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Slight under-correction following total knee arthroplasty for a valgus knee results in similar clinical outcomes

  • Knee Arthroplasty
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Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Background

Restoration of correct coronal alignment is one of the main goals of total knee arthroplasty (TKA). Traditionally, TKA has been considered successful when a neutral mechanical hip–knee–ankle (HKA) axis within 3° is achieved. Recent studies have reported no differences or improved clinical outcomes following a slight under-correction of the HKA axis for a varus knee. However, the influence of under-correction of a valgus knee has not been reported. This study investigated the influence of post-operative HKA alignment in TKA patients with valgus deformity on clinical outcomes.

Methods

Ninety-three knees (93 patients) with pre-operative valgus alignment were evaluated with a mean follow-up period of 60 months. All patients were classified into three groups based on post-operative HKA alignment: neutral (0 ± 3°), mild valgus (3°–6°), and severe valgus (> 6°). These groups were compared using the Western Ontario and McMaster Universities osteoarthritis (WOMAC) index, the Knee Society (KS) knee score, KS function score, α-angle, β-angle, patella tilt angle, and the congruence angle.

Results

Sixty-nine knees were included in the neutral group, seventeen knees in the mild valgus group, and seven knees in the severe valgus group. In all cases, post-operative clinical and functional scores significantly improved compared to pre-operative scores. There were no differences between the three groups in post-operative clinical and functional scores. More post-operative patellar tilt angle outliers (> 10°) and congruence angle outliers (> 16°) were apparent in the severe valgus group (patellar tilt angle, 13 vs. 17 vs. 57.1%, p = 0.022; congruence angle, 32 vs. 47 vs. 71%, p = 0.035).

Conclusions

Slight under-correction following TKA for a valgus knee resulted in similar clinical outcomes. A residual valgus angle of more than 6° can induce patellar maltracking.

Level of evidence

III, Retrospective comparative study.

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References

  1. Ritter MA, Faris PM, Keating EM, Meding JB (1994) Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 299:153–156

    Google Scholar 

  2. Longstaff LM, Sloan K, Stamp N, Scaddan M, Beaver R (2009) Good alignment after total knee arthroplasty leads to faster rehabilitation and better function. J Arthroplast 24(4):570–578. https://doi.org/10.1016/j.arth.2008.03.002

    Article  Google Scholar 

  3. Fang DM, Ritter MA, Davis KE (2009) Coronal alignment in total knee arthroplasty: just how important is it? J Arthroplast 24(6 Suppl):39–43. https://doi.org/10.1016/j.arth.2009.04.034

    Article  Google Scholar 

  4. Morgan SS, Bonshahi A, Pradhan N, Gregory A, Gambhir A, Porter ML (2008) The influence of postoperative coronal alignment on revision surgery in total knee arthroplasty. Int Orthop 32(5):639–642. https://doi.org/10.1007/s00264-007-0391-0

    Article  PubMed  Google Scholar 

  5. Choong PF, Dowsey MM, Stoney JD (2009) Does accurate anatomical alignment result in better function and quality of life? Comparing conventional and computer-assisted total knee arthroplasty. J Arthroplast 24(4):560–569. https://doi.org/10.1016/j.arth.2008.02.018

    Article  Google Scholar 

  6. Slevin O, Hirschmann A, Schiapparelli FF, Amsler F, Huegli RW, Hirschmann MT (2017) 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 Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-017-4744-y

    Article  PubMed  Google Scholar 

  7. Rames RD, Mathison M, Meyer Z, Barrack RL, Nam D (2017) No impact of under-correction and joint line obliquity on clinical outcomes of total knee arthroplasty for the varus knee. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-017-4507-9

    Article  PubMed  Google Scholar 

  8. Vanlommel L, Vanlommel J, Claes S, Bellemans J (2013) Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 21(10):2325–2330. https://doi.org/10.1007/s00167-013-2481-4

    Article  PubMed  Google Scholar 

  9. Howell SM, Papadopoulos S, Kuznik KT, Hull ML (2013) Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc 21(10):2271–2280. https://doi.org/10.1007/s00167-013-2621-x

    Article  PubMed  Google Scholar 

  10. Howell SM, Howell SJ, Kuznik KT, Cohen J, Hull ML (2013) Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res 471(3):1000–1007. https://doi.org/10.1007/s11999-012-2613-z

    Article  PubMed  Google Scholar 

  11. Matziolis G, Adam J, Perka C (2010) Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement. Arch Orthop Trauma Surg 130(12):1487–1491. https://doi.org/10.1007/s00402-010-1064-9

    Article  PubMed  Google Scholar 

  12. Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S (2005) Total knee arthroplasty for severe valgus deformity. J Bone Jt Surg Am 87(Suppl 1 Pt 2):271–284. https://doi.org/10.2106/JBJS.E.00308

    Article  Google Scholar 

  13. Rossi R, Rosso F, Cottino U, Dettoni F, Bonasia DE, Bruzzone M (2014) Total knee arthroplasty in the valgus knee. Int Orthop 38(2):273–283. https://doi.org/10.1007/s00264-013-2227-4

    Article  PubMed  Google Scholar 

  14. Bruzzone M, Ranawat A, Castoldi F, Dettoni F, Rossi P, Rossi R (2010) The risk of direct peroneal nerve injury using the Ranawat “inside-out” lateral release technique in valgus total knee arthroplasty. J Arthroplast 25(1):161–165. https://doi.org/10.1016/j.arth.2008.08.016

    Article  Google Scholar 

  15. Mizuno Y, Kumagai M, Mattessich SM, Elias JJ, Ramrattan N, Cosgarea AJ, Chao EY (2001) Q-angle influences tibiofemoral and patellofemoral kinematics. J Orthop Res 19(5):834–840. https://doi.org/10.1016/S0736-0266(01)00008-0

    Article  PubMed  CAS  Google Scholar 

  16. Boettner F, Renner L, Arana Narbarte D, Egidy C, Faschingbauer M (2016) Total knee arthroplasty for valgus osteoarthritis: the results of a standardized soft-tissue release technique. Knee Surg Sports Traumatol Arthrosc 24(8):2525–2531. https://doi.org/10.1007/s00167-016-4054-9

    Article  PubMed  Google Scholar 

  17. Zhou K, Zhou Z, Shi X, Shen B, Kang P, Yang J, Pei F (2018) Effect of individual distal femoral valgus resection in total knee arthroplasty for patients with valgus knee: a retrospective cohort study. Int J Surg 52:309–313. https://doi.org/10.1016/j.ijsu.2018.02.048

    Article  PubMed  Google Scholar 

  18. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15(12):1833–1840

    PubMed  CAS  Google Scholar 

  19. Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res (248):13–14

  20. Malghem J, Maldague B (1989) Patellofemoral joint: 30 degrees axial radiograph with lateral rotation of the leg. Radiology 170(2):566–567. https://doi.org/10.1148/radiology.170.2.2911687

    Article  PubMed  CAS  Google Scholar 

  21. Cooke TD, Sled EA, Scudamore RA (2007) Frontal plane knee alignment: a call for standardized measurement. J Rheumatol 34(9):1796–1801

    PubMed  Google Scholar 

  22. Kilincoglu V, Unay K, Akan K, Esenkaya I, Poyanli O (2011) Component alignment in simultaneous bilateral or unilateral total knee arthroplasty. Int Orthop 35(1):43–46. https://doi.org/10.1007/s00264-010-0993-9

    Article  PubMed  Google Scholar 

  23. Bae DK, Baek JH, Yoon KT, Son HS, Song SJ (2016) Comparison of patellofemoral outcomes after TKA using two prostheses with different patellofemoral design features. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-016-4264-1

    Article  PubMed  Google Scholar 

  24. Merchant AC, Mercer RL, Jacobsen RH, Cool CR (1974) Roentgenographic analysis of patellofemoral congruence. J Bone Jt Surg Am 56(7):1391–1396

    Article  CAS  Google Scholar 

  25. Moon YW, Seo JG, Yang JH, Shon MS (2008) Analysis of the patellofemoral congruence angle according to the rotational alignment of the femoral component in navigation-guided TKA. Orthopedics 31(10 Suppl 1):62–67

    Google Scholar 

  26. Lee WC, Kwan YH, Chong HC, Yeo SJ (2017) The minimal clinically important difference for knee society clinical rating system after total knee arthroplasty for primary osteoarthritis. Knee Surg Sports Traumatol Arthrosc 25(11):3354–3359. https://doi.org/10.1007/s00167-016-4208-9

    Article  PubMed  Google Scholar 

  27. Karachalios T, Sarangi PP, Newman JH (1994) Severe varus and valgus deformities treated by total knee arthroplasty. J Bone Jt Surg Br 76(6):938–942

    Article  CAS  Google Scholar 

  28. Huang TW, Lee CY, Lin SJ, Lee MS, Hsu RW, Shen WJ (2015) The influence of alignment on midterm outcome after total knee arthroplasty in patients with marked coronal femoral bowing. J Arthroplast 30(9):1531–1536. https://doi.org/10.1016/j.arth.2015.03.027

    Article  Google Scholar 

  29. Waterson HB, Clement ND, Eyres KS, Mandalia VI, Toms AD (2016) The early outcome of kinematic versus mechanical alignment in total knee arthroplasty: a prospective randomised control trial. Bone Jt J 98-B(10):1360–1368. https://doi.org/10.1302/0301-620X.98B10.36862

    Article  CAS  Google Scholar 

  30. Yoon JR, Han SB, Jee MK, Shin YS (2017) Comparison of kinematic and mechanical alignment techniques in primary total knee arthroplasty: a meta-analysis. Medicine (Baltimore) 96(39):e8157. https://doi.org/10.1097/MD.0000000000008157

    Article  Google Scholar 

  31. Keshmiri A, Dotzauer F, Baier C, Maderbacher G, Grifka J, Sendtner E (2017) Stability of capsule closure and postoperative anterior knee pain after medial parapatellar approach in TKA. Arch Orthop Trauma Surg 137(7):1019–1024. https://doi.org/10.1007/s00402-017-2706-y

    Article  PubMed  Google Scholar 

  32. Cerciello S, Robin J, Lustig S, Maccauro G, Heyse TJ, Neyret P (2016) The role of patelloplasty in total knee arthroplasty. Arch Orthop Trauma Surg 136(11):1607–1613. https://doi.org/10.1007/s00402-016-2577-7

    Article  PubMed  Google Scholar 

  33. Popovic N, Lemaire R (2003) Anterior knee pain with a posterior-stabilized mobile-bearing knee prosthesis: the effect of femoral component design. J Arthroplast 18(4):396–400

    Article  CAS  Google Scholar 

  34. Ittenbach RF, Huang G, Barber Foss KD, Hewett TE, Myer GD (2016) Reliability and validity of the anterior knee pain scale: applications for use as an epidemiologic screener. PloS One 11(7):e0159204. https://doi.org/10.1371/journal.pone.0159204

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  35. Feller JA, Bartlett RJ, Lang DM (1996) Patellar resurfacing versus retention in total knee arthroplasty. J Bone Jt Surg Br 78(2):226–228

    Article  CAS  Google Scholar 

  36. Malo M, Vince KG (2003) The unstable patella after total knee arthroplasty: etiology, prevention, and management. J Am Acad Orthop Surg 11(5):364–371

    Article  PubMed  Google Scholar 

  37. Slevin O, Schmid FA, Schiapparelli FF, Rasch H, Amsler F, Hirschmann MT (2017) Coronal femoral TKA position significantly influences in vivo patellar loading in unresurfaced patellae after primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-017-4627-2

    Article  PubMed  Google Scholar 

  38. 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 Jt Surg Am 93(17):1588–1596. https://doi.org/10.2106/JBJS.J.00772

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon street, Gangnam-Gu, Seoul, 06351, South Korea

    Sung-Sahn Lee, Hyeon Lee, Dae-Hee Lee & Young-Wan Moon

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  1. Sung-Sahn Lee
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Correspondence to Young-Wan Moon.

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Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. The protocol used to evaluate radiographic findings and intraoperative navigation data was approved by our institution’s investigational review board (SMC2017-06-008).

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Informed consent was obtained from all individual participants included in the study.

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Lee, SS., Lee, H., Lee, DH. et al. Slight under-correction following total knee arthroplasty for a valgus knee results in similar clinical outcomes. Arch Orthop Trauma Surg 138, 1011–1019 (2018). https://doi.org/10.1007/s00402-018-2957-2

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