Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 25, Issue 9, pp 2825–2834 | Cite as

Unconstrained total knee arthroplasty in significant valgus deformity: a modified surgical technique to balance the knee and avoid instability

  • R. PagotiEmail author
  • S. O’Brien
  • E. Doran
  • D. Beverland



Correction of valgus deformity in total knee arthroplasty (TKA) is technically challenging and has produced variable results. A modified surgical technique involving adapting the distal femoral cut with minimal soft tissue release is proposed. The authors hypothesise that using this technique would result in satisfactory radiological and functional outcome.


The technique involves balancing the knee in extension by changing the distal femoral resection angle and confining soft tissue release to only the posterolateral capsule if required. Retrospective analysis of 276 consecutive TKAs performed using this technique under the care of a single surgeon in patients with valgus knee deformity ≥10° was undertaken. An unconstrained mobile bearing implant was used in all knees with a medial para-patellar approach, and outcome scores were collected prospectively. Ninety six percent of the knees were cementless.


Mean coronal alignment of the lower limb was corrected from 15.6° (±5.7°) to 3.8° (±2.5°). 97.8 % knees had their coronal alignment restored to ≤7°. Seventy-eight knees (28 %) were balanced by only changing the distal femoral resection angle. One hundred and ninety-eight knees (72 %) had release of the posterolateral capsule. Sixteen knees (5.8 %) also had release of iliotibial band. Lateral patellar release was performed in 39 knees (14 %). 93.1 % had central patello-femoral alignment. At between 5.8 and 10.5 year follow-up, there has been one spinout, managed by closed reduction, and one revision of tibial tray for subsidence. The mean American Knee Society clinical score improved from 19.1 to 86.5 (±12.2).


Adequate correction of valgus knee deformity was successfully achieved using this modified technique with satisfactory medium-term outcome and avoidance of instability.


Valgus deformity Total knee arthroplasty Rotating platform Modified surgical technique Mobile bearing Cementless 



The authors would like to thank the outcome team in Musgrave Park for help in collecting the data used in the paper, Michael Parker for his statistical advice and Professor James Nixon for his help in editing the paper.


  1. 1.
    Aglietti P, Buzzi R, Giron F, Zaccherotti G (1996) The Insall-Burstein posterior stabilized total knee replacement in the valgus knee. Am J Knee Surg 9(1):8–12PubMedGoogle Scholar
  2. 2.
    Aglietti P, Lup D, Cuomo P, Baldini A, De Luca L (2007) Total knee arthroplasty using a pie-crusting technique for valgus deformity. Clin Orthop Relat Res 464:73–77PubMedGoogle Scholar
  3. 3.
    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
  4. 4.
    Beverland D (2002) Advanced mobile-bearing surgical technique. Orthopedics 25(2 Suppl):s265–s271PubMedGoogle Scholar
  5. 5.
    Bonner TJ, Eardley WGP, Patterson P, Gregg PJ (2011) The effect of post-operative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years. J Bone Joint Surg Br 93(9):1217–1222CrossRefPubMedGoogle Scholar
  6. 6.
    Brilhault J, Lautman S, Favard L, Burdin P (2002) Lateral femoral sliding osteotomy lateral release in total knee arthroplasty for a fixed valgus deformity. J Bone Joint Surg Br 84:1131–1137CrossRefPubMedGoogle Scholar
  7. 7.
    Buechel FF (1990) A sequential three-step lateral release for correcting fixed valgus knee deformities during total knee arthroplasty. Clin Orthop Relat Res 260:170–175Google Scholar
  8. 8.
    Buechel FF Sr, Buechel FF Jr, Pappas MJ, Dalessio J (2002) Twenty-year evaluation of the New Jersey LCS Rotating Platform Knee Replacement. J Knee Surg 15:84–89PubMedGoogle Scholar
  9. 9.
    Clarke HD, Fuchs R, Scuderi GR, Scott WN, Insall JN (2005) Clinical results in valgus total knee arthroplasty with the “pie crust” technique of lateral soft tissue releases. J Arthroplasty 20:1010–1014CrossRefPubMedGoogle Scholar
  10. 10.
    Clarke HD, Schwartz JB, Math KR, Scuderi GR (2004) Anatomic risk of peroneal nerve injury with the “pie crust” technique for valgus release in total knee arthroplasty. J Arthroplasty 19:40–44CrossRefPubMedGoogle Scholar
  11. 11.
    Clarke HD, Scott WN, Insall JN, Pedersen HB, Math KR, Vigorita VJ, Cushner FD (2001) Anatomy. In: Insall JN, Scott WN (eds) Surgery of the knee. Churchill Livingstone, New York, pp 13–76Google Scholar
  12. 12.
    Deep K (2014) Collateral ligament laxity in knees: What is normal? Clin Orthop Relat Res 472(11):3426–3431CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Easley ME, Insall JN, Scuderi GR, Bullek DD (2000) Primary constrained condylar knee arthroplasty for the arthritic valgus knee. Clin Orthop Relat Res 380:58–64CrossRefGoogle 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:2671–2676CrossRefPubMedGoogle Scholar
  15. 15.
    Ewald FC (1989) The knee society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 248:9–12Google Scholar
  16. 16.
    Fiddian NJ, Blakeway C, Kumar A (1998) Replacement arthroplasty of the valgus knee: a modified lateral capsular approach with repositioning of vastus lateralis. J Bone Joint Surg Br 80(5):859–861CrossRefPubMedGoogle Scholar
  17. 17.
    Galinat BJ, Vernace JV, Booth RE, Rothman RH (1988) Dislocation of the posterior stabilized total knee arthroplasty: a report of two cases. J Arthroplasty 3(4):363–367CrossRefPubMedGoogle Scholar
  18. 18.
    Healy WL, Iorio R, Lemos DW (1998) Medial reconstruction during total knee arthroplasty for severe valgus deformity. Clin Orthop Relat Res 356:161–169CrossRefGoogle Scholar
  19. 19.
    Huang CH, Ma HM, Lee YM, Ho FY (2003) Long-term results of low contact stress mobile-bearing total knee replacements. Clin Orthop Relat Res 416:265–270CrossRefGoogle Scholar
  20. 20.
    Insall J (1971) A midline approach to the knee. J Bone Joint Surg Am 53(8):1584–1586CrossRefPubMedGoogle Scholar
  21. 21.
    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14Google Scholar
  22. 22.
    Karachalios T, Sarangi PP, Newman JH (1994) Severe varus and valgus deformities treated by total knee arthroplasty. J Bone Joint Surg Br 76(6):938–942CrossRefPubMedGoogle Scholar
  23. 23.
    Keblish PA (1991) The lateral approach to the valgus knee: surgical technique and analysis of 53 cases with over two-year follow-up evaluation. Clin Orthop Relat Res 271:52–62Google Scholar
  24. 24.
    Keblish PA, Varma AK, Greenwald AS (1994) Patellar resurfacing or retention in total knee arthroplasty: a prospective study of patients with bilateral replacements. J Bone Joint Surg Br 76:930–937CrossRefPubMedGoogle Scholar
  25. 25.
    Koninckx A, Schwab P-E, 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(8):1765–1770CrossRefPubMedGoogle Scholar
  26. 26.
    Krackow KA, Jones MM, Teeny SM, Hungerford DS (1991) Primary total knee arthroplasty in patients with fixed valgus deformity. Clin Orthop Relat Res 273:9–18Google Scholar
  27. 27.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174CrossRefPubMedGoogle Scholar
  28. 28.
    Miyasaka KC, Ranawat CS, Mullaji A (1997) 10- to 20-year followup of total knee arthroplasty for valgus deformities. Clin Orthop Relat Res 345:29–37CrossRefGoogle Scholar
  29. 29.
    Mullaji A, Kanna R, Marawar S, Kohli A, Sharma A (2007) 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 22(7):953–959CrossRefPubMedGoogle Scholar
  30. 30.
    Napier RJ, Bennett D, McConway J, Wilson R, Sykes AM, Doran E, O’Brien S, Beverland DE (2014) The influence of immediate knee flexion on blood loss and other parameters following total knee replacement. Bone Joint J 96-B(2):201–209CrossRefPubMedGoogle Scholar
  31. 31.
    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):2143–2149CrossRefPubMedGoogle Scholar
  32. 32.
    Peters CL, Jimenez C, Erickson J, Anderson MB, Pelt CE (2013) Lessons learned from selective soft-tissue release for gap balancing in primary total knee arthroplasty: an analysis of 1216 consecutive total knee arthroplasties: AAOS exhibit selection. J Bone Joint Surg Am 95(20):e152CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Politi J, Scott R (2004) Balancing severe valgus deformity in total knee arthroplasty using a lateral cruciform retinacular release. J Arthroplasty 19(5):553–557CrossRefPubMedGoogle Scholar
  34. 34.
    Ritter MA, Faris PM, Keating EM, Meding JB (1994) Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 299:153–156Google Scholar
  35. 35.
    Scuderi GR, Insall JN (1995) Fixed varus and valgus deformities. In: Lotke PA (ed) Knee Arthroplasty. Raven Press, Ltd., New York, pp 111–127Google Scholar
  36. 36.
    Smith JL, Tullos HS, Davidson JP (1989) Alignment of total knee arthroplasty. J Arthroplasty 4(Suppl):S55–S61CrossRefPubMedGoogle Scholar
  37. 37.
    Sperner G, Wanitschek P, Benedetto KP, Glötzer W (1990) Late results in patellar fracture. Aktuelle Traumatol 20(1):24–28PubMedGoogle Scholar
  38. 38.
    Stehlík J, Musil D, Held M, Stárek M (2006) Z-plasty for valgus deformity in total knee arthroplasty. Acta Chir Orthop Traumatol Cech 73(3):169–175PubMedGoogle Scholar
  39. 39.
    Stern SH, Moeckel BH, Insall JN (1991) Total knee arthroplasty in valgus knees. Clin Orthop Relat Res 273:5–8Google Scholar
  40. 40.
    Stiehl JB, Hamelynck KJ, Voorhorst PE (2006) International multi-centre survivorship analysis of mobile bearing total knee arthroplasty. Int Orthop 30(3):190–199CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Strauch M, von Eisenhart Rothe R, Graichen H (2013) A new navigation-based technique for lateral distalizing condylar osteotomy in patients undergoing total knee arthroplasty with fixed valgus deformity. Knee Surg Sports Traumatol Arthrosc 21(10):2263–2270CrossRefPubMedGoogle Scholar
  42. 42.
    Thompson NW, McAlinden MG, Breslin E, Crone MD, Kernohan WG, Beverland DE (2001) Periprosthetic tibial fractures after cementless low contact stress total knee arthroplasty. J Arthroplasty 16(8):984–990CrossRefPubMedGoogle Scholar
  43. 43.
    Thompson NW, Wilson DS, Cran GW, Beverland DE, Stiehl JB (2004) Dislocation of the rotating platform after low contact stress total knee arthroplasty. Clin Orthop Relat Res 425:207–211CrossRefGoogle Scholar
  44. 44.
    Whiteside LA (1993) Correction of ligament and bone defects in total arthroplasty of the severely valgus knee. Clin Orthop Relat Res 234–245(288):234–245Google Scholar
  45. 45.
    Whiteside LA (2002) Soft tissue balancing: the knee. J Arthroplasty 17:23–27CrossRefPubMedGoogle Scholar
  46. 46.
    Windsor RE, Scuderi GR, Moran MC, Insall JN (1989) Mechanisms of failure of the femoral and tibial components in total knee arthroplasty. Clin Orthop Relat Res 248:15–20Google Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  1. 1.Primary Joint UnitMusgrave Park HospitalBelfastUK

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