TKA in valgus knee

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TKA in valgus knee
Beom Koo Lee, M.D. Dept. of Orthopaedic Surgery
Gachon University, Gil Medical Center
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Content

• Pathology of valgus knee
• Classification of valgus knee
• Technique
• Exposure
• Bone resection
• Ligament balancing
• Result

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Pathology of valgus knee

• lateral femoral hypoplasia
• internal femoral torsion
• medial ligament laxity

why knee fail Callahan J Arthroplasty 2004
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Classification

• A type-I deformity
• minimal valgus and medial soft-tissue
  stretching.
• A typical type-II
• fixed valgus deformity has a more substantial
  deformity (gt10) 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 BabhulkarTotal Knee Arthroplasty for
Severe Valgus DeformityJ. Bone Joint Surg. Am.,
Sep 2005 87 271 - 284
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Exposure
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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

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Lateral approach in exposure TKRA in valgus
knee

1. Popular in Europe
2. Fascia lata detachment in extension

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Osteotomy of tibial tubercle in lateral approach

• Osteotomy is trapezoidal
• 7 cm long, 2 cm wide
• Maintain a medial hinge

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Arthrotomy in lateral approach

• Z plasty separates superficial
• and deep layers (retinaculum)

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Closure after lateral approach

• Closure in flexion, Z plasty, use of fat pad

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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 85-89Nicholas Bardakos,
Akin Cil, Brandon Thompson, Greg Stocks
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More external rotation in valgus knee

J Arima, LA Whiteside, DS McCarthy, and SE
WhiteJ BJS 95- A., 77 1331 1334,
1995 Fehring CORR 380, 2000
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Rotation in valgus knee

• The anteroposterior axis appears
• to be a reliable landmark for rotational
  alignment of
• the femoral component in a valgus knee.

J Arima, LA Whiteside, DS McCarthy, and SE
WhiteJ. Bone Joint Surg. Am., Sep 1995 77 1331
- 1334
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Mean femoral rotation to achieve symmetric
flexion space

• Valgus knee 6.0
• (Winemaker JA
  2002)

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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 427-431Tiezheng Sun, Houshan
Lu, Nan Hong, Jian Wu, Chuanhan Feng
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Proximal tibia resection
The Journal of Arthroplasty, Volume 21, Issue 5,
August 2006, Pages 771-774Akira Nagumo, Yasuyuki
Ishibashi, Eiichi Tsuda, Satoshi Toh
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Ligament balancing in valgus knee
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Ligament balancing in valgus knee
tight in extension release ITB
( Whiteside JOAJune'02P23)
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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
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Balancing of severe valgus knee

• Need release of
• LCL, popliteus

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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
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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
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• 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
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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
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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 994-1004Kenneth A. Krackow,
William M. Mihalko
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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
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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
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•                     
                        
• 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
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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
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Tx for severe medial instability in valgus knee

• Alignment control
• MCL tightening or reconstruction
• Constrained prosthesis

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Treatment of severe medial laxity with alignment
Unacceptable stability with valgus alignment
with medial laxity
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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
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Treatment of severe medial laxity with MCL
Advancement or reconstruction
Healy WL, CORR 356161, 1998
Krackow
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Treatment of severe medial laxity with CCK

• Torn but reconstructable
• MCL

Douglas D.R. Naudie AAOS ICL 2004 P212
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Treatment of severe medial laxity with hinged
prosthesis

• Absent or, unreconstructable MCL

Douglas D.R. Naudie AAOS ICL 2004P212
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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 366-370Paul 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
(???)
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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
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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 366-370Paul 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
(???)
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Result
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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
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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).
2004862671-2676
Henry D. Clarke, Robin Fuchs, Giles R.
Scuderi, JA Dec'05 Pages 1010-1014
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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
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Total Knee Arthroplasty After Failed
ProximalTibial Valgus Osteotomy

• There was no difference in the final result after
  follow-up periods of 4-9 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
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Result of extension instabilitymedial
instability

• stable
• Lig Rec 0/1
• Correct alignment 1/1
• Lig advancement 1/1
• PS with lig release 2/2

CCK 3/8 Hinge
2/4
McAuley ICL 2004
Constrained prosthesis without ligament support
would fail
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Summary 1
Good clinical result can be obtained in valgus
knee

• Medullary guide less than 5
• More external femoral rotation
• Careful sequential release

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Summary 2In 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
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Thank you for your attention