Efficacy and mid term results of lateral parapatellar approach without tibial tubercle osteotomy for primary total knee arthroplasty in fixed valgus knees

Robot-assisted surgery and knee arthroplasty in genu valgum: impact of the surgical approach

INTRODUCTION

The placement of a total knee arthroplasty (TKA) in cases of valgus can be performed through an anteromedial or anterolateral approach. The hypothesis of this study was that the anterolateral approach during robotic TKA reduced residual medial laxity of the knee. The main objective of this study was to evaluate the impact of the surgical approach on ligament balancing in robotic TKA for valgus knees ≤192 °, as evidenced by the residual laxity after final implant placement. The secondary objectives were to compare post-operative radiological parameters, the need for tibial tuberosity osteotomy, and complications between the two approaches.

MATERIALS AND METHODS

This was a single-center, multi-operator, comparative study based on a historical-prospective cohort. A total of 81 consecutive patients who underwent Mako® Stryker robotic TKA for valgus knee ≤192 ° were included. Two groups were formed based on the surgical approach: anteromedial (AM) or anterolateral (AL). To homogenize the groups, a 1:1 propensity score matching was performed based on age, gender, and deformity. Residual laxity, evaluated in millimeters, was measured at the end of the procedure with the definitive implants, using the Mako Total Knee SmartRobotics™ software measurements in four stress positions: extension (0-10 °) varus and valgus, then flexion (85-95 °) varus and valgus. Postoperatively, a radiological analysis of the coronal alignment of the TKA, patellar tilt and translation was performed, along with an analysis of complications.

RESULTS

After matching, 37 patients were included in each AL and AM group. The groups were comparable in terms of age, gender, coronal deformity, and ASA score; however, BMI was statistically higher in the AL group (29.0 versus 26.6; p = 0.002). Residual laxity in extension was not statistically different between AL versus AM groups, respectively in medial 1.6 mm versus 2.1 mm (p = 0.326) and in lateral 1.6 mm versus 1.6 mm (p = 0.384). Laxity asymmetry in extension was lower in the AL group versus AM group (0.05 mm versus 0.5 mm; p = 0.031). In flexion, there was no significant difference regarding residual laxity in medial (AL 1.5 mm versus AM 2.4 mm; p = 0.07) and in lateral (AL 2.9 mm versus AM 2.9 mm; p = 0.344). Laxity asymmetry in flexion was greater for the AL approach than for the AM approach (-1.4 mm versus -0.5 mm; p = 0.02). There was no difference regarding postoperative coronal alignment of the implants. Patellar tilt was greater with AM (1.7 ° versus -3.8 °; + in lateral tilt; p < 0.001). Patellar translation was not different between groups. At follow-up, there were 6 complications in the AM group and 4 in the AL group (p = 0.237). Anterior tibial tuberosity osteotomy was performed in 6 versus 1 case respectively for AL and AM (p = 0.107).

CONCLUSION

In comparing residual laxity in robotic TKA for valgus knees ≤192 °, the main finding was that the surgical approach does not significantly impact knee residual laxity. Despite small differences, the anterolateral approach yields a knee laxity profile close to the native knee, with better management of patellar tilt, without increasing the complication rate. Moreover, the Mako workflow does not dictate the choice of surgical approach, remaining equally feasible for both AM and AL approaches.

LEVEL OF EVIDENCE

IV.

Management of patella maltracking after total knee arthroplasty: a systematic review

PURPOSE

Patella maltracking is among the most frequent causes of poor outcomes and early failure after total knee arthroplasty (TKA), with an incidence that ranges from 1 to 20%. Even if there is agreement between authors regarding the preoperative and intraoperative management of patella maltracking in TKA, less clear are postoperative conducts. The purpose of this systematic review is to summarize and compare surgical techniques used to treat patella maltracking after TKA.

METHODS

A systematic review of the literature was performed with a primary search on Medline through PubMed. The PRISMA 2009 flowchart and checklist were used to edit the review. Screened studies had to provide clinical, functional and radiological results and complications of the proposed treatment to be included in the review.

RESULTS

A total of 21 articles were finally included. Three main types of surgical procedures and other minor techniques have been identified to manage patella maltracking after TKA. The choice of the proper technique to use in the specific case depends on several factors, first of all the malpositioning of the prosthetic components.

CONCLUSION

Patella maltracking after TKA represents a frequent and challenging problem for orthopedic surgeons. Treatments described in the literature are often able to correct an abnormal patellar tracking; nevertheless, authors report variable percentages of residual knee pain and dissatisfaction in re-treated patients. Therefore, it would be desirable to prevent the maltracking condition at the time of primary arthroplasty, using proper surgical precautions.

Minimum 2-Year Radiographic and Clinical Outcomes of Kinematic Alignment Total Knee Arthroplasty in the Valgus Knee

Kinematic alignment (KA) total knee arthroplasty (TKA) has gained popularity in the past decade, but outcomes of KA-TKA in the valgus knee have never been specifically evaluated. In this retrospective single institution study, we analyzed patient reported outcomes and radiographic measurements at minimum 2 years following KA-TKA for valgus knees (n = 51) and compared the results to KA-TKA performed for non-valgus knees (n = 275). The same approach, technique, and implants were used in both groups without the need to release soft tissues or use constrained implants. Surgery duration was similar between groups (p = 0.353). Lateral distal femoral angle was lower in the valgus group postoperatively (p = 0.036). In both groups significant improvement was seen in relieving pain and improving function, while average scores were superior in the non-valgus group for visual analog score (p = 0.005), oxford knee score (p = 0.013), and knee injury and osteoarthritis outcome score (p = 0.009). However, these differences did not translate to statistically significant differences in minimal clinical important difference achievement rates. In conclusion, KA-TKA is efficient in relieving pain and improving function, as reported in subjective questionnaires, and holds advantage in patients with valgus alignment by avoiding soft tissue releases and use of constrained implants. Future studies should examine whether bone loss occurs in the lateral distal femur.

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression

BACKGROUND

Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA.

METHODS

The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression.

RESULTS

In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively.

CONCLUSION

Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021?

Total knee arthroplasty in valgus knee deformities continues to be a challenge for a surgeon. Approximately 10% of patients who undergo total knee arthroplasty have a valgus deformity. While performing total knee arthroplasty in a severe valgus knee, one should aware with the technical aspects of surgical exposure, bone cuts of the distal femur and proximal tibia, medial and lateral ligament balancing, flexion and extension gap balancing, creating an appropriate tibiofemoral joint line, balancing the patellofemoral joint, preserving peroneal nerve function, and selection of the implant regarding constraint. Restoration of neutral mechanical axis and correct ligament balance are important factors for stability and longevity of the prosthesis and for good functional outcome. Thus, our review aims to provide step by step comprehensive knowledge about different surgical techniques for the correction of severe valgus deformity in total knee arthroplasty.

Incidence of Soft-Tissue Releases, Clinical and Radiological Outcomes of Lateral Parapatellar Approach for Valgus Arthritic Knees: A 4-year Follow-up Study with A Review of Literature

PURPOSE

To analyse the incidence of additional soft tissue releases with the lateral parapatellar approach, and the clinical and radiological outcomes of total knee arthroplasties performed using the lateral parapatellar approach for valgus arthritic knees. A review of the existing literature on valgus arthritic knees undergoing knee replacement was performed and our results compared.

MATERIALS AND METHODS

This is a prospective cohort study of 50 patients operated by this approach. Operation and clinical records were assessed to determine the number and sequence of soft tissue releases. Functional outcome was measured using the Oxford Knee Score. Radiological assessment included measurement of alignment and implant positioning.

RESULTS

46 patients included. Mean follow-up of 4 years. Additional lateral releases were performed in 11 (24%) cases. Mean valgus alignment corrected from 13.1 degrees pre-operatively to 5.7 degrees post-operatively. Oxford Knee Score improved from a mean pre-operative score of 11.9 to a mean post-operative score of 38.3 at final follow-up. Radiographs revealed lateralisation of the tibial component in 4 patients. No immediate or late post-operative wound complications, late instabilities or revisions were observed.

CONCLUSION

Lateral parapatellar approach is highly effective in correcting the valgus deformity with a low incidence of additional soft tissue releases. Medium-term results indicate an excellent functional outcome with no complications.

Total Knee Arthroplasty for Valgus Deformity via a Lateral Approach: Clinical Results, Comparison to Medial Approach, and Review of Recent Literature

BACKGROUND

Total knee arthroplasty (TKA) for valgus deformity is a challenge. The standard medial parapatellar approach may not be universally useful for this. We have adopted the lateral approach to valgus knees. Here we describe our experience with this approach, present early results, and compare them to the medial approach.

METHODS

Our institutional registry was queried for all patients with valgus deformity who underwent a TKA via a lateral approach between 2013 and 2016. The registry was also queried for patients with valgus deformity who underwent a TKA through a medial approach in previous years and this data was compared to the study group.

RESULTS

Seventy-nine valgus knees in 72 patients were operated through a lateral approach. Deformity was corrected by 10.8°, from 16.2° to 5.4° (P < .001). Patellar tilt improved from -2.3° to 0.3° (P = .037). Seven implants (9%) were constrained. Mean operating time was 87 minutes (range 53-137). Twenty-five knees in 23 patients were operated via the medial approach. Deformity was corrected by 7.3°, from 13.2° to 5.9° (P < .001). Mean operating time was 137 minutes (range 90-230). Constrained implants were used in 16% of cases. The lateral approach allowed better correction of valgus deformity (10.8 vs 7.3, P = .03) and shorter operative times (87 vs 137 minutes, P < .001).

CONCLUSION

A lateral approach TKA for valgus deformity improves knee alignment and patellar tilt. Compared to the medial approach, it allows better correction of the deformity, shorter operating times, and perhaps less use of constrained implants.

Lateral or medial approach for valgus knee in total knee arthroplasty - which one is better? A systematic review

Objective

To identify whether the medial or lateral approach is superior for patients with valgus knees undergoing primary total knee arthroplasty (TKA).

Methods

Studies evaluating the 2 approaches were sourced from the PUBMED, EMBASE, Web of Science, and OVID databases. The quality of included studies was assessed using a modified quality evaluation method, and differences between approaches were systematically reviewed.

Results

Seventeen observational studies were included. The studies were published between 1991 and 2016, and included 5 retrospective studies and 12 prospective studies. Sixteen evaluation methods for the study outcomes were identified. Twelve and eight complication types were identified by studies reporting the lateral and medial approaches for valgus knee, respectively. Several studies showed that pain scores and knee function were superior using a lateral approach.

Conclusion

The lateral approach (combined with a tibial tubercle osteotomy or proximal quadriceps snip) was more useful and safer than the medial approach in the treatment of severe uncorrectable valgus knee deformity in patients undergoing TKA. Most of the available evidence supports the use of a lateral approach provided that the surgeon is familiar with the pathological anatomy of the valgus knee.

Medial femoral epicondyle upsliding osteotomy with posterior stabilized arthroplasty provided good clinical outcomes such as constrained arthroplasty in primary total knee arthroplasty with severe valgus deformity

PURPOSE

A modified technique referred to as a medial femoral epicondyle upsliding osteotomy was proposed to address severe valgus deformity with unconstrained posterior stabilized (PS) arthroplasty. The study compared the effectiveness of the technique and PS arthroplasty with constrained arthroplasty during primary total knee arthroplasty (TKA).

METHODS

Fifty-three patients presenting with valgus knees with a mean valgus angle (VA) greater than 30° were prospectively randomized and divided into two groups, and both groups received primary TKA. Upsliding osteotomy with PS arthroplasty was performed on the knees of 27 patients (group A), while the remaining 26 patients (group B) received a constrained arthroplasty. The Knee Society function score (KSF), Hospital for Special Surgery knee score (HSS), range of motion (ROM), mediolateral stability and hospitalization expenses were recorded. The hip-knee-ankle angle (HKA), femorotibial angle (FTA) and VA were analysed. Complications were also recorded.

RESULTS

The patients received follow-up care for more than 50 months. The postoperative KSF, HSS and ROM showed marked improvement in both groups (p < 0.05). Radiological assessments showed that HKA, FTA and VA for group A were restored to (179.9 ± 3.0)°, (173.0 ± 2.4)° and (7.0 ± 2.4)°, respectively. For group B, the HKA, FTA and VA were restored to (181.5 ± 2.3)°, (172.5 ± 2.3)° and (7.5 ± 2.3)°, respectively. Only two patients from group A demonstrated mild medial laxity in their knees, and the remaining patients from both groups were stable medially and laterally. However, the total hospitalization expenses and material expenses of group A were less than those of group B because of the more expensive constrained prosthesis and stems. No late-onset loosening or recurrent valgus deformity was displayed.

CONCLUSIONS

Both medial femoral epicondyle upsliding osteotomy with PS arthroplasty and constrained arthroplasty showed good outcomes for the restoration of neutral limb alignment and soft tissue balance, which are demonstrated to be safe and effective techniques for correcting severely valgus knees. Therefore, the clinically important finding of this study is that medial femoral epicondyle upsliding osteotomy with PS arthroplasty can be an alternative method for correcting severe valgus knees.

LEVEL OF EVIDENCE

II.

Correcting severe valgus deformity: taking out the knock

Valgus knee deformity can present a number of unique surgical challenges for the total knee arthroplasty (TKA) surgeon. Understanding the typical patterns of bone and soft-tissue pathology in the valgus arthritic knee is critical for appropriate surgical planning. This review aims to provide the knee arthroplasty surgeon with an understanding of surgical management strategies for the treatment of valgus knee arthritis. Lateral femoral and tibial deficiencies, contracted lateral soft tissues, attenuated medial soft tissues, and multiplanar deformities may all be present in the valgus arthritic knee. A number of classifications have been reported in order to guide surgical management, and a variety of surgical strategies have been described with satisfactory clinical results. Depending on the severity of the deformity, a variety of TKA implant designs may be appropriate for use. Regardless of an operating surgeon's preferred surgical strategy, adherence to a step-wise approach to deformity correction is advised. Cite this article: Bone Joint J 2017;99-B(1 Supple A):60-4.

Keblish's lateral surgical approach enhances patellar tilt in valgus knee arthroplasty

Objective

To compare the clinical and radiological outcomes of conventional medial and lateral approaches for total knee replacement in the valgus osteoarthritic knee.

Methods

In this randomized controlled trial, 21 patients with valgus knee osteoarthritis were randomized to total knee replacement through medial or lateral approach. The primary outcome was radiographic patellar tilt. Secondary outcomes were visual analog scale of pain, postoperative levels of hemoglobin, and clinical aspect of the operative wound.

Results

There were no differences between the groups regarding other clinical variables. Mean lateral tilt of the patella was 3.1 degrees (SD ± 5.3) in the lateral approach group and 18 degrees (SD ± 10.2) in the medial approach group (p = 0.02). There were no differences regarding the secondary outcomes.

Conclusion

Lateral approach provided better patellar tilt following total knee replacement in valgus osteoarthritic knee.

Total knee arthroplasty in valgus knees using minimally invasive medial-subvastus approach

BACKGROUND

An ideal approach for valgus knees must provide adequate exposure with minimal complications due to approach per se. Median parapatellar approach is most commonly used approach in TKA including valgus knees. A medial subvastus approach is seldom used for valgus knees and has definite advantages of maintaining extensor mechanism integrity and minimal effect on patellar tracking. The present study was conducted to evaluate outcomes of total knee arthroplasty (TKA) and efficacy of subvastus approach in valgus knees in terms of early functional recovery, limb alignment and complications.

MATERIALS AND METHODS

We retrospectively reviewed 112 knees with valgus deformity between January 2006 and December 2011. All patients were assessed postoperatively for pain using Visual Analog Scale (VAS) and quadriceps recovery in form of time to active straight leg raising (SLR) and staircase competency and clinical outcomes using American Knee Society (AKS) score and radiographic evaluation with average followup of 40 months (range 24-84 months).

RESULTS

The mean VAS on postoperative day (POD) 1 and POD2 at rest was 2.73 and 2.39, respectively and after mobilization was 3.28 and 3.08, respectively (P < 0.001). The quadriceps recovery was very early and 92 (86.7%) patients were able to do active SLR by POD1 with mean time of 21.98 h while reciprocal gait and staircase competency was possible at 43.05 h. The AKS and function score showed significant improvement from preoperative mean score of 39 and 36 to 91 and 79 (P < 0.001), respectively, and the mean range of motion increased from 102° preoperatively to 119° at recent followup (P < 0.001). The mean tibiofemoral valgus was corrected from preoperative 16° (range 10°-35°) to 5° (range 3°-9°) valgus (P < 0.001).

CONCLUSIONS

Mini-subvastus quadriceps approach provides adequate exposure and excellent early recovery for TKA in valgus knees, without increase in incidence of complications.

Current surgical strategies for total arthroplasty in valgus knee

The majority of orthopaedic surgeons even currently agree that primary total arthroplasty in valgus knees with a deformity of more than ten degrees may prove challenging. The unique sets of bone and soft tissue abnormalities that must be addressed at the time of the operation make accurate axis restoration, component orientation and joint stability attainment a difficult task. Understanding the specific pathologic anatomic changes associated with the valgus knee is a prerequisite so as to select the proper surgical method, to optimize component position and restore soft-tissue balance. The purpose of this article is to review the valgus knee anatomical variations, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. It will also be underlying the up-to-date main approaches and surgical techniques be proposed in the English literature both for bone cuts and soft tissue management of valgus knees.

Equivalent results of medial and lateral parapatellar approach for total knee arthroplasty in mild valgus deformities

PURPOSE

When performing total knee arthroplasty (TKA) in valgus knee deformities, a medial or lateral parapatellar approach can be performed, but the lateral approach is often considered technically more difficult. The purpose of this study was to compare intra-operative, early clinical and radiological outcomes of medial and lateral parapatellar approaches for TKA in the setting of moderate knee valgus (<10°).

METHODS

We prospectively analysed 424 knees with pre-operative valgus deformity between 3° and 10° that underwent TKA over an 18-year period; 109 were treated with a medial approach and 315 with a lateral approach. Intra- and post-operative outcomes and complication rates after a minimum follow-up of one year were compared.

RESULTS

Tourniquet (p = 0.25) and surgical (p = 0.62) time were similar between groups. The popliteus tendon was released more frequently in the medial-approach group (p = 0.04), while the iliotibial band was released more frequently in the lateral-approach group (p < 0.001). A tibial tuberosity osteotomy was performed more frequently in the lateral- than medial-approach group (p = 0.003). No significant differences in limb alignment (p = 0.78), or Knee Society Score (KSS) knee (p = 0.32) and function (p = 0.47) results were noted based on surgical approach, and complication rates were similar between groups (p = 0.53).

CONCLUSIONS

Lateral parapatellar approach is a safe and effective surgical technique for performing TKA in moderately valgus knees. These equivalent early results are encouraging for systematic use of the lateral approach in moderately valgus knees.

Lateral Parapatellar Approach Without Tibial Tubercle Osteotomy for Fixed Valgus Deformity Correction in Total Knee Arthroplasty

Introduction

The lateral parapatellar approach provides direct access to the pathological area in a valgus knee deformity and allows sequential titrated release of contracted lateral soft tissues during total knee arthroplasty.

Step 1 Preoperative Planning

Differentiate the flexible and fixed components of the valgus deformity by clinical and radiographic examination.

Step 2 Expansile Lateral Arthrotomy

Open the knee joint from the lateral side by coronal z-plasty of the lateral retinaculum, oblique lateral tenotomy of the quadriceps tendon, and iliotibial band release.

Step 3 Quadriceps Snip and Joint Exposure

Perform a quadriceps snip and expose the knee joint.

Step 4 Tibial and Distal Femoral Cuts

Make proximal tibial and distal femoral cuts in appropriate alignment.

Step 5 Extension Gap Balancing

A rectangular extension gap is the goal.

Step 6 Flexion Gap Balancing

Determine the femoral component size and femoral rotation, and balance the flexion gap.

Step 7 Component Fixation

Confirm tibial rotational alignment, fix the components, and assess patellar tracking.

Step 8 Prosthetic Joint Closure

Perform closure of the prosthetic joint with expanded lateral structures.

Results

Between 2003 and 2009, thirty-two knees with clinical valgus deformity of >10° underwent total knee arthroplasty with an expansile lateral arthrotomy technique¹¹.IndicationsContraindicationsPitfalls & Challenges.