Skip to main content

Advertisement

SpringerLink
Log in

Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function

  • KNEE
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The aim of this study was to demonstrate, whether the degree of limb alignment correction in varus knee osteoarthritis correlated with an increase in ankle symptoms and to define a cut-off value concerning the degree of correction above which to expect ankle problems.

Methods

Ninety-nine consecutive patients with preoperative intraarticular varus knee deformities who underwent total knee arthroplasty were retrospectively analyzed. Patients were examined clinically (Knee Society Score, Forgotten Joint Score, Foot Function Index, Range of Motion of the knee and ankle joint, pain scales) as well as radiologically. The mean follow-up time was 57 months.

Results

The degree of operative limb alignment correction strongly correlated with the Foot Function Index (R = 0.91, p < 0.05). Given this, higher degrees of knee malalignment corrections were associated with worse postoperative outcomes in the knee and ankle joint—despite postoperative improved joint line orientations. Subsequently, a cut-off value for arthritic varus deformities (14.5°) could be calculated, above which the prevalence of ankle symptoms increased manifold [OR = 15.6 (3.2–77.2 95% CI p < 0.05)]. Furthermore, ROM restrictions in the subtalar joint were associated with a worse outcome in the ankle joint.

Conclusions

When correcting excessive intraarticular varus knee osteoarthritis, surgeons have to be aware of possible postoperative ankle symptoms and should consider ankle deformities or decreased subtalar ROM before operative procedures.

Level of evidence

III.

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

Similar content being viewed by others

Abbreviations

FFI:

Foot Function Index

FJS:

Forgotten Joint Score

FS:

Function Score

HKA:

Hip knee angle

KS:

Knee Score

KSS:

Knee Society Score

ROM:

Range of motion

TKA:

Total knee arthroplasty

References

  1. Andreani L, Pianigiani S, Bori E, Lisanti M, Innocenti B (2019) Analysis of biomechanical differences between condylar constrained knee and rotating hinged implants: a numerical study. J Arthroplast

  2. Andrews M, Noyes FR, Hewett TE, Andriacchi TP (1996) Lower limb alignment and foot angle are related to stance phase knee adduction in normal subjects: a critical analysis of the reliability of gait analysis data. J Orthop Res 14:289–295

    Article  CAS  Google Scholar 

  3. 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 Arthroplast 27:430–436.e1

    Article  Google Scholar 

  4. Choi GW, Yang JH, Park JH, Yun HH, Lee YI, Chae JE, Yoon JR (2017) Changes in coronal alignment of the ankle joint after high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 25:838–845

    Article  Google Scholar 

  5. Choi JY, Song SJ, Kim SJ, Kim SH, Park JS, Suh JS (2018) Changes in hindfoot alignment after high or low tibial osteotomy. Foot Ankle Int 39:1097–1105

    Article  Google Scholar 

  6. Gao F, Ma J, Sun W, Guo W, Li Z, Wang W (2017) Radiographic assessment of knee-ankle alignment after total knee arthroplasty for varus and valgus knee osteoarthritis. Knee 24:107–115

    Article  Google Scholar 

  7. Gursu S, Sofu H, Verdonk P, Sahin V (2016) Effects of total knee arthroplasty on ankle alignment in patients with varus gonarthrosis: do we sacrifice ankle to the knee? Knee Surg Sports Traumatol Arthrosc 24:2470–2475

    Article  Google Scholar 

  8. Hess S, Moser LB, Amsler F, Behrend H, Hirschmann MT (2019) Highly variable coronal tibial and femoral alignment in osteoarthritic knees: a systematic review. Knee Surg Sports Traumatol Arthrosc 27:1368–1377

    Article  Google Scholar 

  9. Huang NFR, Dowsey MM, Ee E, Stoney JD, Babazadeh S, Choong PF (2012) Coronal alignment correlates with outcome after total knee arthroplasty: five-year follow-up of a randomized controlled trial. J Arthroplast 27:1737–1741

    Article  Google Scholar 

  10. Kayaalp ME, Keller T, Fitz W, Scuderi GR, Becker R (2019) Translation and validation of the German New Knee Society Scoring System. Clin Orthop Relat Res 477:383–393

    Article  Google Scholar 

  11. Kazemi SM, Qoreishi M, Behboudi E, Manafi A, Kazemi SK (2017) Evaluation of changes in the tibiotalar joint after high tibial osteotomy. Arch Bone Jt Surg 5:149–152

    PubMed  PubMed Central  Google Scholar 

  12. Kim CW, Gwak HC, Kim JH, Lee CR, Kim JG, Oh M, Park JH (2018) Radiologic factors affecting ankle pain before and after total knee arthroplasty for the varus osteoarthritic knee. J Foot Ankle Surg 57:865–869

    Article  Google Scholar 

  13. Krähenbühl N, Horn-Lang T, Hintermann B, Knupp M (2017) The subtalar joint: a complex mechanism. EFORT Open Rev 2:309–316

    Article  Google Scholar 

  14. Krause F, Barandun A, Klammer G, Zderic I, Gueorguiev B, Schmid T (2017) Ankle joint pressure changes in high tibial and distal femoral osteotomies: a cadaver study. Bone Jt J 99-B:59–65

    Article  CAS  Google Scholar 

  15. Lee JH, Jeong BO (2012) Radiologic changes of ankle joint after total knee arthroplasty. Foot Ankle Int 33:1087–1092

    Article  Google Scholar 

  16. Lee KM, Chang CB, Park MS, Kang S-B, Kim TK, Chung CY (2015) Changes of knee joint and ankle joint orientations after high tibial osteotomy. Osteoarthr Cartil 23:232–238

    Article  CAS  Google Scholar 

  17. Levinger P, Menz HB, Fotoohabadi MR, Feller JA, Bartlett JR, Bergman NR (2010) Foot posture in people with medial compartment knee osteoarthritis. J Foot Ankle Res 3:29

    Article  Google Scholar 

  18. Luyckx T, Vanhoorebeeck F, Bellemans J (2015) Should we aim at undercorrection when doing a total knee arthroplasty? Knee Surg Sport Traumatol Arthrosc 23:1706–1712

    Article  CAS  Google Scholar 

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

    Article  CAS  Google Scholar 

  20. Moser LB, Hess S, Amsler F, Behrend H, Hirschmann MT (2019) Native non-osteoarthritic knees have a highly variable coronal alignment: a systematic review. Knee Surg Sports Traumatol Arthrosc 27:1359–1367

    Article  Google Scholar 

  21. Naal FD, Impellizzeri FM, Huber M, Rippstein PF (2008) Cross-cultural adaptation and validation of the Foot Function Index for use in German-speaking patients with foot complaints. Foot ankle Int 29:1222–1228

    Article  Google Scholar 

  22. Norton AA, Callaghan JJ, Amendola A, Phisitkul P, Wongsak S, Liu SS, Fruehling-Wall C (2015) Correlation of knee and hindfoot deformities in advanced knee OA: compensatory hindfoot alignment and where it occurs. Clin Orthop Relat Res 473:166–174

    Article  Google Scholar 

  23. Onodera T, Majima T, Iwasaki N, Kamishima T, Kasahara Y, Minami A (2012) Long-term stress distribution patterns of the ankle joint in varus knee alignment assessed by computed tomography osteoabsorptiometry. Int Orthop 36:1871–1876

    Article  Google Scholar 

  24. Sheehy L, Felson D, Zhang Y, Niu J, Lam Y-M, Segal N, Lynch J, Cooke TDV (2011) Does measurement of the anatomic axis consistently predict hip-knee-ankle angle (HKA) for knee alignment studies in osteoarthritis? Analysis of long limb radiographs from the multicenter osteoarthritis (MOST) study. Osteoarthr Cartil 19:58–64

    Article  CAS  Google Scholar 

  25. Soucie JM, Wang C, Forsyth A, Funk S, Denny M, Roach KE, Boone D (2011) Range of motion measurements: reference values and a database for comparison studies. Haemophilia 17:500–507

    Article  CAS  Google Scholar 

  26. Stufkens SA, Barg A, Bolliger L, Stucinskas J, Knupp M, Hintermann B (2011) Measurement of the medial distal tibial angle. Foot Ankle Int 32:288–293

    Article  Google Scholar 

  27. Suero EM, Sabbagh Y, Westphal R, Hawi N, Citak M, Wahl FM, Krettek C, Liodakis E (2015) Effect of medial opening wedge high tibial osteotomy on intraarticular knee and ankle contact pressures. J Orthop Res 33:598–604

    Article  Google Scholar 

  28. Takakura Y, Tanaka Y, Kumai T, Tamai S (1995) Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Jt Surg Br 77:50–54

    Article  CAS  Google Scholar 

  29. Takeuchi R, Saito T, Koshino T (2008) Clinical results of a valgus high tibial osteotomy for the treatment of osteoarthritis of the knee and the ipsilateral ankle. Knee 15:196–200

    Article  Google Scholar 

  30. Tarr RR, Resnick CT, Wagner KS, Sarmiento A (1985) Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities. Clin Orthop Relat Res 72–80

  31. Thienpont E, Bellemans J, Victor J, Becker R (2013) Alignment in total knee arthroplasty, still more questions than answers…. Knee Surg Sport Traumatol Arthrosc 21:2191–2193

    Article  Google Scholar 

  32. Tonogai I, Hamada D, Sairyo K (2017) Radiographic changes in coronal alignment of the ankle joint immediately after primary total knee arthroplasty for varus knee osteoarthritis. Foot Ankle Online J 10(2):2

    Google Scholar 

  33. Victor JMK, Bassens D, Bellemans J, Gürsu S, Dhollander AAM, Verdonk PCM (2014) Constitutional varus does not affect joint line orientation in the coronal plane. Clin Orthop Relat Res 472:98–104

    Article  Google Scholar 

  34. Wang B, Saltzman CL, Chalayon O, Barg A (2015) Does the subtalar joint compensate for ankle malalignment in end-stage ankle arthritis? Clin Orthop Relat Res 473:318–325

    Article  Google Scholar 

  35. Weaver JK, Derkash RS (1992) Ankle pain following total knee arthroplasty. A case report. J Arthroplast 7:447–451

    Article  Google Scholar 

  36. Weidenhielm L, Svensson OK, Broström LÅ (1992) Change of adduction moment about the hip, knee and ankle joints after high tibial osteotomy in osteoarthrosis of the knee. Clin Biomech 7:177–180

    Article  CAS  Google Scholar 

  37. Xie K, Han X, Jiang X, Ai S, Dai K, Yu Z, Wu H, Qu X, Yan M (2019) The effect of varus knee deformities on the ankle alignment in patients with knee osteoarthritis. J Orthop Surg Res 14:134

    Article  Google Scholar 

  38. Zahn RK, Renner L, Perka C, Hommel H (2019) Weight-bearing radiography depends on limb loading. Knee Surg Sport Traumatol Arthrosc 27:1470–1476

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany

    Frank Graef, S. Tsitsilonis, C. Perka, R. K. Zahn & H. Hommel

  2. Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany

    Frank Graef

  3. Department of Orthopaedics, Märkisch-Oderland Hospital, Brandenburg Medical School Theodor Fontane, Wriezen, Germany

    R. Falk & H. Hommel

Authors
  1. Frank Graef
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. Falk
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Tsitsilonis
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. C. Perka
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R. K. Zahn
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. H. Hommel
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

FG: statistical and data analysis, established the study protocol, wrote the manuscript. RF: data analysis, critical revision of the manuscript. ST: data analysis, critical revision of the manuscript. CP: data analysis, established the study protocol, critical revision of the manuscript. RKZ: data analysis, critical revision of the manuscript. HH: data analysis, established the study protocol, critical revision of the manuscript.

Corresponding author

Correspondence to Frank Graef.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Funding

This study was performed without external funding.

Ethical approval

This study was carried out according to the laws and ethical standards of the local legal representative body and was approved by the local ethics committee of the Brandenburg state of Germany (approval number AS17(bB)/2015).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Graef, F., Falk, R., Tsitsilonis, S. et al. Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function. Knee Surg Sports Traumatol Arthrosc 28, 3758–3765 (2020). https://doi.org/10.1007/s00167-019-05812-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-019-05812-9

Keywords

Search

Navigation