Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 11, pp 3386–3394 | Cite as

Under-corrected knees do not fail more than aligned knees at 8 years in fixed severe valgus total knee replacement

  • Bertrand BoyerEmail author
  • Régis Pailhé
  • Nassima Ramdane
  • David Eichler
  • Franck Remy
  • Matthieu Ehlinger
  • Gilles Pasquier



A fixed severe valgus knee is a surgical challenge. A safe post-operative Hip-Knee-Ankle angle (HKA) range of 180° ± 4 was recommended, but recent studies mentioned equal results from outliers of this range. Nevertheless, no distinction was made between varus and valgus knees, as well as over-corrected or under-corrected knees. Did post-operative nonaligned total knee replacements (TKR) from fixed severe valgus knees behave differently from the properly aligned population? Did over-corrected knees behave differently from under-corrected knees?


Through a multi-center retrospective cohort study, we provided 557 knees of at least 10° of minimal pre-operative valgus; in this population 75 presented a post-operative Hip-Knee-Ankle angle (HKA) outside of the 180° ± 4 range; 23 of them had at least 5° of varus; 52 of them had at least 5° of valgus. Median pre-operative HKA of the entire cohort was 194° (range 190–198). Median follow-up was 8 years (range 5–11); Knee Society Score (KSS) results, HKA, Femoral and Tibial Mechanical Angles (FMA, TMA) and complication rates were obtained. The outlier group (HKA ≤ 175 or ≥ 185) was compared to the control group (HKA 180 ± 4); over-corrected (HKA ≤ 175) and under-corrected (HKA ≥ 185) sub-groups were individually tested against the control group.


The outlier group had a lower Final Knee Score than the aligned group (p = 0.023). In the over-corrected sub-group, median post-operative FMA was 88° (SD 4°) and median TMA was 87° (SD 4°). The complication rate was higher (p = 0.019). Knee (p = 0.018), Function (p = 0.034) and Final Knee Scores (p = 0.03) were statistically lower than in the control group. In the under-corrected sub-group, mean post-operative FMA was 93° (SD 2°) and mean TMA was 91° (SD 2°). The complication rate was lower (p = 0.019) and there was no difference with the control group concerning KSS.


In case of pre-operative fixed severe valgus knee, one should avoid over-correcting HKA angle and especially the TMA. Over-correction of a severe preoperative valgus in a post-operative varus was prejudicial for TKA survival. Keeping a severe valgus knee in low valgus to avoid using a more constrained implant and/or ligament releases will not decrease the 5–10 year implant survival and functional scores.

Level of evidence

Level IV—Case series.


Valgus deformity Knee arthritis Total knee arthroplasty Residual deformity 



No funding was necessary for this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

French Orthopedic Society SOFCOT does not require an ethical approval statement for inhouse studies.


  1. 1.
    Brilhault J, Lautman S, Favard L, Burdin P (2002) Lateral femoral sliding osteotomy lateral release in total knee arthroplasty for a fixed valgus deformity. Bone Joint J 84:1131–1137CrossRefGoogle Scholar
  2. 2.
    Charnley J (1972) The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. Bone Joint J 54:61–76Google Scholar
  3. 3.
    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 20:1010–1014CrossRefGoogle Scholar
  4. 4.
    Devane PA, Horne JG, Martin K, Coldham G, Krause B (1997) Three-dimensional polyethylene wear of a press-fit titanium prosthesis: factors influencing generation of polyethylene debris. J Arthroplasty 12:256–266CrossRefGoogle Scholar
  5. 5.
    D’Lima DD, Chen PC, Colwell CW (2001) Polyethylene contact stresses, articular congruity, and knee alignment. Clin Orthop Relat Res 392:232–238CrossRefGoogle Scholar
  6. 6.
    Eckhoff DG, Bach JM, Spitzer VM, Reinig KD, Bagur MM, Baldini TH, Flannery NM (2005) Three-dimensional mechanics, kinematics, and morphology of the knee viewed in virtual reality. J Bone Joint Surg 87:71–80PubMedGoogle Scholar
  7. 7.
    Gallo J, Goodman SB, Konttinen YT, Wimmer MA, Holinka M (2013) Osteolysis around total knee arthroplasty: a review of pathogenetic mechanisms. Acta Biomater 9:8046–8058CrossRefGoogle Scholar
  8. 8.
    Hadi M, Barlow T, Ahmed I, Dunbar M, McCulloch P, Griffin D (2016) Does malalignment affect patient reported outcomes following total knee arthroplasty: a systematic review of the literature. SpringerPlus 5:1201CrossRefGoogle Scholar
  9. 9.
    Huang T-W, Chuang P-Y, Lee C-Y, Lin S-J, Huang K-C, Shen S-H, Tsai Y-H, Lee MS, Hsu RW-W (2016) Total knee arthroplasty in patients with Ranawat type-II valgus arthritic knee with a marked coronal femoral bowing deformity: comparison between computer-assisted surgery and intra-articular resection. J Orthop Surg 11:88CrossRefGoogle Scholar
  10. 10.
    Insall J, Ranawat CS, Scott WN, Walker P (1976) Total condylar knee replacment: preliminary report. Clin Orthop Relat Res 120:149–154Google Scholar
  11. 11.
    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
  12. 12.
    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
  13. 13.
    Kim Y-H, Park J-W, Kim J-S, Park S-D (2014) The relationship between the survival of total knee arthroplasty and postoperative coronal, sagittal and rotational alignment of knee prosthesis. Int Orthop 38:379–385CrossRefGoogle Scholar
  14. 14.
    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
  15. 15.
    Lombardi AV, Berend KR, Ng VY (2011) Neutral mechanical alignment: a requirement for successful TKA: affirms. Orthopedics 34:504–506Google Scholar
  16. 16.
    Magnussen RA, Weppe F, Demey G, Servien E, Lustig S (2011) Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res 469:3443–3450CrossRefGoogle Scholar
  17. 17.
    Martin JR, Beahrs TR, Stuhlman CR, Trousdale RT (2016) Complex primary total knee arthroplasty: long-term outcomes. J Bone Joint Surg 98:1459–1470CrossRefGoogle Scholar
  18. 18.
    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
  19. 19.
    Mont MA, Mahoney OM (2010) Commentary on an Article by Sebastien Parratte, MD., PhD et al.: “Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements”. J Bone Joint Surg 92-A:e16(1)–e16(2)Google Scholar
  20. 20.
    Nikolopoulos D, Michos I, Safos G, Safos P (2015) Current surgical strategies for total arthroplasty in valgus knee. World J Orthop 6:469CrossRefGoogle Scholar
  21. 21.
    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 92:2143–2149CrossRefGoogle Scholar
  22. 22.
    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 95:e152-1CrossRefGoogle Scholar
  23. 23.
    Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S (2005) Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg 87:271–284CrossRefGoogle Scholar
  24. 24.
    Ritter MA, Davis KE, Davis P, Farris A, Malinzak RA, Berend ME, Meding JB (2013) Preoperative malalignment increases risk of failure after total knee arthroplasty. J Bone Joint Surg 95:126–131CrossRefGoogle Scholar
  25. 25.
    Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA (2011) The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg 93:1588–1596CrossRefGoogle Scholar
  26. 26.
    Rodriguez JA, Bas MA, Orishimo KF, Robinson J, Nicholas SJ (2016) Differential effect of total knee arthroplasty on valgus and varus knee biomechanics during Gait. J Arthroplasty 31:248–253CrossRefGoogle Scholar
  27. 27.
    Schmalzried TP, Szuszczewicz ES, Northfield MR, Akizuki KH, Frankel RE, Belcher G, Amstutz HC (1998) Quantitative assessment of walking activity after total hip or knee replacement. J Bone Joint Surg 80:54–59CrossRefGoogle Scholar
  28. 28.
    Shan L, Shan B, Suzuki A, Nouh F, Saxena A (2015) Intermediate and long-term quality of life after total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg 97:156–168CrossRefGoogle Scholar
  29. 29.
    Smith CR, Vignos MF, Lenhart RL, Kaiser J, Thelen DG (2016) The influence of component alignment and ligament properties on tibiofemoral contact forces in total knee replacement. J Biomech Eng 138:021017CrossRefGoogle Scholar
  30. 30.
    Stucinskas J, Robertsson O, Sirka A, Lebedev A, Wingstrand H, Tarasevicius S (2015) Moderate varus/valgus malalignment after total knee arthroplasty has little effect on knee function or muscle strength. Acta Orthop 86:728–733CrossRefGoogle Scholar
  31. 31.
    Werner FW, Ayers DC, Maletsky LP, Rullkoetter PJ (2005) The effect of valgus/varus malalignment on load distribution in total knee replacements. J Biomech 38:349–355CrossRefGoogle Scholar
  32. 32.
    Whiteside LA (1993) Correction of ligament and bone defects in total arthroplasty of the severely valgus knee. Clin Orthop Relat Res 288:234–245Google Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.Service de chirurgie orthopédiqueCentre Hospitalier Universitaire de Saint EtienneSaint-ÉtienneFrance
  2. 2.Faculté de MédecineJ. Lisfranc Mines de Saint Etienne, INSERM U1059Saint-ÉtienneFrance
  3. 3.Orthopédie et traumatologie du sportcentre hospitalier universitaire Grenoble AlpesGrenoble cedexFrance
  4. 4.Service de Biostatistiques du CHRU de LilleLilleFrance
  5. 5.Université de Lille, Hauts de FranceLilleFrance
  6. 6.Service de chirurgie orthopédique et traumatologiquecentre hospitalier universitaire de StrasbourgStrasbourgFrance
  7. 7.Clinique de Saint OmerBlendecquesFrance
  8. 8.Service d’Orthopédiecentre hospitalier universitaire de LilleLilleFrance

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