Deformity correction with total knee arthroplasty for severe knee osteoarthritis accompanying extra-articular femoral deformity: the results are promising

  • B. Demir
  • B. Özkul
  • M. S. Saygılı
  • E. Çetinkaya
  • D. Akbulut



This study aimed to evaluate patients with severe degenerative osteoarthritis of the knee and extra-articular femoral deformities treated with total knee arthroplasty (TKA) and acute deformity correction.


Ten patients with severe degenerative osteoarthritis of the knee and extra-articular femoral deformities were included, and the median age was 63 years (range 38–67). The etiology was post-traumatic malunion in four patients, rickets sequelae in four patients, and surgical sequelae due to multiple epiphyseal dysplasia in two patients. The severity of degenerative osteoarthritis and deformity analyses were assessed according to the Kellgren–Lawrence and Paley criteria, respectively. The median number of previous operations the patients had undergone was two (range 0–3), and the median Oxford Knee Society score was 9 (range 5–13) before treatment. All patients were treated with primary TKA and deformity correction in the same surgery. The TKA was completed first, followed by an osteotomy at the apex of the deformity. Finally, a retrograde intramedullary nail was inserted.


The median follow-up period was 44 (31–60) months. A stable and functional knee joint, a physiological mechanical axis, and solid osseous union were achieved in all patients. Late prosthetic failure was seen in one patient due to deep infection. The median Oxford Knee Society score was 42 (range 37–47) at the final follow-up.


Combining several procedures in single setting for the treatment of severe knee osteoarthritis accompanied by extra-articular deformity may eliminate the need for multiple surgeries. Furthermore, a proper physiological mechanical axis can be obtained without causing substantial bone loss.

Level of evidence



Extra-articular deformity Knee arthroplasty Retrograde intramedullary nailing 



We thank Peter Mittwede, MD, Ph.D., from Edanz Group ( for editing a draft of this manuscript.


No external funds were received in support of this work. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

Institutional review board (IRB)/Ethics committee approval was obtained (ID number 15) on 9/20/2017 from the Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital (Istanbul, Turkey).

Informed consent

Patients were informed, and they consented to conduct the study.


  1. 1.
    Bargren JH, Blaha JD, Freeman MA (1983) Alignment in total knee arthroplasty. Correlated biomechanical and clinical observations. Clin Orthop Relat Res 173:178–183Google Scholar
  2. 2.
    Bathis H, Perlick L, Tingart M, Luring C, Zurakowski D, Grifka J (2004) Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with the conventional technique. J Bone Jt Surg Br 86:682–687CrossRefGoogle Scholar
  3. 3.
    Baumgart R (2009) The reverse planning method for lengthening of the lower limb using a straight intramedullary nail with or without deformity correction. A new method. Oper Orthop Traumatol 21:221–233CrossRefPubMedGoogle Scholar
  4. 4.
    Baylis WJ, Rzonca EC (1988) Functional and structural limb length discrepancies: evaluation and treatment. Clin Podiatr Med Surg 5:509–520PubMedGoogle Scholar
  5. 5.
    Brinkman JM, Hurschler C, Agneskirchner J, Lobenhoffer P, Castelein RM, van Heerwaarden RJ (2014) Biomechanical testing of distal femur osteotomy plate fixation techniques: the role of simulated physiological loading. J Exp Orthop 1:1. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Chen SH, Tai CL, Yu TC, Wang CW, Lin CW, Chen CY et al (2016) Modified fixations for distal femur fractures following total knee arthroplasty: a biomechanical and clinical relevance study. Knee Surg Sports Traumatol Arthrosc 24:3262–3271CrossRefPubMedGoogle Scholar
  7. 7.
    Dennis DA, Komistek RD, Kim RH, Sharma A (2010) Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res 468:102–107CrossRefPubMedGoogle Scholar
  8. 8.
    Dorr LD, Ranawat CS, Sculco TA, McKaskill B, Orisek BS (2006) Bone graft for tibial defects in total knee arthroplasty. Clin Orthop Relat Res 446:4–9CrossRefPubMedGoogle Scholar
  9. 9.
    El Ghazaly SA, El-Moatasem el HM (2015) Femoral supracondylar focal dome osteotomy with plate fixation for acute correction of frontal plane knee deformity. Strateg Trauma Limb Reconstr 10:41–47CrossRefGoogle Scholar
  10. 10.
    Ettinger M, Calliess T, Howell SM (2017) Does a positioning rod or a patient-specific guide result in more natural femoral flexion in the concept of kinematically aligned total knee arthroplasty? Arch Orthop Trauma Surg 137:105–110CrossRefPubMedGoogle Scholar
  11. 11.
    Frolke JP, Nulend JK, Semeins CM, Bakker FC, Patka P, Haarman HJ (2004) Viable osteoblastic potential of cortical reamings from intramedullary nailing. J Orthop Res 22:1271–1275CrossRefPubMedGoogle Scholar
  12. 12.
    Gandhi R, Tsvetkov D, Davey JR, Mahomed NN (2009) Survival and clinical function of cemented and uncemented prostheses in total knee replacement: a meta-analysis. J Bone Jt Surg Br 91:889–895CrossRefGoogle Scholar
  13. 13.
    Hasler CC, Krieg AH (2012) Current concepts of leg lengthening. J Child Orthop 6:89–104CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Hazratwala K, Matthews B, Wilkinson M, Barroso-Rosa S (2016) Total knee arthroplasty in patients with extra-articular deformity. Arthroplast Today 2:26–36CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Kendall JC, Bird AR, Azari MF (2014) Foot posture, leg length discrepancy and low back pain—their relationship and clinical management using foot orthoses—an overview. Foot (Edinb) 24:75–80CrossRefGoogle Scholar
  17. 17.
    Kessler O, Bull AM, Amis AA (2009) A method to quantify alteration of knee kinematics caused by changes of TKR positioning. J Biomech 42:665–670CrossRefPubMedGoogle Scholar
  18. 18.
    Krettek C, Miclau T, Grun O, Schandelmaier P, Tscherne H (1998) Intraoperative control of axes, rotation and length in femoral and tibial fractures. Technical note. Injury 29(Suppl 3):C29-39PubMedGoogle Scholar
  19. 19.
    Kucukkaya M, Sokucu S, Thaller PH (2015) Surgical techniques for lengthening and deformity correction of the femur with lengthening nails. Tech Orthop 30:183–188CrossRefGoogle Scholar
  20. 20.
    Kuo CC, Bosque J, Meehan JP, Jamali AA (2011) Computer-assisted navigation of total knee arthroplasty for osteoarthritis in a patient with severe posttraumatic femoral deformity. J Arthroplast 26:976 e917-920CrossRefGoogle Scholar
  21. 21.
    Laskin RS, Maruyama Y, Villaneuva M, Bourne R (2000) Deep-dish congruent tibial component use in total knee arthroplasty: a randomized prospective study. Clin Orthop Relat Res 380:36–44CrossRefGoogle Scholar
  22. 22.
    Lombardi AV, Berend KR, Adams JB (2010) Management of bone loss in revision TKA: it’s a changing world. Orthopedics 33:662PubMedGoogle Scholar
  23. 23.
    Lombardi AV Jr, Berend KR, Ng VY (2011) Neutral mechanical alignment: a requirement for successful TKA: affirms. Orthopedics 34:e504-506Google Scholar
  24. 24.
    Lonner JH, Siliski JM, Lotke PA (2000) Simultaneous femoral osteotomy and total knee arthroplasty for treatment of osteoarthritis associated with severe extra-articular deformity. J Bone Jt Surg Am 82:342–348CrossRefGoogle Scholar
  25. 25.
    Makarov MR, Samchukov ML, Birch JG, Johnston CE, Delgado MR, Rampy PL et al (2003) Acute deformity correction of lower extremities under SSEP-monitoring control. J Pediatr Orthop 23:470–477PubMedGoogle Scholar
  26. 26.
    Mullaji AB, Shetty GM (2013) Surgical technique: Computer-assisted sliding medial condylar osteotomy to achieve gap balance in varus knees during TKA. Clin Orthop Relat Res 471:1484–1491CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Nikolaides AP, Kenanidis EI, Papavasiliou KA, Sayegh FE, Tsitouridis I, Kapetanos GA (2014) Measured resection versus gap balancing technique for femoral rotational alignment: a prospective study. J Orthop Surg (Hong Kong) 22:158–162CrossRefGoogle Scholar
  28. 28.
    Oussedik S, Abdel MP, Cross MB, Haddad FS (2015) Alignment and fixation in total knee arthroplasty: changing paradigms. Bone Jt J 97-B:16–19CrossRefGoogle Scholar
  29. 29.
    Ozcan C, Sokucu S, Beng K, Cetinkaya E, Demir B, Kabukcuoglu YS (2016) Prospective comparative study of two methods for fixation after distal femur corrective osteotomy for valgus deformity; retrograde intramedullary nailing versus less invasive stabilization system plating. Int Orthop 40:2121–2126CrossRefPubMedGoogle Scholar
  30. 30.
    Paley D (2002) Principles of deformity correction. Springer, Berlin, Heidelberg, pp 1–30, 61–71, 102–109.
  31. 31.
    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 Jt Surg Am 92:2143–2149CrossRefGoogle Scholar
  32. 32.
    Rose HA, Hood RW, Otis JC, Ranawat CS, Insall JN (1982) Peroneal-nerve palsy following total knee arthroplasty. A review of The Hospital for Special Surgery experience. J Bone Jt Surg Am 64:347–351CrossRefGoogle Scholar
  33. 33.
    Rosenberger RE, Hoser C, Quirbach S, Attal R, Hennerbichler A, Fink C (2008) Improved accuracy of component alignment with the implementation of image-free navigation in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 16:249–257CrossRefPubMedGoogle Scholar
  34. 34.
    Sagi HC, Young ML, Gerstenfeld L, Einhorn TA, Tornetta P (2012) Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a reamer/irrigator/aspirator) and the iliac crest of the same patient. J Bone Jt Surg Am 94:2128–2135CrossRefGoogle Scholar
  35. 35.
    Saito S, Tokuhashi Y, Ishii T, Mori S, Hosaka K, Ishigami H (2010) Femoral corrective osteotomy for malunited supracondylar femoral fracture after TKA in a patient with rheumatoid arthritis. Orthopedics 33:922PubMedGoogle Scholar
  36. 36.
    Shi X, Li H, Zhou Z, Shen B, Yang J, Kang P et al (2017) Individual valgus correction angle improves accuracy of postoperative limb alignment restoration after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 25:277–283CrossRefPubMedGoogle Scholar
  37. 37.
    Sugita T, Aizawa T, Sasaki A, Miyatake N, Fujisawa H, Kamimura M (2015) Autologous morselised bone grafting for medial tibial defects in total knee arthroplasty. J Orthop Surg (Hong Kong) 23:185–189CrossRefGoogle Scholar
  38. 38.
    Thienpont E, Cornu O, Bellemans J, Victor J (2015) Current opinions about coronal plane alignment in total knee arthroplasty: a survey article. Acta Orthop Belg 81:471–477PubMedGoogle Scholar
  39. 39.
    Tirico LE, Demange MK, Bonadio MB, Helito CP, Gobbi RG, Pecora JR (2015) medial closing-wedge distal femoral osteotomy: fixation with proximal tibial locking plate. Arthrosc Tech 4:e687-695CrossRefGoogle Scholar
  40. 40.
    Veltman ES, van Wensen RJ, Defoort KC, van Hellemondt GG, Wymenga AB (2017) Single-stage total knee arthroplasty and osteotomy as treatment of secondary osteoarthritis with severe coronal deviation of joint surface due to extra-articular deformity. Knee Surg Sports Traumatol Arthrosc 25:2835–2840CrossRefPubMedGoogle Scholar
  41. 41.
    Wang JW, Hsu CC (2006) Distal femoral varus osteotomy for osteoarthritis of the knee. Surgical technique. J Bone Jt Surg Am 88(Suppl 1 Pt 1):100–108CrossRefGoogle Scholar
  42. 42.
    Wang JW, Wang CJ (2002) Total knee arthroplasty for arthritis of the knee with extra-articular deformity. J Bone Jt Surg Am 84-a:1769–1774CrossRefGoogle Scholar
  43. 43.
    Xiao-Gang Z, Shahzad K, Li C (2012) One-stage total knee arthroplasty for patients with osteoarthritis of the knee and extra-articular deformity. Int Orthop 36:2457–2463CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Yoo MJ, Yoo JS, Lee JY, Hwang CH (2013) Deformity correction by femoral supracondylar dome osteotomy with retrograde intramedullary nailing in varus deformity of the distal femur after pathologic fracture of giant cell tumor. Knee Surg Relat Res 25:220–224CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

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

Authors and Affiliations

  • B. Demir
    • 1
  • B. Özkul
    • 1
  • M. S. Saygılı
    • 1
  • E. Çetinkaya
    • 1
  • D. Akbulut
    • 1
  1. 1.Department of Orthopaedic Surgery and TraumatologyMetin Sabanci Baltalimani Kemik Hastaliklari Egitim ve Arastirma Hastanesi Ortopedi ve Travmatoloji KlinigiIstanbulTurkey

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