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Constitutional Varus Does Not Affect Joint Line Orientation in the Coronal Plane

  • Symposium: 2013 Knee Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

In a previous study, we described the distribution of coronal alignment in a normal asymptomatic population and recognized the occurrence of constitutional varus in one of four individuals. It is important to further investigate the influence of this condition on the joint line orientation and how the latter is affected by the onset and progression of arthritis.

Questions/purposes

The purposes of this study are (1) to describe the distribution of joint line orientation in the coronal plane in the normal population; (2) to compare joint line orientation between patients with constitutional varus and neutral mechanical alignment; and (3) to compare joint line orientation between a cohort of patients with prearthritic constitutional varus and a cohort of patients with established symptomatic varus arthritis.

Methods

Full-leg standing hip-to-ankle digital radiographs were performed in 248 young healthy individuals and 532 patients with knee arthritis. Hip-knee-ankle (HKA) angle and tibial joint line angle (TJLA) were measured in the coronal plane. Patients were subdivided into varus (HKA ≤ −3°), neutral, and valgus (HKA ≥ 3°).

Results

The mean TJLA in healthy subjects was 0.3° (SD 2.0°). TJLA was parallel to the floor in healthy subgroups with neutral alignment (TJLA 0.3°, SD 1.9) and constitutional varus (TJLA 0.2°, SD 2.2°). In patients with symptomatic arthritis and varus alignment, the TJLA opened medially (mean −1.9°, SD 3.5°).

Conclusions

Constitutional varus does not affect joint line orientation. Advanced medial arthritis causes divergence of the joint line from parallel to the floor. These findings influence decision-making for osteotomy and alignment in total knee arthroplasty.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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References

  1. Ahlbäck S. Osteoarthrosis of the knee: a radiographic investigation. Acta Radiol Diagn (Stockh). 1968;Suppl 277:7–72.

    Google Scholar 

  2. Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res. 2012;470:45–53.

    Article  PubMed Central  PubMed  Google Scholar 

  3. Belo JN, Berger MY, Reijman M, Koes BW, Bierma-Zeinstra SMA. Prognostic factors of progression of osteoarthritis of the knee: a systematic review of observational studies. Arthritis Rheum. 2007;57:13–26.

    Article  CAS  PubMed  Google Scholar 

  4. Birmingham TB, Kramer JF, Kirkley A, Inglis JT, Spaulding SJ, Vandervoort AA. Association among neuromuscular and anatomic measures for patients with knee osteoarthritis. Arch Phys Med Rehabil. 2001;82:1112–1118.

    Google Scholar 

  5. Brouwer GM, van Tol AW, Bergink AP, Belo JN, Bernsen RMD, Reijman M. Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee. Arthritis Rheum. 2007;56:1204–1211.

    Article  CAS  PubMed  Google Scholar 

  6. Cerejo R, Dunlop DD, Cahue S, Channin D, Song J, Sharma L. The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease. Arthritis Rheum. 2002;46:2632–2636.

    Article  PubMed  Google Scholar 

  7. Chao EY, Neluheni EV, Hsu RW, Paley D. Biomechanics of malalignment. Orthop Clin North Am. 1994;25:379–386.

    CAS  PubMed  Google Scholar 

  8. Cooke TDV, Li J, Scudamor RA. Radiographic assessment of bony contributions to knee deformity. Orthop Clin North Am. 1994;25:387–393.

    CAS  PubMed  Google Scholar 

  9. Cooke TDV, Pichora D, Siu D, Scudamore RA, Bryant JT. Surgical implications of varus deformity of the knee with obliquity of joint surfaces. J Bone Joint Surg Br. 1989;71:560–565.

    CAS  PubMed  Google Scholar 

  10. Cooke TDV, Scudamore A, Greer W. Varus knee osteoarthritis: whence the varus? J Rheumatol. 2003;30:2521–2523.

    PubMed  Google Scholar 

  11. Cooke TDV, Scudamore A, Li JA, Wyss U, Bryant T, Costigan P. Axial lower-limb alignment. Comparison of knee geometry in normal volunteers and osteoarthritis patients. Osteoarthritis Cartilage. 1997;5:39–47.

    Article  CAS  PubMed  Google Scholar 

  12. Cooke TDV, Sled E. Optimizing limb position for measuring knee anatomical axis alignment from standing knee radiographs. J Rheumatol. 2009;36:471–477.

    Google Scholar 

  13. Cooke TDV, Sled E, Scudamore RA. Frontal plane alignment. A call for standardized measurement. J Rheumatol. 2007;34:1796–1801.

    PubMed  Google Scholar 

  14. Fang DM, Ritter MA, Davis KE. Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplasty. 2009;24(Suppl):39–43.

    Article  PubMed  Google Scholar 

  15. Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly: the Framingham Osteoarthritis Study. Arthritis Rheum. 1987;30:914–918.

    Article  CAS  PubMed  Google Scholar 

  16. Floerkemeier S, Staubli AE, Schroeter S, Goldhahn S, Lobenhoffer P. Outcome after high tibial open-wedge osteotomy: a retrospective evaluation of 533 patients. Knee Surg Sports Traumatol Arthrosc. 2012 Jun 29 [Epub ahead of print].

  17. Hagstedt B, Norman O, Olsson TH, Tjornstrand B. Technical accuracy in high tibial osteotomy for gonarthrosis. Acta Orthop. 1980;51:963–970.

    Article  CAS  Google Scholar 

  18. Hernigou P, Deschamps G. Alignment influences wear in the knee after medial unicompartmental arthroplasty. Clin Orthop Relat Res. 2004;423:161–165.

    Article  PubMed  Google Scholar 

  19. Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML. Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res. 2012 Sept 21 [Epub ahead of print]. DOI: 10.1007/s11999-012-2613-z.

  20. Howell SM, Kuznik K, Hull ML, Siston RA. Results of an initial experience with custom-fit positioning total knee arthroplasty in a series of 48 patients. Orthopedics. 2008;31:857–863.

    Article  PubMed  Google Scholar 

  21. Howell SM, Kuznik K, Hull ML, Siston RA. Longitudinal shapes of the tibia and femur are unrelated and variable. Clin Orthop Relat Res. 2010;468:1142–1148.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Kapandji IA. The Physiology of Joints: The Lower Limb. Vol 2, 6th ed. Edinburgh, UK: Churchill Livingstone; 2010.

  23. Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J Bone Joint Surg Am. 1987;69:745–749.

    CAS  PubMed  Google Scholar 

  24. Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994;25:425–465.

    CAS  PubMed  Google Scholar 

  25. Sharma L, Song J, Dunlop D, Felson D, Lewis CE, Segal N. Varus and valgus alignment and incident and progressive knee osteoarthritis. Ann Rheum Dis. 2010;69:1940–1945.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Sharma L, Song J, Felson DT, Cahue S, Shamiyeh E, Dunlop DD. The role of knee alignment in disease progression and functional decline in knee osteoarthritis. JAMA. 2001;286:188–196.

    Article  CAS  PubMed  Google Scholar 

  27. Skyttä ET, Lohman M, Tallroth K, Remes V. Comparison of standard anteroposterior knee and hip-to-ankle radiographs in determining the lower limb and implant alignment after total knee arthroplasty. Scand J Surg. 2009;98:250–253.

    PubMed  Google Scholar 

  28. Victor J, Van Doninck D, Labey L, Van Glabbeek F, Parizel P, Bellemans J. A common reference frame for describing rotation of the distal femur. J Bone Joint Surg Br. 2009;91:683–690.

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, De Pintelaan 185, Gent, 9000, Belgium

    Jan M. K. Victor MD, PhD, David Bassens MD, Aad A. M. Dhollander MD, PhD & Peter C. M. Verdonk MD, PhD

  2. Department of Orthopedic Surgery, Leuven University Hospitals, Leuven, Belgium

    Johan Bellemans MD, PhD

  3. Department of Orthopedics and Traumatology, Baltaliman Bone Diseases Training and Research Hospital, İstanbul, Turkey

    Sarper Gürsu MD

Authors
  1. Jan M. K. Victor MD, PhD
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  2. David Bassens MD
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  3. Johan Bellemans MD, PhD
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  4. Sarper Gürsu MD
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  5. Aad A. M. Dhollander MD, PhD
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  6. Peter C. M. Verdonk MD, PhD
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Corresponding author

Correspondence to Jan M. K. Victor MD, PhD.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Victor, J.M.K., Bassens, D., Bellemans, J. et al. Constitutional Varus Does Not Affect Joint Line Orientation in the Coronal Plane. Clin Orthop Relat Res 472, 98–104 (2014). https://doi.org/10.1007/s11999-013-2898-6

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  • DOI: https://doi.org/10.1007/s11999-013-2898-6

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