Total Knee Replacement for Extreme Valgus Deformity
Early Outcome in six Consecutive Cases
Keywords:
Level IV study, levels of constraint, pie‑crusting release, severe valgus, total knee replacementAbstract
Introduction: About 10%–15% of patients who present for total knee replacement (TKR) present with valgus knee deformity. Valgus angulation above 20° is regarded as severe deformity. The aim of this study is to present our initial experience of the surgical management of six consecutive cases with extreme valgus deformity, highlighting surgical techniques and level of constraint required as well as clinical outcome. Patients and Methods: Six consecutive patients with end‑stage osteoarthritis and extreme valgus underwent TKR between 2016 and 2020. Demographic information, radiographic assessment and operative details were documented. Difficulties encountered and techniques used to achieve correction of deformity during surgery were detailed. Post‑operative assessment includes Oxford Knee Score (OKS) and patient satisfaction score. Results: All patients were females. The mean age was 71.8 (range: 67–82). Four patients had pie‑crusting release and valgus‑varus constraint (VVC), one had posterior stabilised implant and one a rotating‑hinge (RH) implant. Complications include one recurrent valgus instability, one partial peroneal nerve palsy treated with drop foot splint and one early post‑operative infection which resolved with treatment. The mean post‑operative follow‑up was 14.2 months (range: 3–48 months). OKS improved from a mean pre‑operative score of 18 (range: 15–21) to post‑operative mean score of 44 (range: 41–46) at a mean 14.8‑month follow‑up. All patients rated their results as satisfactory. Conclusion: Our results show that satisfactory correction of deformity and balance can be achieved, but higher levels of implant constraint were required. Long‑term follow‑up is necessary to ensure that function remains satisfactory.
References
1. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R,Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am 2005;87 Suppl 1:271‑84.
2. Ritter MA, Faris PM, Keating EM. Postoperative alignment of TKR: Itseffect on survival. Clin Orthop 1994;299:153‑6.
3. Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty:Defect classification and alternatives for reconstruction. Instr CourseLect 1999;48:167‑75.
4. Karachalios T, Sarangi PP, Newman JH. Severe varus and valgusdeformities treated by total knee arthroplasty. J Bone Joint Surg Br1994;76:938‑42.
5. Gehrke T, Kendoff D, Haasper C. The role of hinges in primary totalknee replacement. Bone Joint J 2014;96‑B: 93‑5.
6. Malcolm TL, Bederman SS, Schwarzkopf R. Outcome of varus valgusconstrained versus rotating‑hinge implants in total knee arthroplasty.Orthopedics 2016;39:e140‑8.
7. McAuley JP, Engh GA. Constraint in total knee arthroplasty: When andwhat? J Arthroplasty 2003;18:51‑4.
8. Petrou G, Petrou H, Tilkeridis C, Stavrakis T, Kapetsis T, Kremmidas N,et al. Medium‑term results with a primary cemented rotating‑hinge totalknee replacement. A 7‑ to 15‑year follow‑up. J Bone Joint Surg Br2004;86:813‑7.
9. Leng Y, Zeng M, Hu Y, Zhu V, Su W, Xie J. Primary total kneearthroplasty with rotatinghinge prosthesis in severely compromisedknees. Int J Clin Exp Med 2018;11(6):5867-5872 www.ijcem.com/ISSN:1940-5901/IJCEM0063970.
10. Barrack RL. Evolution of the rotating hinge forcomplex total knee arthroplasty. Clin Orthop RelatRes 2001;:292-299. doi:10.1097/00003086-200111000-00038.
11. Badawy M, Fenstad AM, Furnes O. Primary constrained and hingedtotal knee arthroplasty: 2‑ and 5‑year revision risk compared withunconstrained total knee arthroplasty: A report on 401 cases fromthe Norwegian Arthroplasty Register 1994‑2017. Acta Orthop2019;90:467‑72.
12. Pour AE, Parvizi J, Slenker N, Purtill JJ, Sharkey PF. Rotating hingedtotal knee replacement: Use with caution. J Bone Joint Surg Am2007;89:1735‑41.
13. Guenoun B, Latargez L, Freslon M, Defossez G, Salas N, Gayet LE. Complications following rotating hinge Endo‑Modell (Link) kneearthroplasty. Orthop Traumatol Surg Res 2009;95:529‑36.
14. Clarke HD, Fuchs R, Scuderi GR, Scott WN, Insall JN. Clinical resultsin valgus TKA, with the ‘‘pie crust’’ technique of lateral soft tissuereleases. J Arthroplasty 2005;20:1010‑4.
15. Keblish PA. The lateral approach to the valgus knee. Surgical techniqueand analysis of 53 cases with over two-year follow-up evaluation. ClinOrthop Relat Res 1991:52-62.
16. Whiteside LA. Correction of ligament and bone defects intotal arthroplasty of the severely valgus knee. Clin OrthopRelat Res 1993:234-245.
17. Apostolopoulos AP, Nikolopoulos DD, Polyzois I, Nakos A,Liarokapis S, Stefanakis G, et al. Total knee arthroplasty in severevalgus deformity: Interest of combining a lateralapproach with a tibialtubercle osteotomy. Orthopaed Traumatol Surg Res 2010;96:777‑84.
18. Rossi R, Rosso F, Cottino U, Dettoni F, Bonasia DE, Bruzzone M. Totalknee arthroplasty in the valgus knee. Int Orthop 2014;38:273‑83.
19. Rajgopal A, Dahiya V, Vasdev A, Kochhar H, Tyagi V. Long‑term resultsof total knee arthroplasty for valgus knees: Soft‑tissue release techniqueand implant selection. J Orthop Surg (Hong Kong) 2011;19:60‑3.
20. Favorito PJ, Mihalko WM, Krackow KA. Total knee arthroplasty in thevalgus knee. J Am Acad Orthop Surg 2002;10:16‑24.
21. Mihalko WM, Krackow KA. Anatomic and biomechanical aspects of piecrusting posterolateral structures for valgus deformity correction in totalknee arthroplasty: A cadaveric study. J Arthroplasty 2000;15:347‑53.
22. Bruzzone M, Ranawat A, Castoldi F, Dettoni F, Rossi P, Rossi R. Therisk of direct peroneal nerve injury using the Ranawat “inside‑out”lateral release technique in valgus total knee arthroplasty. J Arthroplasty2010;25:161‑5.
23. Clarke HD, Schwarz JB, Math KR, Scuderi GR. Anatomic risk ofperoneal nerve injury with the “pie crust” technique for valgus releasein TKA. J Arthroplasty 2004;19:40‑4.
24. Jones RE, Barrack RL, Skedros J. Good mid‑term result. Modular,mobile‑bearing hinge total knee arthroplasty. Clin Orthop Relat Res2001;392:306‑14.
25. Ritter MA, Keating EM, Faris PM. Screw and cement fixation of largedefects in total knee arthroplasty. A sequel. J Arthroplasty 1993;8:63‑5.
26. Dorr LD, Ranawat CS, Sculco TA, McKaskill B, Orisek BS. Bonegraft for tibial defects in total knee arthroplasty. Clin Orthop Relat Res.1986:153-65.
27. Son WS, Shon OJ, Lee DC, Park SJ, Yang HS. Efficacy of opendebridement and polyethylene exchange in strictly selected patientswith infection after total knee arthroplasty. Knee Surg Relat Res2017;29:172‑9.
Downloads
Published
Issue
Section
License
Copyright (c) 2020 Charles Ayekoloye, Ajibola Babatunde Oladiran, Ajibade Babatunde Omololu, Temitope Olusegun Alonge, Samuel Olusegun Ogunlade, Imonichie I. Adeoye-Sunday, Michael Oluyinka Okunola, Abraham Ajimzo Anejukwo (Author)
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors publishing in the Nigerian Journal of Orthopaedics and Trauma retain the copyright to their work.
All articles are published under the Creative Commons Attribution 4.0 International (CC BY 4.0) licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
