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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 23, Issue 12, pp 3653–3659 | Cite as

Total knee arthroplasty in patients with substantial deformities using primary knee components

  • J. De Muylder
  • J. Victor
  • O. Cornu
  • L. Kaminski
  • E. Thienpont
Knee

Abstract

Purpose

Although advocated for severe varus and valgus deformities, constrained implant designs are associated with a number of disadvantages in total knee arthroplasty (TKA). Combining a minimally invasive surgical approach with an interchangeable posterior stabilized (PS) implant design may allow adequate soft tissue balancing with a minimal amount of constraint and without residual instability.

Methods

Retrospectively 51 patients operated with the minimally invasive far medial subvastus approach for severe varus or valgus deformity, who underwent primary TKA with a fully interchangeable PS implant (Vanguard, Biomet Inc., Warsaw IN, USA) between 2009 and 2013 were examined. Soft tissue releases was performed using a piecrust needling technique. Preoperative alignment and surgical parameters were collected for all patients. All patients underwent preoperative and follow-up radiographic assessment and completed a battery of clinical assessments.

Results

All procedures were performed successfully, with alignment improving from a preoperative mean (SD) varus deformity of 165° (3°) and a mean (SD) valgus deformity of 196° (4.5°) to an overall mean (SD) postoperative mechanical alignment of 179.5° (3.0°). Nine patients had postoperative varus, while three patients had a postoperative valgus deviation from neutral alignment >3°. The mean change in joint line position in extension was −0.0 ± 0.6 mm. Clinical scores at final follow-up were excellent for both groups.

Conclusions

Good TKA outcomes can be achieved in patients with substantial varus or valgus deformities using a combination of a minimally invasive far medial subvastus approach, interchangeable PS implants and soft tissue releases with a piecrust needling technique.

Level of evidence

III.

Keywords

Total knee arthroplasty Minimally invasive surgery Posterior stabilized Prosthesis design Joint deformity 

References

  1. 1.
    Abdel MP, Oussedik S, Parratte S, Lustig S (2014) Coronal alignment in total knee replacement: historical review, contemporary analysis, and future direction. Bone Joint J 96:857–862CrossRefPubMedGoogle Scholar
  2. 2.
    Anderson JA, Baldini A, MacDonald JH, Pellicci PM, Sculco TP (2006) Primary constrained condylar knee arthroplasty without stem extensions for the valgus knee. Clin Orthop Relat Res 442:199–203CrossRefPubMedGoogle Scholar
  3. 3.
    Barrack RL, Stanley T, Burt M, Hopkins S (2004) The effect of stem design on end-of-stem pain in revision total knee arthroplasty. J Arthroplasty 19(Suppl 2):119–124CrossRefPubMedGoogle Scholar
  4. 4.
    Behrend H, Giesinger K, Giesinger JM, Kuster MS (2012) The “forgotten joint” as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty 27:430–436Google Scholar
  5. 5.
    Bellemans J, Banks S, Victor J, Vandenneucker H, Moermans A (2002) Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty. Influence of posterior condylar offset. J Bone Joint Surg Br 84:50–53CrossRefPubMedGoogle Scholar
  6. 6.
    Bellemans J (2011) Multiple needle puncturing: balancing the varus knee. Orthopedics 34(9):e510–e512PubMedGoogle Scholar
  7. 7.
    Bellemans J, Vandenneucker H, Van Lauwe J, Victor J (2010) A new surgical technique for medial collateral ligament balancing: multiple needle puncturing. J Arthroplasty 25(7):1151–1156CrossRefPubMedGoogle Scholar
  8. 8.
    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 470:45–53PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Berend ME, Small SR, Ritter MA, Buckley CA (2010) The effects of bone resection depth and malalignment on strain in the proximal tibia after total knee arthroplasty. J Arthroplasty 25(2):314–318CrossRefPubMedGoogle Scholar
  10. 10.
    Bonutti PM, Mont MA, McMahon M, Ragland PS, Kester M (2004) Minimally invasive total knee arthroplasty. J Bone Joint Surg Am 86-A(Suppl 2):26–32PubMedGoogle Scholar
  11. 11.
    Cameron HU, Hunter GA (1982) Failure in total knee arthroplasty: mechanisms, revisions, and results. Clin Orthop Relat Res 170:141–146PubMedGoogle Scholar
  12. 12.
    Carothers JT, Kim RH, Dennis DA (2008) Bent but not broken: managing severe deformity in total knee arthroplasty. Sem Arthr 19(1):103–108CrossRefGoogle Scholar
  13. 13.
    Dixon M, Parsch D, Brown R, Scott R (2004) The correction of severe varus deformity in total knee arthroplasty by tibial component downsizing and resection of uncapped proximal medial bone. J Arthroplasty 19(1):19–22CrossRefPubMedGoogle Scholar
  14. 14.
    Elkus M, Ranawat CS, Rasquinha VJ, Babhulkar S, Rossi R, Ranawat AS (2004) Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. J Bone Joint Surg Am 86-A(12):2671–2676Google Scholar
  15. 15.
    Ewald FC (1989) The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12PubMedGoogle Scholar
  16. 16.
    Forster MC (2003) Survival analysis of primary cemented total knee arthroplasty: which designs last? J Arthroplasty 18(3):265–270CrossRefPubMedGoogle Scholar
  17. 17.
    Gioe TJ, Killeen KK, Grimm K, Mehle S, Scheltema K (2004) Why are total knee replacements revised?: analysis of early revision in a community knee implant registry. Clin Orthop Relat Res 428:100–106CrossRefPubMedGoogle Scholar
  18. 18.
    Grelsamer RP, Meadows S (1992) The modified Insall-Salvati ratio for assessment of patellar height. Clin Orthop Relat Res 282:170–176PubMedGoogle Scholar
  19. 19.
    Haas SB, Insall JN, Montgomery W 3rd, Windsor RE (1995) Revision total knee arthroplasty with use of modular components with stems inserted without cement. J Bone Joint Surg Am 77(11):1700–1707PubMedGoogle Scholar
  20. 20.
    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14PubMedGoogle Scholar
  21. 21.
    Jawhar A, Shah V, Sohoni S, Scharf HP (2013) Joint line changes after primary total knee arthroplasty: navigated versus non-navigated. Knee Surg Sports Traumatol Arthrosc 21(10):2355–2362CrossRefPubMedGoogle Scholar
  22. 22.
    King BR, Gladnick BP, Lee YY, Lyman S, Della Valle AG (2014) Range of motion and function are not affected by increased post constraint in patients undergoing posterior stabilized total knee arthroplasty. Knee 21(1):194–198CrossRefPubMedGoogle Scholar
  23. 23.
    Koninckx A, Schwab PE, Deltour A, Thienpont E (2014) The minimally invasive far medial subvastus approach for total knee arthroplasty in valgus knees. Knee Surg Sports Traumatol Arthrosc 22:1765–1770CrossRefPubMedGoogle Scholar
  24. 24.
    Krackow KA, Mihalko WM (1999) The effect of medial release on flexion and extension gaps in cadaveric knees: implications for soft-tissue balancing in total knee arthroplasty. Am J Knee Surg 12(4):222–228PubMedGoogle Scholar
  25. 25.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg [Am] 89A(4):780–785CrossRefGoogle Scholar
  26. 26.
    Laskin RS, Beksac B, Phongjunakorn A, Pittors K, Davis J, Shim JC, Pavlov H, Petersen M (2004) Minimally invasive total knee replacement through a mini-midvastus incision: an outcome study. Clin Orthop Relat Res 428:74–81CrossRefPubMedGoogle Scholar
  27. 27.
    Lombardi AV, Jr., Dodds KL, Berend KR, Mallory TH, Adams JB (2004) An algorithmic approach to total knee arthroplasty in the valgus knee. J Bone Joint Surg Am 86-A Suppl 2:62–71Google Scholar
  28. 28.
    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 469:3443–3450PubMedCentralCrossRefPubMedGoogle Scholar
  29. 29.
    Matsumoto T, Muratsu H, Kubo S, Matsushita T, Kurosaka M, Kuroda R (2011) The influence of preoperative deformity on intraoperative soft tissue balance in posterior-stabilized total knee arthroplasty. J Arthroplasty 26(8):1291–1298CrossRefPubMedGoogle Scholar
  30. 30.
    Matziolis G, Adam J, Perka C (2010) Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement. Arch Orthop Trauma Surg 130:1487–1491CrossRefPubMedGoogle Scholar
  31. 31.
    McAuley JP, Engh GA (2003) Constraint in total knee arthroplasty: when and what? J Arthroplasty 18(3 Suppl 1):51–54CrossRefPubMedGoogle Scholar
  32. 32.
    McPherson EJ, Vince KG (1993) Breakage of a total condylar III knee prosthesis. A case report. J Arthroplasty 8(5):561–563CrossRefPubMedGoogle Scholar
  33. 33.
    Mihalko WM, Miller C, Krackow KA (2000) Total knee arthroplasty ligament balancing and gap kinematics with posterior cruciate ligament retention and sacrifice. Am J Orthop (Belle Mead NJ) 29(8):610–616Google Scholar
  34. 34.
    Mihalko WM, Saleh KJ, Krackow KA, Whiteside LA (2009) Soft-tissue balancing during total knee arthroplasty in the varus knee. J Am Acad Orthop Surg 17(12):766–774PubMedGoogle Scholar
  35. 35.
    Moreland JR, Bassett LW, Hanker GJ (1987) Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am 69(5):745–749PubMedGoogle Scholar
  36. 36.
    Morgan H, Battista V, Leopold S (2005) Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg 18(8):515–524Google Scholar
  37. 37.
    Mullaji AB, Padmanabhan V, Jindal G (2005) Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20 degrees. J Arthroplasty 20(5):550–561CrossRefPubMedGoogle Scholar
  38. 38.
    Naudie DD, Rorabeck CH (2004) Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect 53:207–215PubMedGoogle Scholar
  39. 39.
    Niki Y, Matsumoto H, Otani T, Enomoto H, Toyama Y, Suda Y (2010) Accuracy of implant positioning for minimally invasive total knee arthroplasty in patients with severe varus deformity. J Arthroplasty 25(3):381–386CrossRefPubMedGoogle Scholar
  40. 40.
    Pang HN, Yeo SJ, Chong HC, Chin PL, Chia SL, Lo NN (2013) Joint line changes and outcomes in constrained versus unconstrained total knee arthroplasty for the type II valgus knee. Knee Surg Sports Traumatol Arthrosc 21(10):2363–2369CrossRefPubMedGoogle Scholar
  41. 41.
    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 92:2143–2149CrossRefPubMedGoogle Scholar
  42. 42.
    Pour AE, Parvizi J, Slenker N, Purtill JJ, Sharkey PF (2007) Rotating hinged total knee replacement: use with caution. J Bone Joint Surg Am 89(8):1735–1741CrossRefPubMedGoogle Scholar
  43. 43.
    Rajgopal A, Dahiya V, Vasdev A, Kochhar H, Tyagi V (2011) Long-term results of total knee arthroplasty for valgus knees: soft-tissue release technique and implant selection. J Orthop Surg (Hong Kong) 19(1):60–63Google Scholar
  44. 44.
    Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S (2005) Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am 87(Suppl 1):271–284Google Scholar
  45. 45.
    Ritter M, Davis K, Meding J, Pierson J, Berend M, Malinzak R (2011) The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg [Am] 93A(17):1588–1596Google Scholar
  46. 46.
    Ritter MA, Davis KE, Davis P, Farris A, Malinzak RA, Berend ME, Meding JB (2013) Preoperative malalignment increases risk of failure after total knee arthroplasty. J Bone Joint Surg Am 95(2):126–131CrossRefPubMedGoogle Scholar
  47. 47.
    Roos EM, Toksvig-Larsen S (2003) Knee injury and Osteoarthritis Outcome Score (KOOS)—validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes 1:17PubMedCentralCrossRefPubMedGoogle Scholar
  48. 48.
    Selvarajah E, Hooper G (2009) Restoration of the joint line in total knee arthroplasty. J Arthroplasty 24(7):1099–1102CrossRefPubMedGoogle Scholar
  49. 49.
    Sharkey P, Lichstein PM, Shen C, Tokarski AT, Parvizi J (2014) Why are total knee arthroplasties failing today-has anything changed after 10 years? J Arthroplasty doi: 10.1016/j.arth.2013.07.024 Google Scholar
  50. 50.
    Siston RA, Goodman SB, Delp SL, Giori NJ (2007) Coronal plane stability before and after total knee arthroplasty. Clin Orthop Relat Res 463:43–49PubMedGoogle Scholar
  51. 51.
    Thienpont E (2012) Prosthesis selection: choosing the right type of constraint. In: Parvizi J (ed) Principles and techniques in revision total knee arthroplasty. American Academy of Orthopaedic Surgeons, Rosemount, pp 29–39Google Scholar
  52. 52.
    Thienpont E (2013) Faster quadriceps recovery with the far medial subvastus approach in minimally invasive total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21(10):2370–2374CrossRefPubMedGoogle Scholar
  53. 53.
    Thienpont E, Opsomer G, Koninckx A, Houssiau F (2014) Joint awareness in different types of knee arthroplasty evaluated with the Forgotten Joint score. J Arthroplasty 29(1):48–51CrossRefPubMedGoogle Scholar
  54. 54.
    Vanlommel L, Vanlommel J, Claes S, Bellemans J (2013) Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 21:2325–2330CrossRefPubMedGoogle Scholar
  55. 55.
    Verborgt O, Victor J (2004) Post impingement in posterior stabilised total knee arthroplasty. Acta Orthop Belg 70(1):46–50PubMedGoogle Scholar
  56. 56.
    Whiteside LA (1993) Correction of ligament and bone defects in total arthroplasty of the severely valgus knee. Clin Orthop Relat Res 288:234–245PubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

Authors and Affiliations

  • J. De Muylder
    • 1
  • J. Victor
    • 2
  • O. Cornu
    • 1
  • L. Kaminski
    • 1
  • E. Thienpont
    • 1
  1. 1.Department of Orthopaedic SurgeryCliniques universitaires Saint Luc-UCLBrusselsBelgium
  2. 2.Department of Orthopaedic SurgeryUZ GentGhentBelgium

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