans have life styles that demand high flexion positions of the knee such as squatting, kneeling, and cross-legged sitting. Although there were no notable differences in the complication and revision rates following TKA between Westerners and Koreans, the incidence of postoperative deep vein thrombosis and pulmonary thromboembolism was lower in Koreans than Westerners. We hope that further research on implant designs and more interest in TKA will improve outcomes in Korean patients.
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Affiliation(s)
- Dong-Kyoon Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Min-Chul Seo
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Sang-Joon Song
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea. ; Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
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