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Valgus arthritic knees can be classified into nine phenotypes

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope



It is not shown whether anatomical variations exist in valgus arthritic limbs as to support individualized component and limb alignment. The null hypothesis was that there was no phenotypic variation of coronal femoro-tibial morphology in valgus knees. The aim was to determine whether distinct phenotypes of valgus knees could be identified to help surgical planning and classifying valgus knees for outcome studies.


Full-leg weight-bearing radiographs of 233 knees (182 preoperative; 51 of contralateral arthritic knee) were measured for HKA (hip-knee-ankle angle), VCA (valgus correction angle), mLDFA (lateral mechanical distal femoral angle), aLDFA (lateral anatomical distal femoral angle), MPTA (medial proximal tibial angle), MNSA (medial neck shaft angle), TAMA (angle between tibial mechanical and anatomical axes), and TBA (tibial bowing angle).


Nine phenotypes were identified encompassing all 233 knees which could be clubbed into 4 broad types. Type 1 Neutral knees (12.5%) had almost normal values (mean VCA 5.3°, mLDFA 86.9°, aLDFA 81.1°). Type 2 ‘Intra-articular valgus’ (22.7%) showed lateral compartment bone loss (mean mLDFA 83.9°; MPTA 90.2°). Type 3 ‘Extra-articular valgus’ (35.2%) had extra-articular deformity: 3a showed valgus femoral bowing (mean VCA 2.7°); 3b valgus tibial bowing; 3c showed valgus tibial bowing with lateral femoral condyle wear (mean mLDFA 84.3°). Type 4 ‘Varus’ type (29.6%) had features of varus knees: 4a had varus femoral bowing (VCA 8.3°); distal femur in 4b was akin to varus knees (mean mLDFA 89.3°) with lateral tibial bone loss (mean MPTA 91.2°). 4c had varus tibial bowing and deficient lateral femoral condyle (mLDFA 83.7°). 4d had varus tibial bowing and lateral tibial bone loss (mean MPTA 89.8°).


The study identified four broad groups of valgus arthritic knees with nine phenotypes based on coronal plane variations in femoro-tibial morphology. This study may be of value in planning and performing corrective osteotomies, and planning the optimal position of femoral and tibial components in unicompartmental and total knee arthroplasty. The classification presented in this study may aid in categorizing valgus knees for outcome studies.

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We thank Dr. Rahul Shah and Dr. Debjyoti Roy for help in the collection of data and with measurements of the radiographs.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations



AM conceived the study, wrote and reviewed the manuscript: RB analyzed the data and helped to write the paper, AS collected the data, analyzed the data, and reviewed the manuscript; MH helped collect the data, helped analyze the data, and reviewed the manuscript.

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Correspondence to Arun Mullaji.

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RB AS and MH have nothing to disclose. AM is an educational consultant for DePuy and receives royalties from DePuy and Springer.

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Institutional Ethics Committee approval: (Number P13/20).

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Mullaji, A., Bhoskar, R., Singh, A. et al. Valgus arthritic knees can be classified into nine phenotypes. Knee Surg Sports Traumatol Arthrosc 30, 2895–2904 (2022).

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