Skip to main content
SpringerLink
Log in

Lateral Coronal Bowing of Femur and/or Tibia Amplifies the Varus Malalignment of Lower Limb as well as Increases Functional Disability in Patients with Knee Osteoarthritis

  • Original Article
  • Published:
Indian Journal of Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

In the present study, we aimed at assessing the effect of femoral and tibial coronal bowing on varus malalignment and Oxford knee score (OKS) at different grades of knee osteoarthritis (OA).

Materials and Methods

This prospective observational study was conducted at a tertiary referral centre in New Delhi, India. Consecutive patients presenting to the “knee OA” outpatient clinics were invited to take part in the study conducted over a 12-month period. All consented patients underwent long-leg standing alignment radiographs using standardised technique and patient reported knee pain and function were recorded using Oxford knee score. The following radiological parameters were measured from weight-bearing long-leg radiographs of 824 varus aligned limbs via a morphometric software (Matlab R2009a) (1) hip–knee–ankle angle (HKAA), (2) femoral bowing, (3) tibial bowing. The knees were graded according to Kellegren and Lawrence grade (K&L) and OKS was recorded. 3 groups of HKAA were made based on the angle, A (0° to − 3°), B (− 3° to − 10°) and C (< − 10°). Both the femoral and tibial bow were also categorized into three groups depending upon the angle; in-range (− 2° to + 2°), varus (< − 2°), valgus (> + 2°).

Results

The mean (± SD) of HKAA, femoral bow and tibial bow of the whole cohort was − 6.97° ± 5.64°, − 1.54° ± 4.31° and − 1.96° ± 3.5°, respectively. An increase in the lateral bow of both femur and tibia was seen with an increase in the severity of OA. A consequent increase in the varus malalignment was observed with an increase in the lateral bow of both femur as well as the tibia at all grades of OA, with significant correlation observed between HKAA with Femoral bowing and HKAA with tibial bowing. The mean OKS for femoral bow, in-range, varus and valgus was 30.6 ± 11.5, 21.3 ± 11.5 and 35.3 ± 11.4, respectively, and for tibial bow, in-range, varus and valgus was 27.6 ± 11.5, 26. ± 11.5 and 28 ± 11.4, respectively. The difference in the mean OKS was observed to be significant when the varus bow group was compared to in range as well as valgus group (p < 0.01) for both femur and tibia for all the grades of OA.

Conclusion

The present study shows a significant correlation between varus malalignment and the bowing of extremities. Varus coronal bowing of both femur and tibia were seen to have significantly lower mean OKS as compared to valgus bowing or in-range bowing at all grades of knee OA.

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.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Salaffi, F., Carotti, M., Stancati, A., & Grassi, W. (2005). Health-related quality of life in older adults with symptomatic hip and knee osteoarthritis: A comparison with matched healthy controls. Aging Clinical and Experimental Research, 17(4), 255–263.

    Article  Google Scholar 

  2. Thienpont, E., Schwab, P. E., Cornu, O., Bellemans, J., & Victor, J. (2017). Bone morphotypes of the varus and valgus knee. Archives of Orthopaedic and Trauma Surgery, 137(3), 393–400.

    Article  CAS  Google Scholar 

  3. Howell, S. M., Kuznik, K., Hull, M. L., & Siston, R. A. (2010). Longitudinal shapes of the tibia and femur are unrelated and variable. Clinical Orthopaedics, 468(4), 1142–1148.

    Article  Google Scholar 

  4. Sharma, L., Song, J., Felson, D. T., Cahue, S., Shamiyeh, E., & Dunlop, D. D. (2001). The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA, 286(2), 188–195.

    Article  CAS  Google Scholar 

  5. Hunter, D. J., Zhang, Y., Niu, J., Tu, X., Amin, S., Goggins, J., et al. (2005). Structural factors associated with malalignment in knee osteoarthritis: The Boston osteoarthritis knee study. Journal of Rheumatology, 32(11), 2192–2199.

    Google Scholar 

  6. Cooke, T. D. V., Harrison, L., Khan, B., Scudamore, A., & Chaudhary, M. A. (2002). Analysis of limb alignment in the pathogenesis of osteoarthritis: A comparison of Saudi Arabian and Canadian cases. Rheumatology International, 22(4), 160–164.

    Article  Google Scholar 

  7. 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. Clinical Orthopaedics, 470(1), 45–53.

    Article  Google Scholar 

  8. Hsu, R. W., Himeno, S., Coventry, M. B., & Chao, E. Y. (1990). Normal axial alignment of the lower extremity and load-bearing distribution at the knee. Clinical Orthopaedics, 255, 215–227.

    Google Scholar 

  9. Moreland, J. R., Bassett, L. W., & Hanker, G. J. (1987). Radiographic analysis of the axial alignment of the lower extremity. Journal of Bone and Joint Surgery American Volume, 69(5), 745–749.

    Article  CAS  Google Scholar 

  10. Shetty, G. M., Mullaji, A., Bhayde, S., Nha, K. W., & Oh, H. K. (2014). Factors contributing to inherent varus alignment of lower limb in normal Asian adults: Role of tibial plateau inclination. The Knee, 21(2), 544–548.

    Article  Google Scholar 

  11. Victor, J. M. K., Bassens, D., Bellemans, J., Gürsu, S., Dhollander, A. A. M., & Verdonk, P. C. M. (2014). Constitutional varus does not affect joint line orientation in the coronal plane. Clinical Orthopaedics, 472(1), 98–104.

    Article  Google Scholar 

  12. Yau, W. P., Chiu, K. Y., Tang, W. M., & Ng, T. P. (2007). Coronal bowing of the femur and tibia in Chinese: Its incidence and effects on total knee arthroplasty planning. Journal of Orthopaedic Surgery (Hong Kong), 15(1), 32–36.

    Article  CAS  Google Scholar 

  13. Lasam, M. P. G., Lee, K. J., Chang, C. B., Kang, Y. G., & Kim, T. K. (2013). Femoral lateral bowing and varus condylar orientation are prevalent and affect axial alignment of TKA in Koreans. Clinical Orthopaedics, 471(5), 1472–1483.

    Article  Google Scholar 

  14. Mullaji, A. B., Marawar, S. V., & Mittal, V. (2009). A comparison of coronal plane axial femoral relationships in Asian patients with varus osteoarthritic knees and healthy knees. Journal of Arthroplasty, 24(6), 861–867.

    Article  Google Scholar 

  15. Matsumoto, T., Hashimura, M., Takayama, K., Ishida, K., Kawakami, Y., Matsuzaki, T., et al. (2015). A radiographic analysis of alignment of the lower extremities—Initiation and progression of varus-type knee osteoarthritis. Osteoarthritis Cartilage, 23(2), 217–223.

    Article  CAS  Google Scholar 

  16. Kobayashi, H., Akamatsu, Y., Kumagai, K., Kusayama, Y., Aratake, M., & Saito, T. (2017). Influence of coronal bowing on the lower alignment and the positioning of component in navigation and conventional total knee arthroplasty. Orthopaedics and Traumatology Surgery and Research (OTSR), 103(2), 251–256.

    Article  CAS  Google Scholar 

  17. Doré, D. A., Winzenberg, T. M., Ding, C., Otahal, P., Pelletier, J.-P., Martel-Pelletier, J., et al. (2013). The association between objectively measured physical activity and knee structural change using MRI. Annals of the Rheumatic Diseases, 72(7), 1170–1175.

    Article  Google Scholar 

  18. Kellgren, J. H., & Lawrence, J. S. (1957). Radiological assessment of osteo-arthrosis. Annals of the Rheumatic Diseases, 16(4), 494–502.

    Article  CAS  Google Scholar 

  19. Collins, N. J., Misra, D., Felson, D. T., Crossley, K. M., & Roos, E. M. (2011). Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care and Research, 63(Suppl 11), S208-228.

    Article  Google Scholar 

  20. Dawson, J., Fitzpatrick, R., Murray, D., & Carr, A. (1998). Questionnaire on the perceptions of patients about total knee replacement. Journal of Bone and Joint Surgery British Volume, 80(1), 63–69.

    Article  CAS  Google Scholar 

  21. Victor, J., Urlus, M., Bellemans, J., & Fabry, G. (1994). Femoral intramedullary instrumentation in total knee arthroplasty: The role of pre-operative X-ray analysis. The Knee, 1(2), 123–125.

    Article  Google Scholar 

  22. 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. Journal of Arthroplasty, 25(3), 381–386.

    Article  Google Scholar 

  23. Mullaji, A. B., Shetty, G. M., Lingaraju, A. P., & Bhayde, S. (2013). Which factors increase risk of malalignment of the hip-knee-ankle axis in TKA? Clinical Orthopaedics, 471(1), 134–141.

    Article  Google Scholar 

  24. Kim, S. H., Oh, M. K., Namgung, R., & Park, M. J. (2014). Prevalence of 25-hydroxyvitamin D deficiency in Korean adolescents: Association with age, season and parental vitamin D status. Public Health Nutrition, 17(1), 122–130.

    Article  Google Scholar 

  25. Saibaba, B., Dhillon, M. S., Chouhan, D. K., Kanojia, R. K., Prakash, M., & Bachhal, V. (2015). Significant incidence of extra-articular tibia vara affects radiological outcome of total knee arthroplasty. Knee Surgery and Related Research, 27(3), 173–180.

    Article  Google Scholar 

  26. Kim, C.-W., & Lee, C.-R. (2018). Effects of femoral lateral bowing on coronal alignment and component position after total knee arthroplasty: A comparison of conventional and navigation-assisted surgery. Knee Surgery and Related Research, 30(1), 64–73.

    Article  Google Scholar 

  27. Nagamine, R., Miura, H., Bravo, C. V., Urabe, K., Matsuda, S., Miyanishi, K., et al. (2000). Anatomic variations should be considered in total knee arthroplasty. Journal of Orthopaedic Science, 5(3), 232–237.

    Article  CAS  Google Scholar 

  28. Akamatsu, Y., Kobayashi, H., Kusayama, Y., Kumagai, K., & Saito, T. (2016). Femoral shaft bowing in the coronal and sagittal planes on reconstructed computed tomography in women with medial compartment knee osteoarthritis: A comparison with radiograph and its predictive factors. Archives of Orthopaedic and Trauma Surgery, 136(9), 1227–1232.

    Article  Google Scholar 

  29. Akamatsu, Y., Mitsugi, N., Kobayashi, H., Kumagai, K., Kusayama, Y., & Saito, T. (2012). Relationship between shaft bowing in the femur and tibia and bone mineral density in women with varus knee osteoarthritis. Osteoarthritis Cartilage, 1(20), S219.

    Article  Google Scholar 

  30. Moyer, R. F., Birmingham, T. B., Chesworth, B. M., Kean, C. O., & Giffin, J. R. (2010). Alignment, body mass and their interaction on dynamic knee joint load in patients with knee osteoarthritis. Osteoarthritis Cartilage, 18(7), 888–893.

    Article  CAS  Google Scholar 

  31. Thambiah, M., Nathan, S., Seow, B., Liang, S., & Lingaraj, K. (2015). Patient satisfaction after total knee arthroplasty: An Asian perspective. Singapore Medical Journal, 56(05), 259–263.

    Article  Google Scholar 

  32. Jacobs, C. A., & Christensen, C. P. (2014). Factors influencing patient satisfaction two to five years after primary total knee arthroplasty. Journal of Arthroplasty, 29(6), 1189–1191.

    Article  Google Scholar 

  33. Bourne, R. B., Chesworth, B. M., Davis, A. M., Mahomed, N. N., & Charron, K. D. J. (2010). Patient satisfaction after total knee arthroplasty: Who is satisfied and who is not? Clinical Orthopaedics, 468(1), 57–63.

    Article  Google Scholar 

  34. Lin, Y.-H., Chang, F.-S., Chen, K.-H., Huang, K.-C., & Su, K.-C. (2018). Mismatch between femur and tibia coronal alignment in the knee joint: Classification of five lower limb types according to femoral and tibial mechanical alignment. BMC Musculoskeletal Disorders, 19(1), 411.

    Article  Google Scholar 

  35. Slevin, O., Hirschmann, A., Schiapparelli, F. F., Amsler, F., Huegli, R. W., & Hirschmann, M. T. (2018). Neutral alignment leads to higher knee society scores after total knee arthroplasty in preoperatively non-varus patients: A prospective clinical study using 3D-CT. Knee Surgery Sports Traumatology Arthroscopy, 26(6), 1602–1609.

    Article  Google Scholar 

Download references

Funding

The study was conducted under project approved by UK-India Education and Research Initiative (UKIERI) and funded by Department of Science and technology, Ministry of Science and Technology, New Delhi, India.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India

    Mayur Nayak, Vijay Kumar, Rahul Yadav & Rajesh Malhotra

  2. Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India

    Deep Narayan Srivastava

  3. Chapel Allerton Hospital, University of Leeds, Leeds, UK

    Hemant Pandit

Authors
  1. Mayur Nayak
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vijay Kumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rahul Yadav
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Deep Narayan Srivastava
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hemant Pandit
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rajesh Malhotra
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MN; Drafting of the article, Critical revision of the article for important intellectual content, Collection and assembly of data, Final approval of the article. VK; Conception and design, Provision of study materials or patients, Final approval of the article. RY; Collection of data, analysis and interpretation of data and drafting of article. DNS; Analysis and interpretation of the data, Critical revision of the article for important intellectual content, final approval of the article. HP; Conception and design, Final approval of the article. RM; Conception and design, Drafting of the article, Critical revision of the article for important intellectual content, final approval of the article.

Corresponding author

Correspondence to Rajesh Malhotra.

Ethics declarations

Conflict of interest

All authors have no potential conflicts of interest, including financial interests, activities, relationships, and affiliations, to disclose.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.

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

Nayak, M., Kumar, V., Yadav, R. et al. Lateral Coronal Bowing of Femur and/or Tibia Amplifies the Varus Malalignment of Lower Limb as well as Increases Functional Disability in Patients with Knee Osteoarthritis. JOIO 55 (Suppl 1), 88–96 (2021). https://doi.org/10.1007/s43465-020-00303-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43465-020-00303-3

Keywords

Search

Navigation