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    Moiz Ali
    Total knee arthroplasty in patients with valgus knee deformity remains challenging. This review discusses the pre-operative evaluation, surgical techniques, soft tissue balancing, and implant choices for correcting valgus deformities. A thorough pre-operative assessment is important to plan bone resection and deformity correction. While the medial parapatellar approach is most common, the lateral approach provides better access for soft tissue releases. Minimal soft tissue releases are preferred to avoid complications. Implant selection depends on the degree of instability, with more constrained implants used for severe deformities. Adhering to principles of accurate alignment and implant selection can lead to good outcomes.

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    Presentation 1

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    Moiz Ali
    14 views16 pages
    Total knee arthroplasty in patients with valgus knee deformity remains challenging. This review discusses the pre-operative evaluation, surgical techniques, soft tissue balancing, and implant choices for correcting valgus deformities. A thorough pre-operative assessment is important to plan bone resection and deformity correction. While the medial parapatellar approach is most common, the lateral approach provides better access for soft tissue releases. Minimal soft tissue releases are preferred to avoid complications. Implant selection depends on the degree of instability, with more constrained implants used for severe deformities. Adhering to principles of accurate alignment and implant selection can lead to good outcomes.

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    Total knee arthroplasty in patients with valgus knee deformity remains challenging. This review discusses the pre-operative evaluation, surgical techniques, soft tissue balancing, and implant choices for correcting valgus deformities. A thorough pre-operative assessment is important to plan bone resection and deformity correction. While the medial parapatellar approach is most common, the lateral approach provides better access for soft tissue releases. Minimal soft tissue releases are preferred to avoid complications. Implant selection depends on the degree of instability, with more constrained implants used for severe deformities. Adhering to principles of accurate alignment and implant selection can lead to good outcomes.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    14 views16 pages

    Presentation 1

    Uploaded by

    Moiz Ali
    Total knee arthroplasty in patients with valgus knee deformity remains challenging. This review discusses the pre-operative evaluation, surgical techniques, soft tissue balancing, and implant choices for correcting valgus deformities. A thorough pre-operative assessment is important to plan bone resection and deformity correction. While the medial parapatellar approach is most common, the lateral approach provides better access for soft tissue releases. Minimal soft tissue releases are preferred to avoid complications. Implant selection depends on the degree of instability, with more constrained implants used for severe deformities. Adhering to principles of accurate alignment and implant selection can lead to good outcomes.

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    Total knee arthroplasty

    in valgus knee deformity: is it


    still a challenge in 2021?
    D. Alesi  · A. Meena  · S. Fratini  · V. G. Rinaldi  · E. Cammisa  · G. Lullini  · V. Vaccari  ·
    S. Zafagnini
    • Journal:               Musculoskeletal Surgery
    • Year:                     2021
    • Impact factor:     1.76
    • Place of study:
    1. Istituto Ortopedico Rizzoli, Via G.B. Pupilli, Bologna, Italy 
    2. University of Bologna, Bologna, Italy 
    3. VMMC and Safdarjung Hospital, New Delhi, India 
    4. IRCCS Istituto delle Scienze Neurologiche, Via Altura, Bologna, Italy
    Introduction
    • TKA in valgus knee deformities - challenge in prosthetic surgery
    • Approximately 10% of patients
    • Osteoarthritis - most common cause of valgus deformity
    • Others
    • post-traumatic arthritis
    • rheumatoid arthritis
    • Rickets
    • renal osteodystrophy
    • The valgus arthritic knee:
    • hypoplastic lateral condyle
    • lateral tibial plateau bone loss
    • external rotation deformity of the tibia
    • femoral and tibial metaphyseal valgus remodeling
    • patellar malalignment
    • Tightening of lateral soft tissue structures – ITB, LCL, posterolateral capsule (PLC), PCL, popliteus tendon
    Objective
    • Thus, our review aims at providing a step by step comprehensive
    analysis of different surgical techniques for the correction of severe
    valgus deformity in total knee arthroplasty
    Pre-operative Evaluation
    • Patient Counselling:
    • Potential peroneal palsy
    • Clinical Evaluation:
    • weight-bearing alignment
    • flexion contracture
    • ligamentous instability
    • Radiological assessment:
    • Weight-bearing anteroposterior, lateral, and sunrise radiographs
    • measurement of the limb axis deviation - long-standing views for coronal alignment.
    • osseous deformity, patellar thickness and position
    • alignment of the ipsilateral hip
    • tibial subluxation
    • appropriate angles of femoral and tibial resection
    • need for augmentation of osseous deficiencies
    • On the lateral radiograph - any posterior osteophytes identified and then removed
    Surgical Approach
    • Medial parapatellar
    • Standard approach - most surgeons prefer this technique
    • Satisfactory long-term results

    • Difficult to reach posterolateral corner and release tight soft tissue structures
    in moderate and severe valgus knee arthritis
    • Higher potential risk for over-release of medial soft tissues resulting in
    instability.
    • Lateral Parapatellar Approach
    • Studies have reported better clinical outcomes
    • Facilitates direct access for the release of tight lateral ligamentous structures with
    preservation of the medial structures
    • Optimizes patellar tracking and preserves medial blood supply to the patella - reducing
    the use of constrained implants

    • Technical difficulties:
    • need of a tibial tubercle osteotomy to achieve an adequate exposure
    • difficulties in soft tissue closure after alignment correction

    • Lateral approach is still considered a second choice


    Mechanical alignment and bone resection
    • Both femoral and tibial pathology should be addressed
    • Distal femoral resection:
    • 3° of valgus is used to prevent under-correction of the underlying deformity as opposed to the typical 5°
    to 7°
    • Medial femoral condyle - reference point
    • Minimal amount of bone removed from the lateral femoral condyle – atrophic/hypoplastic
    • Femoral component rotation
    • posterolateral femoral condyle is often deficient - Relying on posterior condylar axis can result in
    malrotation of the femoral component.
    • AP axis (Whiteside’s line), the trans-epicondylar axis, and the tibial shaft axis should be used as
    reference
    • Tibial cut:
    • should be orthogonal to the tibial mechanical axis, should be confirmed with alignment guide first
    • If planned tibial cut is based on proximal tibial anatomy - may result in under-correction of the deformity
    if there is unrecognized extra-articular tibial valgus
    Soft Tissue Balancing
    • Key component in achieving good functional results and knee stability
    • No consensus regarding the structures that need to be addressed during TKR and
    the order of their release.
    • However, an adequate lateral soft tissue release should be performed - prevents residual
    valgus deformity and patellofemoral alignment problems
    • High rate of late-onset instability - when ITB is divided transversely above the
    joint line, and the LCL and the POP are released from the lateral femoral condyle
    • Peroneal nerve palsy and/or late-onset instability are reported with large lateral
    release
    • Peroneal palsy - serious possible complication
    • Prevention: keeping knee in slight flexion in immediate postoperative period
    • There is not enough evidence in the literature to conclude which is
    the best technique for lateral soft tissues release.
    • There are neither prospective nor controlled studies on this issue
    • Trend toward minimal release over the past few years, with extensive
    release being associated with higher instability, loosening, and
    reoperations.
    Implant choice
    • No consensus on the degree of implant constraint
    • Cruciate-retaining (CR) and cruciate-sacrificing implants - satisfactory clinical
    results
    • PCL substituting implants:
    • avoid concerns with PCL balancing and deal with a potentially abnormal native ligament.
    • Cruciate-retaining designs:
    • preserve condylar bone in the event of further revision surgery - especially among younger patients

    • Choice of implant:
    • Degree of joint instability
    • Presence of bone defects
    • Grade I valgus knees - CR implants can be used
    • If laxity on the coronal plane (MCL insufficiency) - a greater constraint
    such as posterior-stabilized (PS), condylar constrained knee (CCK) or
    hinged implants
    • When the coronal deformity is mild (<10°) - PS implant can be used
    • More severe deformities - many surgeons use CCK implant:
    • larger cam and can adopt stems - distribute and dissipate joint stresses along the
    metaphysis and the diaphysis
    • Necessary to remove a larger portion of femoral intercondylar bone to
    accommodate the femoral box
    • decreases the remaining bone stock available for revisions
    • Hinged implant:
    • Elderly patients with severe ligamentous insufficiency
    • major bone defects
    • valgus deformity greater than 20°
    • rheumatoid arthritis
    • Limitations:
    • need to cement long stems into the tibia and femur, which can be an obstacle to removing them
    during revisions
    • risk of loosening or rupture of the implant

    • Advisable to use the lowest possible degree of constraint to achieve optimal


    stability
    Conclusion
    • The surgical treatment of valgus knee deformity can still present a
    number of unique challenges.
    • Multiple surgical techniques have been described to treat this
    dysfunction with satisfactory clinical results
    • Adherence to a stepwise approach to deformity correction and
    implant choice is recommended.

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