Skip to main content
SpringerLink
Log in

Bone morphotypes of the varus and valgus knee

  • Knee Arthroplasty
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Background

Coronal deformity correction with total knee arthroplasty (TKA) is an important feature in the treatment of osteoarthritis (OA). The hypothesis of this study was that bone morphology would be different in varus and valgus deformity, both before osteoarthritis development as well as during and after the disease process of OA.

Materials and methods

Retrospective study with measurements on preoperative and postoperative full leg standing radiographs of 96 patients who underwent TKA. The included patients were selected for this study because they had an OA knee on one side and a non-arthritic knee on the contralateral side presenting the same type of alignment as the to-be-operated knee (varus or valgus alignment on both sides). The control group of 46 subjects was a group of patients with neutral mechanical alignment who presented for ligamentous problems. A single observer measured mechanical alignment, anatomical alignment, anatomical–mechanical femoral angle and intra-articular bone morphology parameters with an accuracy of 1°.

Results

Varus OA group has less distal femoral valgus (mLDFA 89°) than control group (87°) and valgus OA group (mLDFA 85°). Varus OA group has same varus obliquity as control group (MPTA 87°) but more than valgus OA group (MPTA 90°). Joint Line Congruency Angle (JLCA) is 3°open on lateral side in varus and medially open in valgus OA group (2°). The non-arthritic valgus group presents a constitutional mechanical valgus of 184° Hip–Knee–Ankle (HKA) angle.

Discussion

Varus deformity in OA as measured with an HKA angle (HKA) <177° is a combination of distal femoral wear, tibial varus obliquity and lateral joint line opening. Valgus deformity in OA with an HKA > 183° is a combination of femoral distal joint line obliquity and wear combined with medial opening due to medial collateral ligament stretching. The clinical importance of bone morphotype analysis is that it shows the intra-articular potential of alignment correction when mechanical axis cuts are performed.

Conclusion

Bone morphology in varus and valgus deformity is different before and after osteoarthritis. Perpendicular cuts to mechanical axes do not necessarily lead to neutral mechanical axis. Constitutional mechanical valgus was observed as 184° HKA angle before the development of OA.

Level of evidence

Level IV study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Abdel M, Oussedik S, Parratte S, Lustig S, Haddad FS (2014) Coronal alignment in total knee replacement: historical review, contemporary analysis, and future direction. Bone Joint J 96-B(7):857–862

    Article  CAS  PubMed  Google Scholar 

  2. Allen MM, Pagnano MW (2016) Neutral mechanical alignment: Is it Necessary? Bone Joint J 98-b(1 Suppl A):81–83

    Google Scholar 

  3. Athwal KK, Daou HE, Kittl C, Davies AJ, Deehan DJ, Amis AA (2015) The superficial medial collateral ligament is the primary medial restraint to knee laxity after cruciate-retaining or posterior-stabilised total knee arthroplasty: effects of implant type and partial release. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3796-0

    Google Scholar 

  4. Bellemans J, Colyn W, Vandenneucker H, Victor J (2012) The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 470(1):45–53

    Article  PubMed  Google Scholar 

  5. Boettner F, Renner L, Arana Narbarte D, Egidy C, Faschingbauer M (2016) Total knee arthroplasty for valgus osteoarthritis: the results of a standardized soft-tissue release technique. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4054-9

    Google Scholar 

  6. Bowman A, Shunmugam M, Watts AR, Bramwell DC, Wilson C, Krishnan J (2016) Inter-observer and intra-observer reliability of mechanical axis alignment before and after total knee arthroplasty using long leg radiographs. Knee 23(2):203–208

    Article  PubMed  Google Scholar 

  7. Brouwer RW, Jakma TS, Bierma-Zeinstra SM, Ginai AZ, Verhaar JA (2003) The whole leg radiograph: standing versus supine for determining axial alignment. Acta Orthop Scand 74(5):565–568

    Article  PubMed  Google Scholar 

  8. Calliess T, Bauer K, Stukenborg-Colsman C, Windhagen H, Budde S, Ettinger M (2016) PSI kinematic versus non-PSI mechanical alignment in total knee arthroplasty: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-016-4136-8

    Google Scholar 

  9. Cherian JJ, Kapadia BH, Banerjee S, Jauregui JJ, Issa K, Mont MA (2014) Mechanical, anatomical, and kinematic axis in TKA: concepts and practical applications. Curr Rev Musculoskelet Med 7(2):89–95

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cooke TD, Li J, Scudamore RA (1994) Radiographic assessment of bony contributions to knee deformity. Orthop Clin North Am 25(3):387–393

    CAS  PubMed  Google Scholar 

  11. De Muylder J, Victor J, Cornu O, Kaminski L, Thienpont E (2015) Total knee arthroplasty in patients with substantial deformities using primary knee components. Knee Surg Sports Traumatol Arthrosc 23(12):3643–3659

    Article  Google Scholar 

  12. Fahlman L, Sangeorzan E, Chheda N, Lambright D (2014) Older Adults without Radiographic Knee Osteoarthritis: Knee Alignment and Knee Range of Motion. Clin Med Insights Arthritis Musculoskelet Disord 7:1–11

    Article  PubMed  PubMed Central  Google Scholar 

  13. Fang D, Ritter M, Davis K (2009) Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty 24(6 Suppl):39–43

    Article  PubMed  Google Scholar 

  14. Hawi N, Yarboro S, Suero EM, Liodakis E, Meller R, Krettek C, Citak M (2014) Laser method for intraoperative evaluation of lower extremity alignment: comparison of a novel technique to CT and a conventional method. Arch Orthop Trauma Surg 134(5):645–650

    Article  PubMed  Google Scholar 

  15. Hsu RW, Himeno S, Coventry MB, Chao EY (1990) Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clin Orthop Relat Res 255:215–227

    Google Scholar 

  16. Hungerford DS, Krackow KA (1985) Total joint arthroplasty of the knee. Clin Orthop Relat Res 192:23–33

    Google Scholar 

  17. Insall JN, Binazzi R, Soudry M, Mestriner LA (1985) Total knee arthroplasty. Clin Orthop Relat Res 192:13–22

    Google Scholar 

  18. Ishii Y, Noguchi H, Matsuda Y, Kiga H, Takeda M, Toyabe S (2009) Preoperative laxity in osteoarthritis patients undergoing total knee arthroplasty. Int Orthop 33(1):105–109

    Article  PubMed  Google Scholar 

  19. Kawakami H, Sugano N, Yonenobu K, Yoshikawa H, Ochi T, Hattori A, Suzuki N (2004) Effects of rotation on measurement of lower limb alignment for knee osteotomy. J Orthop Res 22(6):1248–1253

    Article  PubMed  Google Scholar 

  20. Kennedy WR, White RP (1987) Unicompartmental arthroplasty of the knee. Postoperative alignment and its influence on overall results. Clin Orthop Relat Res 221:278–285

    Google Scholar 

  21. Kornilov N, Kulyaba T, Petukhov A, Ignatenko V, Thienpont E (2015) Computer navigation helps achieving appropriate gap balancing and restoration of alignment in total knee arthroplasty for fixed valgus knee osteoarthritis irrespective of the surgical approach. Acta Orthop Belg 81(4):673–681

    PubMed  Google Scholar 

  22. Krackow KA, Pepe CL, Galloway EJ (1990) A mathematical analysis of the effect of flexion and rotation on apparent varus/valgus alignment at the knee. Orthopedics 13(8):861–868

    CAS  PubMed  Google Scholar 

  23. Magnussen RA, Weppe F, Demey G, Servien E, Lustig S (2011) Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res 469(12):3443–3450

    Article  Google Scholar 

  24. Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 69(5):745–749

    Article  CAS  PubMed  Google Scholar 

  25. Nam D, Vajapey S, Haynes JA, Barrack RL, Nunley RM (2016) Does use of a variable distal femur resection angle improve radiographic alignment in primary total knee arthroplasty? J Arthroplasty 10.1016/j.arth.2016.01.070

  26. Paley D, Tetsworth K (1992) Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur. Clin Orthop Relat Res 280:48–64

    Google Scholar 

  27. Parratte S, Pagnano MW, Trousdale RT, Berry DJ (2010) Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am 92(12):2143–2149

    Article  PubMed  Google Scholar 

  28. Paternostre F, Schwab P, Thienpont E (2014) The difference between weight-bearing and non-weight-bearing alignment in patient-specific instrumentation planning. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2687-5

    Google Scholar 

  29. Pfitzner T, von Roth P, Perka C, Matziolis G (2014) Intramedullary control of distal femoral resection results in precise coronal alignment in TKA. Arch Orthop Trauma Surg 134(4):459–465

    Article  PubMed  Google Scholar 

  30. Ritter MA, Faris PM, Keating EM, Meding JB (1994) Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 299:153–156

    Google Scholar 

  31. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD (2001) The role of knee alignment in disease progression and functional decline in knee osteoarthritis. Jama 286(2):188–195

    Article  CAS  PubMed  Google Scholar 

  32. Specogna AV, Birmingham TB, Hunt MA, Jones IC, Jenkyn TR, Fowler PJ, Giffin JR (2007) Radiographic measures of knee alignment in patients with varus gonarthrosis: effect of weightbearing status and associations with dynamic joint load. Am J Sports Med 35(1):65–70

    Article  PubMed  Google Scholar 

  33. Stucinskas J, Robertsson O, Lebedev A, Wingstrand H, Smailys A, Tarasevicius S (2016) Measuring long radiographs affects the positioning of femoral components in total knee arthroplasty: a randomized controlled trial. Arch Orthop Trauma Surg 136(5):693–700

    Article  PubMed  Google Scholar 

  34. Thippanna RK, Kumar MN (2016) Lateralization of femoral entry point to improve the coronal alignment during total knee arthroplasty in patients with bowed femur. J Arthroplasty. 10.1016/j.arth.2016.02.057

    PubMed  Google Scholar 

  35. van Raaij TM, Brouwer RW, Reijman M, Bierma-Zeinstra SM, Verhaar JA (2009) Conventional knee films hamper accurate knee alignment determination in patients with varus osteoarthritis of the knee. Knee 16(2):109–111

    Article  PubMed  Google Scholar 

  36. Victor JM, Bassens D, Bellemans J, Gursu S, Dhollander AA, Verdonk PC (2014) Constitutional varus does not affect joint line orientation in the coronal plane. Clin Orthop Relat Res 472(1):98–104

    Article  PubMed  Google Scholar 

  37. Willcox NM, Clarke JV, Smith BR, Deakin AH, Deep K (2012) A comparison of radiological and computer navigation measurements of lower limb coronal alignment before and after total knee replacement. J Bone Joint Surg Br 94(9):1234–1240

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University Hospital Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium

    E. Thienpont, P. E. Schwab & O. Cornu

  2. ZOL Ziekenhuizen, Genk, Belgium

    J. Bellemans

  3. University Hospital Gent, Ghent, Belgium

    J. Victor

Authors
  1. E. Thienpont
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. P. E. Schwab
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. O. Cornu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. Bellemans
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. J. Victor
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to E. Thienpont.

Ethics declarations

Conflict of interest

E. Thienpont: Royalties from Medacta, Zimmer Biomet; Consultancy fees from Depuy-Synthes, Lima, Medacta, Zimmer Biomet; Board function in Belgian Knee Society, European Knee Society. PE Schwab: nothing to disclose. O. Cornu: nothing to disclose. J. Bellemans: Royalties from Smith & Nephew; Consultancy fees from Corin, Smith & Nephew, Stryker; Stock from Stryker; Publisher royalties from Springer, Acco; Board function in European Knee Society. J. Victor: Royalties from Smith & Nephew; Consultancy fees from Corin, Smith & Nephew, Zimmer Biomet; Research support from Corin, Depuy-Synthes, Smith & Nephew, Zimmer Biomet; Board functions in European Knee Society, BVOT.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Thienpont, E., Schwab, P.E., Cornu, O. et al. Bone morphotypes of the varus and valgus knee. Arch Orthop Trauma Surg 137, 393–400 (2017). https://doi.org/10.1007/s00402-017-2626-x

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-017-2626-x

Keywords

Search

Navigation