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Gorur A, Czerwonka N, El-Othmani MM, Held MB, Neuwirth AL, Geller JA. Outcomes of Image-Free Robotic Assisted Total Knee Arthroplasty in Patients Who Have Valgus Knee Deformities. J Arthroplasty 2024:S0883-5403(24)00248-1. [PMID: 38518959 DOI: 10.1016/j.arth.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Valgus knee deformities pose a unique challenge in total knee arthroplasty (TKA) due to the complexity of achieving ligamentous balance and satisfactory alignment compared to varus or neutral deformities. Robotic-assisted (RA) TKA could aid in achieving improved component alignment and balance. METHODS We retrospectively evaluated a matched cohort of patients to compare image-free RA-TKA (n = 44) versus conventional manual (CM) TKA (n = 30) techniques in patients who have valgus deformity of 5 to 15 degrees, including radiographic and patient-reported outcomes measures (PROMs) over a 3-year period. The patient reported outcome measures (PROMs) studied to determine outcomes were: Western Ontario McMaster University Arthritis Index, Knee Society Score-Function Score, and Short Form 12-item Survey. RESULTS Overall, the RA-TKA cohort showed faster improvement in PROMs (37.16 ± 1 8.8 versus 25.74 ± 17.7, P = .02), shorter length of stay (1.41 versus 2.29 days, P = .02), and shorter operating room times (120.79 versus 123.67 minutes, P = .02) than CM-TK). Additionally, there was no difference in the use of primary versus varus-valgus constrained polyethylene liners between the cohorts. CONCLUSIONS In this investigation, RA-TKA yielded a slightly faster patient recovery, more objective measurements of ligamentous balance, and proved noninferior PROMs compared to CM-TKA for preoperative valgus knee deformities.
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Affiliation(s)
- Alaka Gorur
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Natalia Czerwonka
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Mouhanad M El-Othmani
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael B Held
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander L Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jeffrey A Geller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Palanisami D, Dhanasekaran S, Kanugula SK, Natesan R, Shanmuganathan R. Outcomes of lateral femoral sliding osteotomy in primary total knee arthroplasty for type two fixed valgus deformity. INTERNATIONAL ORTHOPAEDICS 2024; 48:111-117. [PMID: 37648763 DOI: 10.1007/s00264-023-05950-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE The aim of our study was to determine the surgical outcomes of patients who underwent lateral femoral sliding osteotomy (LFSO) with total knee arthroplasty (TKA) for Ranawat's type 2 fixed valgus deformity. METHODS The consecutive patients who underwent primary TKA with posterior-stabilized implant and LFSO for fixed valgus deformity were reviewed. The radiological parameters analyzed were pre- and postoperative hip-knee-ankle (HKA) angle and tibio-femoral angle in varus-valgus stress views. The clinical outcome was measured by Oxford knee score (OKS), knee society score (KSS), and functional score (KSS-F). The complications and any reoperation were noted in the follow-up. RESULTS There were total 28 patients included with an average follow-up time of 47.2 ± 24.9 months. The average arc of motion was 101.3 ± 23.8° preoperatively and 102.7 ± 11.8° postoperatively (p > 0.05). The average deformity in varus and valgus stress views was 196.6 ± 4.8 and 207.8 ± 7.4°, respectively. There was significant improvement in HKA from 205.2 ± 8.3° preoperatively to 181.9 ± 3.7° postoperatively (p < 0.05). At the final follow-up, bony union of the osteotomy fragment was noted in all the patients. There was significant improvement in OKS, KSS, and KSS-F score from a preoperative 15.1 ± 3.9, 35.1 ± 10.6, and 26.6 ± 12.6 to 40.3 ± 2.9, 85.6 ± 4.8, and 89.4 ± 7.7, postoperatively (p < 0.05), respectively. One patient had acute periprosthetic joint infection that was managed with debridement and polyethylene insert exchange. CONCLUSION Lateral femoral sliding osteotomy is an effective technique for optimal soft tissue balance in fixed valgus deformity. It provides satisfactory clinical outcome with restoration of knee alignment without using the constrained implants.
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Affiliation(s)
| | | | - Sandeep Kumar Kanugula
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043, India
| | - Rajkumar Natesan
- Department of Orthopaedics, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, 641 043, India
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Mannino A, Weinberg ME, Scuderi GR. Total Knee Arthroplasty in the Valgus Knee. J Knee Surg 2024; 37:86-91. [PMID: 37800175 DOI: 10.1055/a-2186-6013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
An estimated 10 to 15% of total knee arthroplasties (TKAs) are implanted for a diagnosis of arthritis when a valgus deformity is present. There are various techniques and considerations that must be considered for a successful TKA in a patient with a valgus deformity. This article provides a detailed summary of the anatomy, pathology, bone preparation, soft tissue management, implant selection, and complications when performing a TKA in a patient with valgus deformity.
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Affiliation(s)
- Angelo Mannino
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Maxwell E Weinberg
- Department of Orthopedic Surgery, Long Island Jewish Valley Stream, Valley Stream, New York
| | - Giles R Scuderi
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
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Functional Alignment Philosophy in Total Knee Arthroplasty-Rationale and Technique for the Valgus Morphotype Using an Image Based Robotic Platform and Individualized Planning. J Pers Med 2023; 13:jpm13020212. [PMID: 36836446 PMCID: PMC9961945 DOI: 10.3390/jpm13020212] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 01/27/2023] Open
Abstract
Functional alignment (FA) is a novel philosophy to deliver a total knee arthroplasty (TKA) that respects individual bony and soft tissue phenotypes within defined limitations. The purpose of this paper is to describe the rationale and technique of FA in the valgus morphotype with the use of an image-based robotic-platform. For the valgus phenotype the principles are personalized pre-operative planning, reconstitution of native coronal alignment without residual varus or valgus of more than 3°, restoration of dynamic sagittal alignment within 5° of neutral, implant sizing to match anatomy, and achievement of defined soft tissue laxity in extension and flexion through implant manipulation within the defined boundaries. An individualized plan is created from pre-operative imaging. Next, a reproducible and quantifiable assessment of soft tissue laxity is performed in extension and flexion. Implant positioning is then manipulated in all three planes if necessary to achieve target gap measurements and a final limb position within a defined coronal and sagittal range. FA is a novel TKA technique that aims to restore constitutional bony alignment and balance the laxity of the soft tissues by placing and sizing implants in a manner that respects variations in individual anatomy and soft tissues within defined limits.
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Eller K, Scior W, Graichen H. Dynamic gap analysis of valgus knees shows large inter-individual variability of gaps. Knee Surg Sports Traumatol Arthrosc 2022; 31:1398-1404. [PMID: 36083353 DOI: 10.1007/s00167-022-07088-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/24/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to investigate the dynamic gap widths of valgus knees in extension and flexion to evaluate the influence of deformity on gap differences and to find out whether different ligamentous subtypes in valgus knees exist. METHODS Dynamic gap widths of 1000 consecutive total knee arthroplasty (TKA) patients were measured at different flexion angles by applying a computer-assisted surgery (CAS) technique. 198 knees showed a valgus deformity and were assessed regarding its degree of fulfillment of the following criteria of valgus knee: 1. Medial extension gap greater than lateral; 2. Medial flexion gap greater than lateral; 3. Flexion gap greater than extension gap. A single-factor ANOVA subgroup analysis was performed, based on the amount of deformity. The effect of other patient factors (age, gender, weight) on gap differences was investigated. RESULTS The medial extension gap (3.7 ± 2.2 mm) was significantly (p < 0.01) larger than the lateral extension gap (1.1 ± 2.9 mm). The amount of deformity correlated highly with gap difference in extension (r2 = 0.67) but not in flexion. In 92.4% (183), the flexion gap (6.2 ± 3.1 mm) was significantly (p < 0.01) larger than the extension gap (2.4 ± 2.3 mm). Only 29.3% (58) of patients met all three criteria, this was mainly due to the fact that in flexion the medial gap was larger than the lateral in only 35.4% (70). Patient factors showed no significant influences (NS) on the gap widths. CONCLUSION Valgus knees show large variability in terms of gap widths. The extent of deformity correlates highly with gap difference in extension, but not in other flexion angles. Vast majority of valgus knees were valgus in extension only. Because of this variability, it should be aimed for an individualized balancing technique based on intraoperative gap sizes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Kim Eller
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany.
| | - Wolfgang Scior
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany
| | - Heiko Graichen
- Department for Arthroplasty, Sports-Traumatology and General Orthopaedics, Asklepios Orthopaedic Hospital Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany
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Barbotte F, Delord M, Pujol N. Coronal knee alignment measurements differ on long-standing radiographs vs. by navigation. Orthop Traumatol Surg Res 2022; 108:103112. [PMID: 34648999 DOI: 10.1016/j.otsr.2021.103112] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 02/19/2021] [Accepted: 03/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The long-standing radiograph (LSR) is the reference tool for assessing knee alignment after total knee arthroplasty (TKA). However, its value is debatable, as many factors can influence measurement accuracy. Computer-assisted surgery (CAS) provides accurate measurements. Few studies have compared LSR and computer-assisted measurements of knee alignment. The objective of this study was to compare hip-knee-ankle (HKA) angle values obtained before and after TKA on LSRs to those obtained during CAS. HYPOTHESIS The HKA angle values measured on LSRs before and after surgery are identical to those measured during CAS. MATERIAL AND METHODS The HKA angles of 126 knees were measured on bipedal full-weight-bearing LSRs obtained before and 3 months after TKA. The results were compared to the values obtained during CAS. RESULTS Before surgery, the standard deviation was 2.672, with limits of agreement of {-5.391; + 5.082}. The intra-class coefficients were good for the overall measurements (0.9), good for detecting>10° varus (0.89), fair for<10° varus and valgus (0.66 and 0.71, respectively), poor for>10° valgus (0.43) and poor for normal alignment (0). Post-operatively, the standard deviation was 3.113, with limits of agreement of {-6.426; +5.776}. The intra-class coefficient was poor for the overall measurements (0.20), negative for normal alignment (-0.05) and<10° valgus (-0.05), and positive for<10° varus (0.017) and for>10° varus and valgus (0.33). CONCLUSION Before TKA, the LSR overestimates the deformity compared to CAS. After surgery, the two methods are not comparable. These findings underline the relevance of routinely obtaining LSRs and for using LSR results to estimate costs for healthcare insurance reimbursement purposes. LEVEL OF EVIDENCE IV, retrospective observational cohort study.
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Affiliation(s)
| | - Marc Delord
- Centre hospitalier de Versailles, Le Chesnay, France
| | - Nicolas Pujol
- Centre hospitalier de Versailles, Le Chesnay, France.
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Chalmers BP, LaGreca M, Addona J, Sculco PK, Haas SB, Mayman DJ. Characterizing the Magnitude of and Risk Factors for Functional Limb Lengthening in Patients Undergoing Primary Total Knee Arthroplasty. HSS J 2022; 18:271-276. [PMID: 35645637 PMCID: PMC9097002 DOI: 10.1177/15563316211009140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/15/2021] [Indexed: 02/07/2023]
Abstract
Background: There is little data on the magnitude and factors for functional leg lengthening after primary total knee arthroplasty (TKA). Questions/Purpose: We sought to determine the incidence of and risk factors for functional leg lengthening after primary TKA. Methods: We retrospectively reviewed consecutive unilateral primary TKAs at a single institution from 2015 to 2018. Of the 782 TKAs included, 430 (55%) were performed in women; the mean age was 66 years, and the mean body mass index was 29 kg/m2. Preoperatively, 541 (69%) knees were varus deformities and 223 (29%) were valgus deformities. Hip to ankle biplanar radiographs were obtained preoperatively and 6 weeks postoperatively for all patients. Two independent researchers measured leg length, coronal plane deformity, lateral knee flexion angle, and overall mechanical alignment on all preoperative and postoperative radiographs. Results: The mean overall ipsilateral functional leg lengthening was 7.0 mm. Seven hundred knees (90%) were overall functionally lengthened, including 462 (59%) knees lengthened >5 mm and 250 (31%) knees lengthened 10 mm or more. A valgus deformity and coronal plane deformity of 10° or more were significant risk factors for increased functional lengthening. Patients with severe valgus deformities (>10°) had the largest amount of functional lengthening, at a mean of 13.5 mm. Conclusion: After primary TKA, 90% of limbs are functionally lengthened, including roughly one-third over a centimeter. Valgus knee deformities and severe deformities (>10°) were significant risk factors for increased limb lengthening.
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Affiliation(s)
- Brian P. Chalmers
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA,Brian P. Chalmers, MD, Department of
Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for
Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Mark LaGreca
- Department of Medicine, Philadelphia
College of Osteopathic Medicine, Philadelphia, PA, USA
| | | | - Peter K. Sculco
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - Steve B. Haas
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
| | - David J. Mayman
- Department of Orthopedic Surgery, Adult
Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY,
USA
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8
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Evaluation of the rate of post-operative dislocation in patients with ipsilateral valgus knee deformity after primary total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2022; 46:1507-1514. [DOI: 10.1007/s00264-022-05372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/06/2022] [Indexed: 10/18/2022]
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9
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Li F, Wang C, Zhao MW, Geng X, Li JY, Zhou G, Sun D, Tian H. Modified Medial Collateral Ligament Indentation Technique in Total Knee Arthroplasty with Severe Type II Valgus Deformity. Orthop Surg 2022; 14:663-670. [PMID: 35174652 PMCID: PMC9002074 DOI: 10.1111/os.13230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To explore the feasibility and clinical efficacy of a modified medial collateral ligament indentation technique in total knee arthroplasty (TKA) with severe type II valgus deformity. Methods Consecutive patients with Krackow type II valgus deformity >20° who underwent a primary unilateral TKA between May 2008 and June 2017 were studied retrospectively. A medial collateral ligament indentation technique was performed in 20 patients (MCLI group), and 23 patients received the routine lateral structures release technique (LSR group). Radiological parameters, such as the valgus angle (VA), and functional outcomes including the use of constraint implants, Knee Society Score (KSS), Knee Society Function score (KSF), and thickness of the polyethylene insert were compared between the two groups. Results A total of 43 consecutive patients had a minimum 2‐year follow‐up. The preoperative VA was comparable between the MCLI (23.5° ± 5.8°) and LSR groups (21.3° ± 3.2°, P = 0.134), as was the postoperative VA (1.1° ± 2.1° and 2.5° ± 3.0°, respectively, P = 0.084). The mean KSS and KSF scores in the MCLI group were 30.2 ± 4.8 and 38.8 ± 4.8, respectively, before surgery, and they increased to 91.3 ± 2.6 and 86.5 ± 2.4 at the last follow‐up. The scores in the LSR group were 31.5 ± 7.5 and 36.5 ± 7.8 before surgery and 92.4 ± 3.5 and 88.5 ± 3.6 at the last follow‐up. While no statistically significant differences in pre‐ or postoperative functional scores were found between the two groups, the MCLI group had thinner polyethylene inserts (9.5 ± 1.1 mm vs 12.9 ± 1.5 mm) and less use of constrained condylar inserts (15% vs 69.6%). During follow‐up, the MCLI group had fewer complications. Conclusion A modified MCLI technique can achieve good outcomes in TKA with type II valgus deformity of >20°. It can maintain a normal joint line level, reduce the use of constrained condylar knee prostheses, and is a reliable choice for severe genu valgum.
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Affiliation(s)
- Feng Li
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Cheng Wang
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Min-Wei Zhao
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Xiao Geng
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Jun-Yang Li
- Centre for Robotics and Automation, Shenzhen Research Institute of City University of Hong Kong, Shenzhen, China
| | - Ge Zhou
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Dong Sun
- Centre for Robotics and Automation, Shenzhen Research Institute of City University of Hong Kong, Shenzhen, China
| | - Hua Tian
- Peking University Third Hospital, Department of Orthopaedics / Engineering Research Center of Bone and Joint Precision Medicine, Beijing Key Laboratory of Spinal Disease Research, Beijing, China
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Puijk R, Rassir R, Kok LM, Sierevelt IN, Nolte PA. Common peroneal nerve palsy after TKA in valgus deformities; a systematic review. J Exp Orthop 2022; 9:12. [PMID: 35059901 PMCID: PMC8776926 DOI: 10.1186/s40634-021-00443-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/08/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The aim of this systematic review is to investigate the prevalence of Common Peroneal Nerve Palsy after total knee arthroplasty in valgus deformities. Furthermore, the effectiveness of a peroneal nerve release prior to arthroplasty to prevent the palsy will be investigated. METHODS PubMed and Google Scholar were searched. Search terms regarding valgus deformity and total knee arthroplasty were used. Data analysis and extraction were performed using the web application 'Rayyan QCRI' according to PRISMA guidelines and screened according to the inclusion and exclusion criteria. RESULTS Twenty-seven studies were included, representing 1397 valgus knees. Knee balancing was performed in 19 studies with lateral soft tissue releases (1164 knees) and 8 studies (233 knees) with an additional osteotomy. Two studies (41 knees) in the lateral soft tissue release group conducted a peroneal nerve release simultaneous to arthroplasty. Common peroneal nerve palsies occurred in 26 cases (1.9%). Overall, no significant difference in palsy ratio between studies was found by using a peroneal nerve release (p = 0.90), between lateral soft tissue releases and osteotomies (p = 0.11) or between releases of specific ligaments. CONCLUSION Common peroneal nerve palsies occur in 1.9% of the cases after total knee arthroplasty in valgus deformities. No difference in the number of palsies was seen when using a peroneal nerve release or using different balancing techniques. However, literature about peroneal nerve releases was very limited, therefore, the effectiveness of a peroneal nerve release remains unclear. LEVEL OF EVIDENCE LEVEL III: Systematic review.
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Affiliation(s)
- Raymond Puijk
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2130AT, Hoofddorp, the Netherlands.
| | - Rachid Rassir
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2130AT, Hoofddorp, the Netherlands
| | - Laura M Kok
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2130AT, Hoofddorp, the Netherlands
| | - Inger N Sierevelt
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2130AT, Hoofddorp, the Netherlands
- Specialized Center of Orthopedic Research and Education (SCORE), Xpert Orthopedie, Amsterdam, the Netherlands
| | - Peter A Nolte
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Spaarnepoort 1, 2130AT, Hoofddorp, the Netherlands
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11
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Castellarin G, Bori E, Biava M, Talevi G, Innocenti B. The use of mobile bearing TKA in valgus deformities - A clinical study. J Orthop 2022; 29:6-10. [PMID: 35241879 PMCID: PMC8858731 DOI: 10.1016/j.jor.2021.12.002] [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: 12/02/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The number of patients presenting valgus deformities undergoing total knee arthroplasty (TKA) represents approximately 10% of the total number of TKAs performed: the presence of valgus deformity requires the implant to have proper alignment, stability and balance to achieve successful clinical outcomes, especially for knees with high coronal deformities, but these have proven to be difficult goals to achieve and therefore the use of constrained prostheses is often recommended for these cases. However, even though the use of unconstrained mobile bearing for severe knee deformities is rare, it has been shown to give successful outcomes and therefore the aim of this study is to evaluate whether this surgical technique can achieve satisfactory clinical results and correct alignment, as well as good patient satisfaction. METHODS This study presents the results of 69 TKA performed with cemented mobile bearing implants by a single surgeon on knee affected by valgus deformities. Asymmetric inserts were adopted for all the implants and an alignment surgical tool, dedicated for valgus patients, was used during the operation. Angles of valgus, WOMAC surveys and Numeric Rating Scale for pain were recorded to evaluate the results of the operations. RESULTS A total of 67 pre-op WOMAC questionnaire surveys were collected, with the mean result of this evaluation being 15.9 points. The Numeric Rating Scale for pain had an average of 2.2 for 68 tests. The deformities were corrected from a mean total preoperative valgus angle of 12.5° to a postoperative valgus deformity average of 0.6°. During follow-up, only one patient had serious complications due to the rupture of the extensor apparatus following a domestic accident involving falling. Further 10 patients have mild complications related to injuries such as pain of varying intensity, burning, or swelling of the knee. The level of satisfaction from 0 to 10 (0 not at all satisfied and 10 perfectly satisfied) had an average score of 7.7. CONCLUSIONS The surgical approach presented, involving a less constrained model if compared to the ones usually chosen, allowed to achieve correct alignment and high patient satisfaction using mobile bearing implants on valgus knee deformities; further patient follow-up will be performed to evaluate long-term outcomes, but the results achieved already represent a significative finding.
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Affiliation(s)
| | - Edoardo Bori
- BEAMS Department, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Mathieu Biava
- BEAMS Department, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Giacomo Talevi
- BEAMS Department, Université Libre de Bruxelles, Bruxelles, Belgium
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12
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Abstract
Aims A comprehensive classification for coronal lower limb alignment with predictive capabilities for knee balance would be beneficial in total knee arthroplasty (TKA). This paper describes the Coronal Plane Alignment of the Knee (CPAK) classification and examines its utility in preoperative soft tissue balance prediction, comparing kinematic alignment (KA) to mechanical alignment (MA). Methods A radiological analysis of 500 healthy and 500 osteoarthritic (OA) knees was used to assess the applicability of the CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (aHKA) that estimates constitutional limb alignment and joint line obliquity (JLO). Intraoperative balance was compared within each phenotype in a cohort of 138 computer-assisted TKAs randomized to KA or MA. Primary outcomes included descriptive analyses of healthy and OA groups per CPAK type, and comparison of balance at 10° of flexion within each type. Secondary outcomes assessed balance at 45° and 90° and bone recuts required to achieve final knee balance within each CPAK type. Results There was similar frequency distribution between healthy and arthritic groups across all CPAK types. The most common categories were Type II (39.2% healthy vs 32.2% OA), Type I (26.4% healthy vs 19.4% OA) and Type V (15.4% healthy vs 14.6% OA). CPAK Types VII, VIII, and IX were rare in both populations. Across all CPAK types, a greater proportion of KA TKAs achieved optimal balance compared to MA. This effect was largest, and statistically significant, in CPAK Types I (100% KA vs 15% MA; p < 0.001), Type II (78% KA vs 46% MA; p = 0.018). and Type IV (89% KA vs 0% MA; p < 0.001). Conclusion CPAK is a pragmatic, comprehensive classification for coronal knee alignment, based on constitutional alignment and JLO, that can be used in healthy and arthritic knees. CPAK identifies which knee phenotypes may benefit most from KA when optimization of soft tissue balance is prioritized. Further, it will allow for consistency of reporting in future studies. Cite this article: Bone Joint J 2021;103-B(2):329–337.
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Affiliation(s)
- Samuel J MacDessi
- CPAK Research Group, Sydney, Australia.,Sydney Knee Specialists, St George Private Hospital, Kogarah, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Ian A Harris
- Orthopaedic Surgery, University of New South Wales, South Western Sydney Clinical School, Liverpool, NSW, Australia.,Whitlam Orthopaedic Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Johan Bellemans
- CPAK Research Group, Sydney, Australia.,Department of Orthopaedic Surgery, Hasselt University, ZOL Hospitals, Genk, Belgium.,ArthroClinic, Leuven, Belgium
| | - Darren B Chen
- CPAK Research Group, Sydney, Australia.,Sydney Knee Specialists, St George Private Hospital, Kogarah, Australia
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Alesi D, Meena A, Fratini S, Rinaldi VG, Cammisa E, Lullini G, Vaccari V, Zaffagnini S, Marcheggiani Muccioli GM. Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021? Musculoskelet Surg 2021; 106:1-8. [PMID: 33587251 PMCID: PMC8881420 DOI: 10.1007/s12306-021-00695-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/02/2021] [Indexed: 10/31/2022]
Abstract
Total knee arthroplasty in valgus knee deformities continues to be a challenge for a surgeon. Approximately 10% of patients who undergo total knee arthroplasty have a valgus deformity. While performing total knee arthroplasty in a severe valgus knee, one should aware with the technical aspects of surgical exposure, bone cuts of the distal femur and proximal tibia, medial and lateral ligament balancing, flexion and extension gap balancing, creating an appropriate tibiofemoral joint line, balancing the patellofemoral joint, preserving peroneal nerve function, and selection of the implant regarding constraint. Restoration of neutral mechanical axis and correct ligament balance are important factors for stability and longevity of the prosthesis and for good functional outcome. Thus, our review aims to provide step by step comprehensive knowledge about different surgical techniques for the correction of severe valgus deformity in total knee arthroplasty.
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Affiliation(s)
- D Alesi
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - A Meena
- VMMC and Safdarjung Hospital, Central Institute of Orthopedics, New Delhi, 110029, India
| | - S Fratini
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - V G Rinaldi
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - E Cammisa
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - G Lullini
- UO Medicina Riabilitativa e Neuroriabilitazione, IRCCS Istituto delle Scienze Neurologiche, Via Altura 3, 40139, Bologna, Italy
| | - V Vaccari
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
| | - S Zaffagnini
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - G M Marcheggiani Muccioli
- 2nd Orthopedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy. .,University of Bologna, Bologna, Italy.
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Incidence of Soft-Tissue Releases, Clinical and Radiological Outcomes of Lateral Parapatellar Approach for Valgus Arthritic Knees: A 4-year Follow-up Study with A Review of Literature. Indian J Orthop 2020; 55:38-45. [PMID: 34122753 PMCID: PMC8149535 DOI: 10.1007/s43465-020-00294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To analyse the incidence of additional soft tissue releases with the lateral parapatellar approach, and the clinical and radiological outcomes of total knee arthroplasties performed using the lateral parapatellar approach for valgus arthritic knees. A review of the existing literature on valgus arthritic knees undergoing knee replacement was performed and our results compared. MATERIALS AND METHODS This is a prospective cohort study of 50 patients operated by this approach. Operation and clinical records were assessed to determine the number and sequence of soft tissue releases. Functional outcome was measured using the Oxford Knee Score. Radiological assessment included measurement of alignment and implant positioning. RESULTS 46 patients included. Mean follow-up of 4 years. Additional lateral releases were performed in 11 (24%) cases. Mean valgus alignment corrected from 13.1 degrees pre-operatively to 5.7 degrees post-operatively. Oxford Knee Score improved from a mean pre-operative score of 11.9 to a mean post-operative score of 38.3 at final follow-up. Radiographs revealed lateralisation of the tibial component in 4 patients. No immediate or late post-operative wound complications, late instabilities or revisions were observed. CONCLUSION Lateral parapatellar approach is highly effective in correcting the valgus deformity with a low incidence of additional soft tissue releases. Medium-term results indicate an excellent functional outcome with no complications.
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Knee or Spine Surgery First? A Survey of Treatment Order for Patients With Concurrent Degenerative Knee and Lumbar Spinal Disorders. J Arthroplasty 2020; 35:2039-2043. [PMID: 32247672 DOI: 10.1016/j.arth.2020.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/27/2020] [Accepted: 03/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) and lumbar spine surgery have been reported to affect the outcomes of each other. There is insufficient evidence to guide the choice of treatment order for patients with both disorders that are equally symptomatic. METHODS Five clinical scenarios of concurrent, advanced, degenerative knee and lumbar spinal disorders were designed to survey surgeons' choices of treatment order and rationale. The spinal disorder was consistently degenerative lumbar spinal stenosis, but the knee conditions varied to include (1) osteoarthritis (OA) with varus deformity, (2) OA with valgus deformity, (3) rheumatoid arthritis with a severe flexion contracture, (4) OA without deformity, and (5) bilateral OA with windswept deformities. The survey was distributed to selected clinical members of the Knee Society and Scoliosis Research Society in North America. The surgeons' choices were compared among the 5 scenarios, and their comments were analyzed using text-mining. RESULTS Responses were received from 42 of 74 (57%) knee arthroplasty surgeons and 55 of 100 (55%) spine surgeons. The percentages of knee arthroplasty surgeons recommending "TKA first" differed significantly among scenarios: 29%, 79%, 55%, 7%, and 81% for scenarios 1 through 5, respectively (P < .001). A similar pattern was noted for the spine surgeons. CONCLUSION For patients with concurrent degenerative knee and lumbar spinal disorders, the severity and type of knee deformity influenced the preference of treatment order in both specialties. Severe valgus deformity and windswept deformities of the knee would drive the decision toward "TKA first."
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Cheng X, Wang Z, Zhang Y, Wang M, Zhang X. Tightening medial collateral ligament during total knee arthroplasty for patients with fixed valgus deformity: A novel technique. J Orthop Surg (Hong Kong) 2020; 27:2309499019834695. [PMID: 30862275 DOI: 10.1177/2309499019834695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND This study aimed to explore a new surgical technique for gap balance by tightening the medial collateral ligament (MCL) in total knee arthroplasty (TKA) in patients with fixed valgus deformity. MATERIALS AND METHODS A prospective analysis was performed on 15 patients (16 knees) with a fixed valgus deformity that was corrected by tightening the MCL during TKA. A single surgeon performed all the 16 TKAs using nonconstrained posterior substituting implant, with two knees treated with long-stem tibial prosthesis. Clinical scores, knee stability, and radiographic evaluations were recorded preoperatively and postoperatively. RESULTS Complete weight-bearing could be carried out under the protection of the brace postoperatively. At the third month after surgery, X-rays showed the brace was not worn. The mean follow-up was 26.6 months (range 12-42 months). The average preoperative mechanical axis was 15.4 ± 2.3° (range 11-25°), and postoperatively it was 0.6 ± 0.1° (range 0-2°). No complication relative to the technique occurred. CONCLUSION This new surgical technique has demonstrated excellent early clinical results and can be a good supplement for fixed valgus knee arthroplasty. Level of Evidence: III.
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Affiliation(s)
- Xingwang Cheng
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Zhibing Wang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yuan Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Min Wang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xia Zhang
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
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Putman S, Ehlinger M, Tillie B, Puliero B, Ramdane N, Remy F, Pasquier G. Total knee replacement on more than 20° valgus: A case control study. Orthop Traumatol Surg Res 2019; 105:613-617. [PMID: 30930092 DOI: 10.1016/j.otsr.2018.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Lower-limb valgus deformity exceeding 20° is a particular case, with few publications assessing the impact of the severity of the valgus. The present retrospective case control study compared a series of>20° valgus versus a series of 10-20° valgus, assessing (1) operative data [approach, type of total knee replacement (TKR)], (2) complications and implant survival, and (3) clinical and radiological results. HYPOTHESIS Severe valgus deformity requires TKR with greater constraint, incurring a higher rate of complications and poorer implant survival. MATERIAL AND METHOD A multicenter retrospective study for the period January 2006 to December 2010 included 53 patients, with a mean age of 72±10 years, presenting>20° valgus. The study series was matched for age and gender with a series of 53 cases of 10-20° valgus. Convexity laxity was greater in the>20° group (p=0.004). RESULTS There was no significant inter-group difference in approach (p=0.13). Greater constraint was more frequent in the>20° group (7/53 versus 1/53; p=0.03), independently of convexity laxity or Krackow grade (p=0.14). There were 7 complications (13.2%) in the>20° group and 7 in the 10-20° group (NS). Eight-year survivorship was 95.12% in the>20° group and 94.9% in the 10-20° group (p=0.63). There were no significant differences in Oxford score (p=0.30) or HKA angle (p=0.78) at last follow-up. CONCLUSION The study hypothesis was partially confirmed: greater constraint was more frequent in>20° valgus. The number of complications was low, and survival was identical to that of a control group with less severe deformity. LEVEL OF EVIDENCE III, retrospectivecase controlstudy.
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Affiliation(s)
- Sophie Putman
- Département universitaire de chirurgie orthopédique et de traumatologie, hôpital Salengro, CHRU de Lille, rue Emile-Laine, 59037 Lille, France.
| | - Matthieu Ehlinger
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 30, boulevard Sébastien-Brant, 67400 Ilkirch, France
| | - Bruno Tillie
- Hôpital privé Les Bonnettes, 2, rue du Dr Forgeois, BP 990, 62012 Arras, France
| | - Benjamin Puliero
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - Nassima Ramdane
- University Lille, CHU Lille, EA 2694 - santé publique: epidémiologie et qualité des soins, 59000 Lille, France
| | - Franck Remy
- Clinique chirurgicale de Saint-Omer, 71, rue Ambroise-Paré, 62575 Blendecques, France
| | - Gilles Pasquier
- Département universitaire de chirurgie orthopédique et de traumatologie, hôpital Salengro, CHRU de Lille, rue Emile-Laine, 59037 Lille, France
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- Société française de chirurgie de la hanche et du genou (SFHG), 56, rue Boissonade, 75014 Paris cedex, France
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Lateral femoral sliding osteotomy in total knee arthroplasty with valgus deformity greater than twenty degrees. INTERNATIONAL ORTHOPAEDICS 2019; 43:2511-2517. [PMID: 30659318 DOI: 10.1007/s00264-019-04295-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/06/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Lateral femoral sliding osteotomy has been reported as an effective technique for total knee arthroplasty (TKA) with significant valgus deformity. This study aims to investigate its utility in TKA with valgus deformity greater than 20°, for which few studies have examined. METHODS Consecutive TKA patients with valgus deformity treated with the sliding osteotomy at our institution were retrospectively studied. Constraint implants were not used. Radiological and clinical parameters at follow-ups were compared with those pre-operatively. Radiological parameters included the hip-knee-ankle angle (HKA), the anatomical lateral distal femoral angle (aLDFA), the anatomical lateral plateau ankle angle (aLPTA), and the angle between the femoral mechanical axis and transepicondylar line (femoral transepicondylar angle, FTEA) which was used to reflect concurrent extra-articular valgus and corresponding local alignment. Clinical outcome measures included the Knee Society Score and Functional Score. RESULTS Twenty-five patients operated on between July 2011 and February 2017 were enrolled. The average follow-up time was 3.3 (1.5~7.9) years. The pre-operative HKA of 202.7 ± 2.3° (equivalent to valgus of 22.7 ± 2.3°) was reduced to 180.4 ± 2.3° at final follow-ups (P < 0.001). The aLFDA, aLPTA, and FTEA were all significantly improved, with the last one increased from 84.2 ± 1.8° to 89.6 ± 1.6° (t = - 11.35, P < 0.001). All clinical scores were significantly improved without major complications. CONCLUSIONS Lateral femoral sliding osteotomy can be effective and safe for TKA with severe valgus deformity greater than 20°.
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Lee SS, Lee YI, Kim DU, Lee DH, Moon YW. Factors affecting femoral rotational angle based on the posterior condylar axis in gap-based navigation-assisted total knee arthroplasty for valgus knee. PLoS One 2018; 13:e0197335. [PMID: 29763429 PMCID: PMC5953479 DOI: 10.1371/journal.pone.0197335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 04/28/2018] [Indexed: 11/25/2022] Open
Abstract
Background Achieving proper rotational alignment of the femoral component in total knee arthroplasty (TKA) for valgus knee is challenging because of lateral condylar hypoplasia and lateral cartilage erosion. Gap-based navigation-assisted TKA enables surgeons to determine the angle of femoral component rotation (FCR) based on the posterior condylar axis. This study evaluated the possible factors that affect the rotational alignment of the femoral component based on the posterior condylar axis. Materials and methods Between 2008 and 2016, 28 knees were enrolled. The dependent variable for this study was FCR based on the posterior condylar axis, which was obtained from the navigation system archives. Multiple regression analysis was conducted to identify factors that might predict FCR, including body mass index (BMI), Kellgren-Lawrence grade (K-L grade), lateral distal femoral angles obtained from the navigation system and radiographs (NaviLDFA, XrayLDFA), hip-knee-ankle (HKA) axis, lateral gap under varus stress (LGVS), medial gap under valgus stress (MGVS), and side-to-side difference (STSD, MGVS − LGVS). Results The mean FCR was 6.1° ± 2.0°. Of all the potentially predictive factors evaluated in this study, only NaviLDFA (β = −0.668) and XrayLDFA (β = −0.714) predicted significantly FCR. Conclusions The LDFAs, as determined using radiographs and the navigation system, were both predictive of the rotational alignment of the femoral component based on the posterior condylar axis in gap-based TKA for valgus knee. A 1° increment with NaviLDFA led to a 0.668° decrement in FCR, and a 1° increment with XrayLDFA led to a 0.714° decrement. This suggests that symmetrical lateral condylar hypoplasia of the posterior and distal side occurs in lateral compartment end-stage osteoarthritis with valgus deformity.
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Affiliation(s)
- Sung-Sahn Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong-In Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong-Uk Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae-Hee Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wan Moon
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- * E-mail:
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