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Surgical Technique: Computer-assisted Sliding Medial Condylar Osteotomy to Achieve Gap Balance in Varus Knees During TKA

  • Symposium: Special Considerations for TKA in Asian Patients
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Extensive posteromedial release to correct severe varus deformity during TKA may result in mediolateral or flexion instability and may require a constrained implant. We describe a technique combining computer navigation and medial condylar osteotomy in severe varus deformity to achieve a primary goal of ligament balance during TKA.

Description of Technique

The goal of this procedure was to achieve mediolateral gap balance in varus knees with rigid, recalcitrant medial contracture, with or without excessive lateral laxity, not amenable to extensive medial soft tissue releases. A sliding medial condylar osteotomy (SMCO) was performed under navigation guidance and the condylar block internally fixed using cancellous screws.

Methods

We prospectively evaluated mediolateral laxity, Knee Society scores, and knee ROM after SMCO in 12 varus arthritic knees in 11 patients (five men, six women) undergoing TKA with a minimum followup of 2 years (mean, 2 years; range, 2–2.5 years).

Results

The degree of mediolateral knee laxity improved from Grade 2 (in four knees) and Grade 3 (in eight knees) preoperatively to Grade 1 (< 5 mm) in all knees at last followup. Mean Knee Society score improved from 30 (range, 10–54) to 92 (range, 86–100). Mean knee flexion improved from 106° (range, 90°–120°) to 112° (range, 100°–124°), and no knee had any extensor lag or residual flexion deformity (> 5°). Three knees had asymptomatic fibrous union at the osteotomy site.

Conclusions

Computer-assisted SMCO in varus knees with recalcitrant medial contracture achieves improved mediolateral stability and knee function after TKA. Our technique uses navigation to accurately reposition the medial condylar block to equalize medial and lateral gaps, thereby ensuring a stable well-aligned knee without deploying constrained implants.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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References

  1. Bellemans J. Multiple needle puncturing: balancing the varus knee. Orthopedics. 2011;34:e510–e512.

    PubMed  Google Scholar 

  2. Bellemans J, D’Hooghe P, Vandenneucker H, Van Damme G, Victor J. Soft tissue balance in total knee arthroplasty: does stress relaxation occur perioperatively? Clin Orthop Relat Res. 2006;452:49–52.

    Article  PubMed  Google Scholar 

  3. Cheung KW, Yung SH, Chiu KH. Primary total knee replacement using constrained condylar prosthesis in knee with severe varus deformity. Hong Kong J Orthop Surg. 2002;6:65–68.

    Google Scholar 

  4. Dixon MC, Parsch D, Brown RR, Scott RD. The correction of severe varus deformity in total knee arthroplasty by tibial component downsizing and resection of uncapped proximal medial bone. J Arthroplasty. 2004;19:19–22.

    Article  PubMed  Google Scholar 

  5. Engh GA. The difficult knee: severe varus and valgus. Clin Orthop Relat Res. 2003;416:58–63.

    Article  PubMed  Google Scholar 

  6. Engh GA, Ammeen D. Results of total knee arthroplasty with medial epicondylar osteotomy to correct varus deformity. Clin Orthop Relat Res. 1999;367:141–148.

    Article  PubMed  Google Scholar 

  7. Fickert S, Jawhar A, Sunil P, Scharf HP. Precision of Ci-navigated extension and flexion gap balancing in total knee arthroplasty and analysis of potential predictive variables. Arch Orthop Trauma Surg. 2012;132:565–574.

    Article  PubMed  CAS  Google Scholar 

  8. Heesterbeek PJ, Wymenga AB. Correction of axial and rotational alignment after medial and lateral releases during balanced gap TKA: a clinical study of 54 patients. Acta Orthop. 2010;81:347–353.

    Article  PubMed  Google Scholar 

  9. Hernández-Vaquero D, Sandoval-García MA. Hinged total knee arthroplasty in the presence of ligamentous deficiency. Clin Orthop Relat Res. 2010;468:1248–1253.

    Article  PubMed  Google Scholar 

  10. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14.

    PubMed  Google Scholar 

  11. Lachiewicz PF, Soileau ES. Ten-year survival and clinical results of constrained components in primary total knee arthroplasty. J Arthroplasty. 2006;21:803–808.

    Article  PubMed  Google Scholar 

  12. Laskin RS. Fixed varus deformity. In: Hungerford DS, Krackow KA, Kenna RV, eds. Total Knee Arthroplasty: A Comprehensive Approach. Baltimore, MD: Lippincott Williams & Wilkins; 1984:184–185.

  13. Lombardi AV Jr, Berend KR, Leith JR, Mangino GP, Adams JB. Posterior-stabilized constrained total knee arthroplasty for complex primary cases. J Bone Joint Surg Am. 2007;89(suppl 3):90–102.

    Article  PubMed  Google Scholar 

  14. Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg. 2005;13:515–524.

    PubMed  Google Scholar 

  15. Mullaji A, Kanna R, Marawar S, Kohli S, Sharma A. Comparison of limb and component alignment using computer-assisted navigation versus image intensifier-guided conventional total knee arthroplasty: a prospective, randomized, single-surgeon study of 467 knees. J Arthroplasty. 2007;22:953–959.

    Article  PubMed  Google Scholar 

  16. Mullaji A, Sharma A, Marawar S, Kanna R. Quantification of effect of sequential posteromedial release on flexion and extension gaps: a computer-assisted study in cadaveric knees. J Arthroplasty. 2009;24:795–805.

    Article  PubMed  Google Scholar 

  17. Mullaji A, Shetty GM. Computer-assisted total knee arthroplasty for arthritis with extra-articular deformity. J Arthroplasty. 2009;24:1164–1169.

    Article  PubMed  Google Scholar 

  18. Mullaji AB, Marawar SV, Mittal V. A comparison of coronal plane axial femoral relationships in Asian patients with varus osteoarthritic knees and healthy knees. J Arthroplasty. 2009;24:861–867.

    Article  PubMed  Google Scholar 

  19. Mullaji AB, Padmanabhan V, Jindal G. Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20 degrees. J Arthroplasty. 2005;20:550–561.

    Article  PubMed  Google Scholar 

  20. Mullaji AB, Shetty GM, Lingaraju AP, Bhayde S. Which Factors Increase Risk of Malalignment of the Hip-Knee-Ankle Axis in TKA? Clin Orthop Relat Res. 2012 August 16. [Epub ahead of print].

  21. Noble PC, Scuderi GR, Brekke AC, Sikorskii A, Benjamin JB, Lonner JH, Chadha P, Daylamani DA, Scott WN, Bourne RB. Development of a new Knee Society scoring system. Clin Orthop Relat Res. 2012;470:20–32.

    Article  PubMed  Google Scholar 

  22. Parratte S, Pagnano MW. Instability after total knee arthroplasty. J Bone Joint Surg Am. 2008;90:184–194.

    PubMed  Google Scholar 

  23. Sekiya H, Takatoku K, Takada H, Sasanuma H, Sugimoto N. Postoperative lateral ligamentous laxity diminishes with time after TKA in the varus knee. Clin Orthop Relat Res. 2009;467:1582–1586.

    Article  PubMed  Google Scholar 

  24. Shetty GM, Mullaji A, Bhayde S. Computer guided restoration of joint line and femoral offset in cruciate substituting total knee arthroplasty. Knee. 2011;19:611–616.

    Article  PubMed  Google Scholar 

  25. Skyttä ET, Haapamäki V, Koivikko M, Huhtala H, Remes V. Reliability of the hip-to-ankle radiograph in determining the knee and implant alignment after total knee arthroplasty. Acta Orthop Belg. 2011;77:329–335.

    PubMed  Google Scholar 

  26. Verdonk PC, Pernin J, Pinaroli A, Ait Si Selmi T, Neyret P. Soft tissue balancing in varus total knee arthroplasty: an algorithmic approach. Knee Surg Sports Traumatol Arthrosc. 2009;17:660–666.

    Article  PubMed  Google Scholar 

  27. Yau WP, Chiu KY, Tang WM, Ng TP. Coronal bowing of the femur and tibia in Chinese: its incidence and effects on total knee arthroplasty planning. J Orthop Surg (Hong Kong). 2007;15:32–36.

    CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. The Arthritis Clinic, 101, Cornelian, Kemp’s Corner, Cumballa Hill, Mumbai, 400036, India

    Arun B. Mullaji FRCS Ed, MCh Orth, MS Orth

  2. Department of Orthopaedic Surgery, Breach Candy Hospital, Mumbai, India

    Arun B. Mullaji FRCS Ed, MCh Orth, MS Orth & Gautam M. Shetty MS Orth

Authors
  1. Arun B. Mullaji FRCS Ed, MCh Orth, MS Orth
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  2. Gautam M. Shetty MS Orth
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Corresponding author

Correspondence to Arun B. Mullaji FRCS Ed, MCh Orth, MS Orth.

Additional information

One of the authors (ABM) is a consultant for DePuy India (Mumbai, India). The other author (GMS) certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Breach Candy Hospital, Mumbai, India.

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Mullaji, A.B., Shetty, G.M. Surgical Technique: Computer-assisted Sliding Medial Condylar Osteotomy to Achieve Gap Balance in Varus Knees During TKA. Clin Orthop Relat Res 471, 1484–1491 (2013). https://doi.org/10.1007/s11999-012-2773-x

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  • DOI: https://doi.org/10.1007/s11999-012-2773-x

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