Total Knee Arthroplasty in Total Knee Arthroplasty in Valgus kneeValgus knee

H.Makhmalbaf MDH.Makhmalbaf MD

Consultant Knee surgeonConsultant Knee surgeon

Mashad UniversityMashad University

The Typical patientThe Typical patient

Sever valgus deformitySever valgus deformity

Elderly woman in7th or8th decadeElderly woman in7th or8th decade

Has had “knock knees” Has had “knock knees”

Also had patellofemoral problemsAlso had patellofemoral problems

Valgus deformity progressesValgus deformity progresses

Loss of lateral joint spaceLoss of lateral joint space

Attenuation of MCLAttenuation of MCL

The typical patientThe typical patient

PFJ involvement & patella dysplasia on PFJ involvement & patella dysplasia on X-RayX-Ray

Patella subluxation & concave patellaPatella subluxation & concave patella

Patella alta & a very thin patellaPatella alta & a very thin patella

Chondrocalcinosis & calcification of Chondrocalcinosis & calcification of meniscimenisci

Long leg film of tibia shows valgus bowLong leg film of tibia shows valgus bow

The typical patientThe typical patient

The valgus tibia is problematic if using The valgus tibia is problematic if using intramedullary guide intramedullary guide

The long leg film is necessary to templateThe long leg film is necessary to template

The diagnosis is usually OA or RAThe diagnosis is usually OA or RA

Hypermobile knee or hyperextentionHypermobile knee or hyperextention

In RA might have stiff knee & flexion cont.In RA might have stiff knee & flexion cont.

Clinical features of valgus vs varusClinical features of valgus vs varus

Valgus knees tolerate significant damageValgus knees tolerate significant damage

In windblown knees varus knee is more In windblown knees varus knee is more symptomaticsymptomatic

Varus knee should be operated on 1Varus knee should be operated on 1stst

Source of deformity is also differentSource of deformity is also different

Medial tibial plateau is deficient & tibial Medial tibial plateau is deficient & tibial joint line in sever varus in varus kneesjoint line in sever varus in varus knees

The femoral joint line is still in 5-7 valgusThe femoral joint line is still in 5-7 valgus

Valgus vs varus kneeValgus vs varus knee

In valgus knees, is from the femurIn valgus knees, is from the femur

The tibial joint line usually in neutralThe tibial joint line usually in neutral

The femoral joint line is in marked valgusThe femoral joint line is in marked valgus

Deformity due to hypoplasia of lat.femoral Deformity due to hypoplasia of lat.femoral condylecondyle

Both distally & posteriorlyBoth distally & posteriorly

The tibial defect in valgus is containedThe tibial defect in valgus is contained

Variants of valgusVariants of valgus

Based on degree of deformityBased on degree of deformity

Status of MCL, osseous deficiency &Status of MCL, osseous deficiency &

The amount of release must be performedThe amount of release must be performed

Variant I: mild & correctable deformityVariant I: mild & correctable deformity

Variant II: greater deformity ,intact soft Variant II: greater deformity ,intact soft tissuetissue

Variant III: stretched MCL, Marked bone Variant III: stretched MCL, Marked bone loss & deformity & lateral contractureloss & deformity & lateral contracture

Type of prosthesisType of prosthesis

In variant I: P CR or PS may be usedIn variant I: P CR or PS may be used

In variant II: may require a PS implantIn variant II: may require a PS implant

Invariant III: a PSC (constrained) should Invariant III: a PSC (constrained) should be usedbe used

Complete set of instruments if preferred Complete set of instruments if preferred

Lateral femoral condyle hypoplasiaLateral femoral condyle hypoplasia

Is present in sever valgus deformityIs present in sever valgus deformityExists both distally & posteriorlyExists both distally & posteriorlyIn distal femoral resection don’t cut to the In distal femoral resection don’t cut to the defectdefectThe deficiency must be augmentedThe deficiency must be augmentedIf not, causes large extension gapIf not, causes large extension gapAnd elevation of joint lineAnd elevation of joint lineAnd mid-flexion laxity, distorting kinematicAnd mid-flexion laxity, distorting kinematic

The angle of DF cutThe angle of DF cut

5 degree is preferred5 degree is preferred

7 degree cut is better for balance but?7 degree cut is better for balance but?

55oo or less to overcorrect the deformity or less to overcorrect the deformity

Less tension on MCL on WBLess tension on MCL on WB

But needs more lateral releaseBut needs more lateral release

Distal metaphyseal bow Distal metaphyseal bow

More medial point of entrance in the notch More medial point of entrance in the notch

Balancing the knee in flex.& Balancing the knee in flex.& extensionextension

Create symmetric flexion extension gapsCreate symmetric flexion extension gaps

Valgus knees could be balanced in flexion Valgus knees could be balanced in flexion & extension independently& extension independently

In flexion the tissues are not tightIn flexion the tissues are not tight

Nor the medial tissues are lax in flexionNor the medial tissues are lax in flexion

Draw Whiteside line & transepicondylar axDraw Whiteside line & transepicondylar ax

In sever valgus int rotation of femoral In sever valgus int rotation of femoral component is necessarycomponent is necessary

Flexion extension balanceFlexion extension balance

Lateral release, after bone cutsLateral release, after bone cuts

Put spacers, varus & valgus testsPut spacers, varus & valgus tests

Inverted cruciform releaseInverted cruciform release

LCL, poplliteal, & Biceps tendon releaseLCL, poplliteal, & Biceps tendon release

PS in sever valgus & CR in mild onePS in sever valgus & CR in mild one

Surgical approachSurgical approach

SummarySummary

Associated with PFJ diseaseAssociated with PFJ disease

Lat femoral condyle hypoplasiaLat femoral condyle hypoplasia

Medial laxity, a valgus tibial bowMedial laxity, a valgus tibial bow

Conservative bone cutsConservative bone cuts

Cruciform release of ITB & capsuleCruciform release of ITB & capsule

Protect peroneal nerveProtect peroneal nerve

PS or CR kneePS or CR knee

Thank youThank you