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TKA in valgus knee
Beom Koo Lee, M.D.
Dept. of Orthopaedic Surgery
Gachon University, Gil Medical Center
Content
• Pathology of valgus knee
• Classification of valgus knee
• Technique
Exposure
Bone resection
Ligament balancing
• Result
Pathology of valgus knee
• lateral femoral hypoplasia
• internal femoral torsion
• medial ligament laxity
why knee fail
Callahan J Arthroplasty 2004
Classification
• A type-I deformity
minimal valgus and medial soft-tissue stretching.
• A typical type-II
fixed valgus deformity has a more substantial deformity (>10°)
with medial soft tissue stretching
• A type-III deformity
a severe osseous deformity after a prior osteotomy with an
incompetent medial soft-tissue sleeve, which is best managed
with a constrained or hinged total-knee design. -
Amar S. Ranawat, Chitranjan S. Ranawat, Mark Elkus,
Vijay J. Rasquinha, Roberto Rossi, and Sushrut Babhulkar
Total Knee Arthroplasty for Severe Valgus Deformity
J. Bone Joint Surg. Am., Sep 2005; 87: 271 - 284
Exposure
Techn pitfall in exposure TKRA in
valgus knee
1. Skin incision more medially for medial ligament
reconstruction
2. Adequate proximal quadriceps incision to
facilitate sufficient lateral retraction of patella
3. Minimal medial exposure flexion
Lateral approach in exposure
TKRA in valgus knee
1.
Popular in Europe
2.
Fascia lata detachment in
extension
:
Osteotomy
of tibial tubercle
in lateral approach
- Osteotomy is trapezoidal
7 cm long, 2 cm wide
- Maintain a medial hinge
Arthrotomy in lateral approach
- Z plasty separates superficial
and deep layers (retinaculum)
Closure after lateral approach
Closure in flexion, Z plasty, use of fat pad
Patients with coxa valga or reduced hip offset generally
require a VCA less than 5°.
Femoral guide angle in valgus knee ;\
3-5
Mechanical Axis Cannot be Restored in Total Knee Arthroplasty With a Fixed Valgus
Resection Angle: A Radiographic Study
The Journal of Arthroplasty, Volume 22, Issue 6, Supplement 1, September 2007,
Pages 85-89
Nicholas Bardakos, Akin Cil, Brandon Thompson, Greg Stocks
More external rotation in
valgus knee
J Arima, LA Whiteside, DS McCarthy, and SE White
BJS 95- A.,; 77: 1331 – 1334, 1995
• JFehring
CORR 380, 2000
Rotation in valgus knee
• The anteroposterior
axis appears
• to be a reliable
landmark for
rotational
alignment of J Arima, LA Whiteside, DS McCarthy, and SE
White
• the femoral
J. Bone Joint Surg. Am., Sep 1995; 77: 1331 component in a1334
valgus knee.
Mean femoral rotation to achieve
symmetric flexion space

Valgus knee : 6.0
(Winemaker JA 2002)
Tibia rotation
Patella ligament near its medial 10%
in
healthy Chinese knees, whereas it
intersected the
medial 20% in varus knees and the
medial 30% in valgus knees.
The Journal of Arthroplasty, Volume 24, Issue 3, April
2009, Pages 427-431
Tiezheng Sun, Houshan Lu, Nan Hong, Jian Wu,
Chuanhan Feng
Proximal tibia resection
The Journal of Arthroplasty, Volume 21,
Issue 5, August 2006, Pages 771-774
Akira Nagumo, Yasuyuki Ishibashi, Eiichi
Tsuda, Satoshi Toh
Ligament balancing
in valgus knee
Ligament balancing in valgus knee
tight in
extension
release ITB
( Whiteside JOAJune'02P23)
Balancing severe valgus deformity in total knee
arthroplasty using
lateral cruciform retinacular release
Preoperative valgus averaged
17°
Stable flexion and extension gaps
were achieved in all cases,
Richard Scott MD
.
J arthroplasty July 2004
Balancing of severe
valgus knee
Need release of
LCL, & popliteus
Sequence of release in valgus knee
John Bottros MD
J arthroplasty June 2006 P 12
Miyasaka, Kenji C. MD;
CORR 345 1997 P27
Fehring: Clin Orthop, 380. 2000.P72-79
Sequence of release in valgus knee
Christopher L. Peters, R. Alexander Mohr, Kent N. Bachus
J. Arthroplasty, 2001, Pages 721-729
William M . Mihalko, Kenneth A Krackow
JBJS 85-A 2003 ; 135
• Division of these
structures(Popliteus release,
lateral collateral ligament
release) increased the risk of
instability .
James P. McAuley1 , Matthew B. Collier2,
W. G. Hamilton2, Ehsan Tabaraee2 and G. A. Engh2
CORR Nov 2008
Lateral Epicondylar Osteotomy Using Computer Navigation in Total
Knee Arthroplasty for Rigid Valgus Deformities
Arun B. Mullaji et al
JA January 2010, Pages 166-169
Sequence of release
We suggest that when severe
valgus deformities are present,
the LCL should be considered
first
for release and the Pop and ITB
be used to grade the release.
The Journal of Arthroplasty, Volume 14, Issue 8,
December 1999, Pages 994-1004
Kenneth A. Krackow, William M. Mihalko
Biomechanical aspect of pie crust of PL str
for valgus deformity
1st cut ;7 cut parallel to
cut surface
2.1
2nd cut; 7 more cut
3.9
LCL cut at joint line
6.2
popliteus cut in joint
8.15
Clark J arthroplasty 2005 Dec P1010
Mihalko JOA april'00 P 347
Pie crust
this
technique is best suited for
correction of mild to
moderate fixed valgus
deformities of 20 or less.
Clark
J arthroplasty
2005 Dec P1010
• Anatomic dissection
studies also showed
that in full extension
the peroneal nerve may
be at risk during this
technique.
the lateral structures
should be made with only
the tip of the knife blade,
and soft-tissue
penetration should be
limited to 5 mm or less
Clarke
J Arthroplasty 2004 P40
when MCL elongation is 10 mm or more,
stretched beyond its normal length
Extensive lateral release
would cause destabilizing of joint
& Stabilizing this knee with thicker
components involves actual
lengthening of the limb, with risk of
damage to the neurovascular
structures
Insall 4th edit
Tx for severe medial instability
in valgus knee
Alignment control
MCL tightening or reconstruction
Constrained prosthesis
Treatment of severe medial laxity with
alignment
Unacceptable stability with
valgus alignment with medial laxity
Treatment of severe medial laxity with
alignment
• if the patient had any varus deformity
or even perfect tibiofemoral
alignment, the medial instability
possibly would not be symptomatic.
Rubash CORR 380 2000 P 116
Krackow CORR 404 2002 P152
Treatment of severe medial laxity with MCL
Advancement or reconstruction
Krackow
Healy WL, CORR
356:161, 1998
Treatment of severe medial laxity with CCK
• Torn but
reconstructable
• MCL
Douglas D.R. Naudie
AAOS ICL 2004 P212
Treatment of severe medial laxity with
hinged prosthesis
• Absent or,
unreconstructable
MCL
Douglas D.R. Naudie
AAOS ICL 2004P212
CR in severe valgus knee
• The advantages of retaining the PCL include
its role as a secondary restraint to varus or
valgus stresses, the avoidance of postcam
dislocation
The Journal of Arthroplasty, Volume 23, Issue 3, April 2008,
Pages 366-370
Paul Kubiak, Michael J. Archibeck, Richard E. White Jr
James P. McAuley1 , Matthew B. Collier2,
W. G. Hamilton2, Ehsan Tabaraee2 and G. A. Engh2
CORR Nov 2008
CR in valgus knee
• , it not only resists posterior subluxation
forces but also serves as a secondary
stabilizer that resists varus/valgus instability.
• When large collateral ligament releases are
required, there is less flexion instability than
in cases in which the cruciate is removed.
Consequently, flexion/extension gap
balancing is simplified
Aaron G. RosenbergDonald M.
Knapke
Insall
CR in severe valgus knee
• at a minimum 10-year follow-up, very
good results with a 93% revision-free
survivorship at 10 years and no
revisions for instability or loosening
The Journal of Arthroplasty, Volume 23, Issue 3, April 2008,
Pages 366-370
Paul Kubiak, Michael J. Archibeck, Richard E. White Jr
James P. McAuley1 , Matthew B. Collier2,
W. G. Hamilton2, Ehsan Tabaraee2 and G. A. Engh2
CORR Nov 2008
Result
Result of extensive lateral release at
ligament
• Division of these
structures(Popliteus
release, lateral collateral
ligament release)
increased the risk of
revision and was
associated with lower
Knee Society scores.
James P. McAuley , Matthew B. Collier,
W. G. Hamilton, Ehsan Tabarae2 and G. A. Engh
CORR Nov 2008
Clinical Results in Valgus Total Knee Arthroplasty
With the “Pie Crust”
• Importantly, there were no clinical failures
or cases of postoperative instability and
no cases of radiographic loosening or
wear.
Mark Elkus, MD1, Chitranjan S. Ranawat, MD1, Vijay J. Rasquinha, MD1, Sushrut
Babhulkar, MD1, Roberto Rossi, MD1 and Amar S. Ranawat, MD1
The Journal of Bone and Joint Surgery (American). 2004;86:2671-2676
Henry D. Clarke, Robin Fuchs, Giles R. Scuderi,
JA Dec'05 Pages 1010-1014
Total knee arthroplasty in patients with valgus deformities of ≥ 20°
( sequential release)
Merrill A. Ritter, Gregory W. Faris, Philip
M. Faris, Kenneth E. Davis
The Journal of Arthroplasty, 2004, Pages 862-866
Total Knee Arthroplasty After Failed Proximal
Tibial Valgus Osteotomy
•
There was no difference in the final result after follow-up periods of 49 years with respect to average Hospital for Special Surgery score,
degree of knee flexion, and later knee revisions between the 14
osteotomized and 99 nonosteotomized patients
•
but a significantly greater blood loss and other postoperative
complications were noted among the previously osteotomized group of
patients, indicating a more complicated procedure for the knee
arthroplasty operation compared with the nonosteotomized group of
patients.
Hans Bergenudd, Arne Sahlström, Lennart Sanzén
The Journal of Arthroplasty,1997, Pages 635-638
Result of extension instability
medial instability
•
•
•
•
stable
Lig Rec
0/1
Correct alignment
1/1
Lig advancement
1/1
PS with lig release
2/2
CCK
Hinge
3/8
2/4
McAuley
ICL 2004
Constrained prosthesis without ligament
Summary 1
Good clinical result can be obtained in valgus
knee
• Medullary guide less than 5
• More external femoral rotation
• Careful sequential release
Summary 2
In severe medial laxity in valgus knee
• Totally destabilizing by extensive lateral
release should be avoided
• The slight varus alignment with or
without MCL reconstruction or
constrained prosthesisis should be
used
• . Even the constrained prosthesis without
suport of ligament will fail