Total knee arthroplasty in patients with pre-existing fracture deformity

Total Knee Arthroplasty in the Post-Traumatic Knee: Revision Risks and Functional Outcomes Compared to Osteoarthritic Knees. A Report of Primary Procedures From the Dutch Arthroplasty Register

BACKGROUND

Total knee arthroplasty (TKA) for post-traumatic arthritis (PTA) poses higher challenges and increased risks of complications compared to TKA for osteoarthritis (OA). This study aimed to compare implant survivorships, reasons for revision, and patient-reported outcome measures between OA and PTA as indications for TKA.

METHODS

We selected all primary TKAs for PTA or OA between 2007 and 2020 from the Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies). The study included 3,897 TKA procedures for PTA (median follow-up 4.6 years; interquartile range: 2.2, 7.3) and 255,259 procedures for OA (median follow-up 4.7 years; interquartile range 2.2, 7.6). A total of 10,480 revision procedures were performed across both groups (238 in PTA knees; 10,242 in OA knees). We analyzed the prevalence of preoperative comorbidities and postoperative complications, as well as the reasons for revision, and calculated the implant survival rates.

RESULTS

The survival revision rate in the OA group was significantly lower at both follow-up moments (5- and 10- years). The likelihood for revision was increased in TKA for PTA compared to TKA for OA (hazards ratio: 1.16 [95% confidence interval 1.02 to 1.33], P = .03). The most common reason for a revision was instability and arthrofibrosis in the PTA group compared to patellar pain for the OA group.

CONCLUSION

This study demonstrated an increased risk for revision for any reason in TKA for PTA compared to OA. Revision for instability and arthrofibrosis were more prevalent in the PTA group, while revision for patellar pain was less prevalent compared to TKA for OA.

Total knee arthroplasty for severe valgus deformity of the knee with extra-articular deformities of the femur and tibia using a 3-dimensional image matching software system

INTRODUCTION AND IMPORTANCE

Knee osteoarthritis with femoral and/or tibial extra-articular deformities makes total knee arthroplasty (TKA) technically difficult to perform, especially using intramedullary-based instrumentation systems. The Athena Knee 3-dimensional (3-D) image matching software is effective for TKA with an extra-articular deformity, especially in case of using a long-stem prosthesis or not available computer-assisted navigation systems.

CASE PRESENTATION

A 79-year-old woman presented with right knee pain secondary to a progressive valgus deformity and gait disturbance. She had experienced a supracondylar femoral fracture fifteen years ago, and a tibial shaft fracture ten years ago on the same side; both of fractures were treated surgically. She had a severe valgus knee deformity and extra-articular deformity of femur and tibia, and valgus stress test detected medial knee instability. The range of motion was 0° in extension and 75° in flexion. Severe medial knee laxity compelled us to use a constrained and long-stem prosthesis, resulting in the use of an intramedullary guided system. The 3-D software system helped us to determine the amount of bone to cut as well as the appropriate entry points for the intramedullary rods and mechanical axis restoration. At two years after surgery, knee range of motion improved to 90° in flexion, and walking ability had also advanced from the use of two crutches to that of a T cane.

CONCLUSION

The 3-D image matching software system for preoperative planning was useful for TKA with extra-articular deformity, especially in the case of a long-stem prosthesis without using a navigation system.

Congenital Fibular Deficiency: Total Knee Arthroplasty with Extraarticular Deformity: A Case Report

CASE

A total knee arthroplasty (TKA) was performed on a 35-year-old man with congenital fibular deficiency and a 20° varus and 28° antecurvatum tibial deformity of the left lower limb.

CONCLUSION

One-stage TKA and correction of the extraarticular deformity by means of intraarticular bone resections and a standard soft tissue release were performed to restore the limb's mechanical axis. Patients with congenital fibular deficiency present a wide range of limb deformities because of bone deficiencies or treatment sequels, which might require a specific surgical technique and small-sized implants to obtain good results during a TKA.

The outcomes of post-traumatic arthritis vs osteoarthritis following primary total knee arthroplasty: A protocol of matched cohort study

BACKGROUND

Total knee arthroplasty (TKA) for treatment of end-stage post-traumatic arthritis (PTA) has specific technical difficulties and complications. The aim of this study was to examine the outcome of TKA after PTA and to compare it with a cohort osteoarthritis (OA).

METHODS

A retrospective review of patients undergoing primary TKA at a single university hospital from 2013 to 2016 was performed. A minimum follow-up of 4 years was required. Patients in the study group were matched 1:2 with patients in the cohort group based on the following criteria: age at time of TKA (±3 years), body mass index (±3 points), sex, and American Society of Anesthesiologists score (±1 point). Outcome measures included surgical time, intraoperative complications, Oxford Knee Score, range of motion, postoperative complications, and revision.

RESULTS

This clinical trial is expected to determine whether PTA is associated with increased risks of complications and revision or reduced functional outcomes following TKA.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5455).

Lingering risk: A meta-analysis of outcomes following primary total knee arthroplasty for patients with post-traumatic arthritis

BACKGROUND

Currently, no meta-analysis exists to elucidate the outcomes of primary total knee arthroplasty (TKA) in patients with post-traumatic arthritis (PTA). The primary aim of this meta-analysis was to compare revision and complication rates for patients with PTA versus osteoarthritis (OA).

METHODS

The following databases were used for searching existing literature (from their inception to October 2019): PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science. The primary outcomes were the incidences of revision and complications, Secondary outcomes included operative time and patient-reported outcomes (PRO) scores.

RESULTS

Nine studies with a total of 6,783,990 patients were included. This study found that there was a statistically significant difference in the rates of superficial wound infection, periprosthetic infection, stiffness, wound complications, and revision, with these outcomes occurring more frequently in patients with PTA. However, PTA did not increase the risks for periprosthetic fracture, aseptic loosening or instability, and VTE. Moreover, PTA was associated with increased operative time, worse postoperative PRO scores, and similar changes in PRO scores.

CONCLUSIONS

This meta-analysis highlight the complexity of PTA and demonstrates increased risks of infection, wound complications, stiffness, and revision. Surgeons can use this information to help aid in counseling patients preoperatively.

Revision strategy for malunited tibial plateau fracture caused by failure of initial treatment

Objective

The aim of this study was to evaluate our treatment algorithm and results in revision surgery of malunited tibial plateau fracture after failure of initial treatment.

Methods

Our revision strategy was as follows: First, we determined the presence of any infection. Second, we determined whether the patient required total knee arthroplasty (TKA). Third, based on the characteristics of the tibial plateau fracture malunion, patients underwent one of the following surgical methods to achieve reduction: original fracture line osteotomy, tibial tubercle + original fracture line osteotomy, fibula head + original fracture line osteotomy, and metaphyseal open window reduction rod technique. The results was assessed with healing time, Rasmussen score, knee range of motion and complication rates.

Results

A total of 25 patients 16 men and 9 women; Mean age: 47.4 years (range: 35–63 years) underwent tibial plateau fracture revision operation. The time interval between the two surgeries was 2–24 months. The follow-up time was 12–30 months, and the operation time was 120–300 min. All patients received bone union at the last follow-up. The healing time was 3–6 months. The postoperative Rasmussen score was 19–29 (mean 23.8) compared with 14.4 points before the operation (p < 0.05). The postoperative knee joint activity was 60–110° (mean 95.0°), compared with 57.8° before the operation (p < 0.05). Six patients still had a 2-mm collapse on the articular surface, and 4 patients still had slight valgus (<5°). Except for 2 TKA cases, fracture reduction was excellent in 15 cases and good in 8 cases, with a good rate of 100%. Superficial wound infections occurred in 3 patients.

Conclusion

Because revision of tibial plateau fracture malunion caused by failure of initial treatment is difficult, it is necessary to create a detailed surgical plan before the operation. Satisfactory clinical effects can be obtained if the correct revision strategy is used. The key to success is adopting a proper revision strategy according to the unique characteristics of the patient's tibial plateau fracture malunion.

Level of Evidence

Level IV, Therapeutic Study.

Single-stage total knee arthroplasty and osteotomy as treatment of secondary osteoarthritis with severe coronal deviation of joint surface due to extra-articular deformity

PURPOSE

Severe extra-articular deformities can be treated with single-stage total knee replacement (TKA) and osteotomy. Aim of this study was to examine the patient-reported outcome measures (PROMs) and the complications after single-stage TKA and osteotomy. We hypothesized patients achieve good outcome after single-stage TKA and osteotomy, which is comparable to outcome after primary TKA without deformity.

METHODS

Twenty-one patients with severe extra-articular deformity who underwent single-stage TKA and deformity-correcting osteotomy were reviewed and invited to fill in PROMs including the Oxford Knee Score, the Short Form-12, a Visual Analogue Scale for pain, and questions about satisfaction and quality of life.

RESULTS

The mean follow-up period was 64 months. Ten patients were treated with TKA and supracondylar femoral osteotomy. Although PROMs showed good results (mean quality of life score was 85 out of 100), two patients had a revision of the osteotomy due to non-union. Eleven patients were treated with TKA and high tibial osteotomy. Patients were satisfied with the results (mean quality of life score was 81 out of 100). Two patients developed infection requiring debridement, resulting in one arthrodesis and one gastrocnemius transfer for wound closure.

CONCLUSION

In general, patients were satisfied with the postoperative result. Outcome was comparable to patients after primary TKA in the literature. However, serious complications need to be taken into account.

LEVEL OF EVIDENCE

III.

Total knee arthroplasty with corrective osteotomy for knee osteoarthritis associated with malunion after tibial plateau fracture: a case report

Background

When surgeons perform total knee arthroplasty in patients with knee osteoarthritis due to malunion following fractures around the knee joint, corrective osteotomy is recommended for severe deformities. Most such deformities are coronal plane varus or valgus deformities, and reports of sagittal plane flexion or extension deformities are rare. We describe a case in which a one-stage total knee arthroplasty was performed with extension corrective osteotomy in the sagittal plane.

Case presentation

A 71-year-old Japanese man presented with left knee pain. He had knee osteoarthritis associated with malunion after a tibial plateau fracture. Plain radiography showed a varus deformity in the coronal plane and a marked flexion deformity in the sagittal plane. We performed total knee arthroplasty concurrently with extension corrective osteotomy using a long stem. Full weight bearing was permitted at 6 weeks postoperatively, and the patient was able to walk without assistance.

Conclusions

This surgical method appears to be beneficial for shortening the duration of treatment and improving knee function.

Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification?

BACKGROUND

Total knee arthroplasty (TKA) is often the best answer for end-stage, posttraumatic osteoarthritis after intra-articular and periarticular fractures about the knee. Although TKA in this setting is often considered more technically demanding, outcomes are typically worse for patients. This study examines the intraoperative differences and 30-day outcomes in posttraumatic vs primary TKA cohorts.

METHODS

Patients undergoing TKA were selected from the National Surgical Quality Improvement Program database from 2010 to 2013. Patients were stratified on the basis of concurrent procedures and administrative codes indicating posttraumatic diagnoses. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether posttraumatic arthritis was a risk factor for poor outcomes.

RESULTS

A total of 67,675 primary and 674 posttraumatic TKAs were identified. Posttraumatic TKA patients were on average younger and healthier than the primary TKA population. The posttraumatic TKA group had higher rates of superficial surgical site infections and bleeding requiring transfusion. History of posttraumatic knee osteoarthritis was found to be an independent risk factor for prolonged operative time, increased length of hospital stay, and 30-day hospital readmission.

CONCLUSION

We have demonstrated increased intraoperative times, heightened transfusion requirements and surgical site infections, and higher readmission rates after conversion TKA in the posttraumatic cohort. In contrast to total hip arthroplasty, current diagnosis and reimbursement schemes do not differentiate posttraumatic patients from primary osteoarthritis groups undergoing TKA. We believe that classification reform would improve medical documentation and improve patient care.

TKA for Posttraumatic Osteoarthritis Is More Complex and Needs More Surgical Resources

The purpose of this study was to evaluate the surgical effort of total knee arthroplasty (TKA) for posttraumatic osteoarthritis (PTOA) compared with primary osteoarthritis (OA). A total of 1841 TKAs were analyzed, including 170 patients with PTOA, that resulted from soft tissue trauma in 83 patients and fractures in 87 patients. Results showed that patients were significantly younger at the time of surgery in the posttraumatic group (62 vs 71 years; P<.001). Furthermore, fracture was associated with 3.7 years earlier need of TKA compared with soft tissue trauma. Operation time was significantly longer for both of the posttraumatic groups compared with OA (P<.001). Patients undergoing TKA after knee injuries are younger and surgical treatment is more challenging compared with TKA for OA. Extended operation time and implant systems with higher constraint and modular options are required. [Orthopedics. 2016; 39(3):S36-S40.].

Outcomes after Total Knee Arthroplasty for post-traumatic arthritis

INTRODUCTION

Total Knee Arthroplasty (TKA) is an important treatment for posttraumatic arthritis (PTA), but evidence on outcomes is sparse. The purpose of this study was to evaluate the impact of PTA versus primary osteoarthritis (OA) on postoperative outcomes after TKA.

METHODS

We queried the entire Medicare database from 2005 to 2012. International Classification of Diseases, 9th revision and Current Procedural Terminology codes were used to identify the procedure, indication, and complications. Patients with minimum two-years follow-up were selected. Odds ratios (ORs), confidence intervals, and p-values (p) were calculated.

RESULTS

For PTA, 3509 patients had TKA. For OA, 257,611 patients with TKA served as controls. The average Charlson Comorbidity Index for both groups was five. PTA patients were younger; only eight out of 29 Elixhauser comorbidities were higher. PTA patients had higher incidence of periprosthetic infection (OR 1.72, p<0.001), cellulitis or seroma (OR 1.19, p<0.001), knee wound complications (OR 1.80, p<0.001), TKA revision (OR 1.23, p=0.01), and arthrotomy/incision and drainage (OR 1.55, p<0.001). Blood transfusion rate was lower in PTA patients. There were no significant differences in bleeding complications, prosthetic dislocation, broken prostheses, periprosthetic fracture, osteolysis and polywear, neurovascular injury, and extensor mechanism rupture.

DISCUSSION AND CONCLUSION

This study represents, to our knowledge, TKA outcomes in the largest cohort of PTA patients to date. Our findings indicate that these patients are at higher risk for many, but not all, postoperative surgical complications despite being as healthy as patients receiving TKA for primary OA.

Total Knee Arthroplasty for Osteoarthritis Secondary to Fracture of the Tibial Plateau. A Prospective Matched Cohort Study

A prospective matched cohort study was performed to compare outcomes of total knee arthroplasties (TKA) between 29 patients with posttraumatic osteoarthritis (POA) after a fracture of tibial plateau and 58 patients underwent routine TKA. Mean follow-up was 6.7 years. There were no significant differences in KSS, WOMAC, SF12 scores or range of motion. In the control group there were no complications. In the posttraumatic group, complications occurred in 4 patients (13.7%) (P=0.010) including partial patellar tendon detachment, superficial infection, skin necrosis, and knee stiffness. Only this last patient required revision for manipulation under anesthesia. Also, there was a revision for tibial aseptic loosening in each group. TKA is an effective treatment for POA after tibial plateau fracture. We recommend the prior removal of hardware, as well as tibial tubercle osteotomy when necessary.

Lower function, quality of life, and survival rate after total knee arthroplasty for posttraumatic arthritis than for primary arthritis

BACKGROUND AND PURPOSE

Total knee arthroplasty (TKA) for treatment of end-stage posttraumatic arthritis (PTA) has specific technical difficulties and complications. We compared clinical outcome, postoperative quality of life (QOL), and survivorship after TKA done for PTA with those after TKA performed for primary arthritis (PA).

PATIENTS AND METHODS

We retrospectively reviewed patients who were operated on at our institution for PTA between 1998 and 2005 (33 knees), and compared them to a matched group of patients who were operated on for PA during the same period (407 knees). Clinical outcomes and postoperative QOL were compared in the 2 groups using Knee Society score (KSS), range of motion (ROM) of the knee, and the knee osteoarthritis outcomes score (KOOS). Implant survival rate was calculated using Kaplan-Meier analysis.

RESULTS

At a mean follow-up of 11 (5-15) years, KSS knee increased from mean 39 (SD 18) to 87 (SD 16) in the PA group (p = 0.003), and from 31 (SD 11) to 77 (SD 15) in the PTA group (p = 0.003). KSS function increased from 55 (12) to 89 (25) in the PA group (p = 0.008) and from 44 (SD 14) to 81 (SD 10) in the PTA group (p = 0.008). Postoperative ROM also improved in both groups, from 83° to 108° in the PTA group (p < 0.001) as opposed to 116° to 127° in the PA group (p = 0.001), with lower results in the PTA group (p < 0.001). KOOS was lower in the PTA group (p < 0.001). The survival rate of TKA at 10 years with an endpoint defined as "any surgery on the operated knee" showed better results in the PA group (99%, CI: 98-100 vs. 79%, CI: 69-89; p < 0.001).

INTERPRETATION

Patients and surgeons should be aware that clinical outcome and implant survival after TKA for PTA are lower than after TKA done for PA.

One-stage total knee arthroplasty with pre-existing fracture deformity: post-fracture total knee arthroplasty

The aim of the study was to assess the results of treating knee osteoarthrosis with total knee arthroplasty (TKA) after previous tibia and/or femur fractures resulting in axial limb deformities. Thirty-six knees (34 patients) were operated on. At the most recent follow-up, 4.8 years after surgery, all but one patient demonstrated an improvement in both clinical and functional KSS. This male patient required revision after 2 years. Improved range of motion was generally noted, especially extension, however, two patients with both tibia and femur fractures had worse results. TKA is an effective method of treatment for patients with arthrosis after a previous femur or tibia fractures. When deformity is severe semi-constrained or constrained, implants with extensions may be necessary.

One-stage femoral osteotomy and computer-assisted navigation total knee arthroplasty for osteoarthritis in a patient with femoral subtrochanteric fracture malunion

Extra-articular femoral deformity in total knee arthroplasty (TKA) is realigned by either intra-articular correction or extra-articular osteotomy. The more distant the deformity is away from knee joint, the more likely it is corrected by the former method. No report described the use of antegrade cephalomedullary femoral nail to fix the osteotomy followed by computer-assisted navigation TKA. This report described the unusual use of this method to manage a 64-year-old man with femoral subtrochanteric fracture malunion and osteoarthritis of knee. He demonstrated a satisfactory functional outcome and good lower limb alignment.

One-stage total knee arthroplasty for patients with osteoarthritis of the knee and extra-articular deformity

PURPOSE

The purpose of this paper is to review our experience and study the feasibility and clinical results of one-stage total knee arthroplasty (TKA) for patients with osteoarthritis of the knee with extra-articular deformity.

METHODS

Nine patients with osteoarthritis of the knee associated with extra-articular deformity underwent one-stage TKA from June 2006 to April 2010. There were two men and seven women, with an average age of 51 years (range 34-69 years); four of them had tibial deformities and five had femoral deformities. Eight of the cases resulted from malunion after fracture healing and one from femoral recurvatum. Six of the cases had uniplanar and three had biplanar deformities. The average angles of the femoral deformities were 13.3° in the coronal plane (8-22) and 11.3° in the sagittal plane (6-15); one femur had 10° external rotational deformity. Tibial deformity of 16° in the coronal plane (11-22) was noted, and one had sagittal plane deformity of 21°.

RESULTS

All patients were followed for an average of 29 months. The average Hospital for Special Surgery (HSS) knee score improved from 18.7 points pre-operatively to 89.8 points at the time of last follow-up; the range of knee motion improved from 46.7° preoperatively to 100.6° postoperatively. The average angle of mechanical axis deviation was restored from 11.8° preoperatively to 1° postoperatively. One of the patients had unsatisfactory clinical results due to delayed union at the osteotomy site. No complications such as infection, deep vein thrombosis, ligament instability, low level or subluxed/dislocated patella or component loosening were observed. One-stage TKA with intra-articular correction of the extra-articular deformity was performed in seven patients, included proper planning, appropriate bone cuts to restore alignment and the necessary soft tissue releases to balance the knee in flexion and extension. Two patients underwent simultaneous extra-articular correctional osteotomy and TKA because the deformity was so large. Five knees that had good collateral ligamentous stability and balance received a posterior stabilised prosthesis; four knees that had ligamentous instability received a constrained condylar knee (CCK) prosthesis.

CONCLUSIONS

One-stage TKA is a technically difficult but effective treatment for patients with osteoarthritis of the knee and extra-articular deformity. If feasible we recommend TKA with intra-articular bone resection and soft tissue balancing.

Computer-navigated TKA for the treatment of osteoarthritis associated with extra-articular femoral deformity

The purpose of this study was to evaluate the efficacy of computed-navigated total knee arthroplasty for the treatment of osteoarthritis associated with extra-articular femoral deformity. Between January 2008 and June 2010, twelve patients (12 knees) with osteoarthritis combing extra-articular femoral deformity underwent total knee arthroplasty using the Stryker Navigation System 3.1 (Kalamazoo, Michigan), a wireless and imageless system. Average follow-up was 12.3 ± 8.2 months (range, 3-24 months). Full-length weight-bearing anteroposterior radiographs, knee range of motion, and Knee Society Score were obtained for all patients pre- and postoperatively. The data were analyzed with SPSS version 12.0 statistical software (SPSS, Inc, Chicago, Illinois). Average preoperative overall mechanical axis of the 12 knees was -10.0° ± 4.4° of varus (range, -5° to -18.5°) and average postoperative mechanical axis was -0.9° ± 0.8° (range -2° to 0°). Average Knee Society Score increased from 40.8 ± 7.7 preoperatively to 94.9 ± 2.4 postoperatively, and average function score increased from 39.6 ± 12.3 preoperatively to 95.4 ± 4.0 postoperatively. Average knee range of motion improved from 83.7° ± 18.7° preoperatively to 115.0° ± 8.2° postoperatively. The results of the study showed that computer-navigated total knee arthroplasty may be a valuable option for patients with deformed femurs in which conventional instruments are difficult to use. Follow-up observation of the long-term therapeutic effect of computer-navigated total knee arthroplasty is still needed.

Thermal necrosis after simultaneous tibial osteotomy and total knee arthroplasty using press-fit extension-stem

One-staged tibial corrective osteotomy and total knee arthroplasty is a challenging but effective treatment for arthritic knees with extra-articular deformity. Although osteocutaneous thermal necrosis is accepted as a complication of intramedullary reamed nailing following long bone fractures, only 15 cases have been reported in the English literature at present. This report illustrates a rare case of thermal necrosis in a patient undergoing tibial corrective osteotomy coincident with long-stemmed total knee arthroplasty. Excessive reaming with a machine reamer is hypothesized as the cause of this serious complication. In this report, we highlight this rare but serious complication after long-stemmed total knee arthroplasty.

Total knee arthroplasty in valgus knee

Total knee arthroplasty (TKA) in valgus knee has the reputation of being more difficult than in well aligned or varus knee, and there is no management consensus. Results on a continuous series of 100 TKAs on valgus knee were compared to the literature data, to define surgical strategy adapted to the various types of valgus knee.

Computer-assisted total knee arthroplasty for arthritis with extra-articular deformity

Forty extra-articular deformities (22 femoral and 18 tibial) in 34 patients (mean age, 63.1 years) were studied. Mean coronal extra-articular deformity was 9.3 degrees ; mean preoperative limb alignment was 166.7 degrees . Three limbs underwent simultaneous corrective osteotomy; the rest were treated with intra-articular correction during computer-assisted total knee arthroplasty (TKA). Mean postoperative limb alignment was 179.1 degrees . At a mean follow-up of 26.4 months, the Knee Society knee score improved from a mean preoperative score of 49.7 to 90.4 points postoperatively; function score improved from 47.3 to 84.9 points. Computer-assisted TKA is a useful alternative to conventional TKA for knee arthritis with extra-articular deformity where accurate restoration of limb alignment may be challenging because of the presence of a deformed tibia or femur or in the presence of hardware.

Extra-articular deformity is always correctable intra-articularly: in the affirmative

Patients with arthritis of the knee and an extra-articular deformity present a unique technical challenge, as it becomes more difficult to restore the mechanical axis during total knee replacement (TKR). Current treatment options include a 2-stage procedure in which an extra-articular correctional osteotomy is performed several months before the primary TKR, a 1-stage procedure in which an extra-articular correctional osteotomy is performed at the time of the index TKR, or a 1-stage procedure in which TKR is performed with correction of the extra-articular deformity. One-stage TKR with intra-articular correction of the extra-articular deformity is our treatment of choice. With proper planning, appropriate bone cuts to restore alignment, and the necessary soft tissue releases to balance the knee in flexion and extension, a satisfactory TKR can be achieved. Two patients with arthritis and a severe extra-articular deformity (varus/valgus deformity >20 degrees , recurvatum and malunion of a tibial or femoral fracture) were treated with 1-stage TKR with intra-articular correction of the extra-articular deformity. The technique followed had been successfully performed in 15 previous cases. The procedure was clinically successful in both patients without complications. At 2-year follow-up, Knee Society Scores improved from 40 to 95 and there was no evidence of instability in either case.