Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the operative procedures and clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. We will describe the evolving surgical technique being utilized to tackle these challenging cases. Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° “valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected. The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up. Thus far, this is the largest reported study that specifically evaluates TAR with significant preoperative valgus alignment, in addition to having the longest follow-up. Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed

Introduction. Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results. Materials & Methods. We have treated 20 (22 limbs – 2 patients requiring staged bilateral corrections) patients for distal femoral varus and valgus deformities with CWDFO between 2019 and 2022. Out of these 4 patients (5 limbs) requiring large corrections of distal femoral angular deformities were treated with Neutral Wedge (NW) technique. 3 patients (four limbs) had distal femoral valgus deformity and one distal femoral varus deformity. Indication for NW technique is an angular deformity (varus or valgus of distal femur) requiring > 12 mm opening/closing wedge correction. We approached the closing side first and marked out the half of the calculated wedge with K – wires in a uniplanar fashion. Then an external fixator with two Schanz screws is applied on the opposite side, inserting the distal screw parallel to the articular surface and the proximal screw 6–7 cm proximal to the first pin and at right angles to the femoral shaft mechanical axis. Then the measured wedge is removed and carefully saved. External fixator is now used to close the wedge and over correct, creating an appropriate opening wedge on the opposite side. A Tomofix (Depuoy Synthes) plate is applied on the closing side with two screws proximal to osteotomy and two distally (to be completed later). Next the osteotomy on the opposite side is exposed, the graft is inserted. mLDFA is measured under image intensifier to confirm satisfactory correction. Closing wedge side fixation is then completed followed by fixation of opposite side with a Tomofix or a locking plate. Results. 3 patients (4 limbs) had genu valgum due to constitutional causes and one was a case of distal femoral varus from a fracture. Preoperative mLDFA ranged from 70–75° and in one case of varus deformity it was 103°. We achieved satisfactory correction of mLDFA in (85–90°) in 4 limbs and one measured 91°. Femoral length was not altered. JLCA was not affected post correction. Patients were allowed to weight bear for transfers for the first six weeks and full weight bearing was allowed at six weeks with crutches until healing of osteotomy. All osteotomies healed at 16–18 weeks (average 16.8 weeks). Patients regained full range of movement. We routinely recommend removal of metal work to facilitate future knee replacement if one is needed. Follow up ranged from 4 months to 2 yrs. Irritation from metal work was noted in 2 patients and resolved after removing the plates at 9 months post-surgery. Conclusions. NWDFO is a good option for large corrections. We describe a technique that facilitates accurate correction of deformity in these complex cases. Osteotomy heals predictably with uniplanar osteotomy and dual plate fixation. Metal work might cause irritation like other osteotomy and plating techniques in this location

Introduction. Hip dysplasia is the most common congenital deformity of the musculoskeletal system. This is a pathology that brings the hip joint from subluxation to dislocation. Frequency of hip dysplasia − 16 children per 1000 newborns. Materials and Methods. Diagnostic methods of research are X-ray inspection which is necessarily carried out at internal rotation (rotation) of an extremity as lateral rotation of a hip on the radiograph always increases an angle of a valgus deviation of a neck. Surgical treatment is performed in the subclavian area of the femur. An external fixation device is applied and a corrective corticotomy is performed, and valgus deformity and anteversion are eliminated. The duration of treatment is 2.5–3 months. Results. Frequency of hip dysplasia − 16 children per 1000 newborns. We perform about 30 operations a year, including 60% girls and 40% boys. In addition, valgus deformity can be traced -. - in cerebral palsy. - after polio. - at progressing muscular dystrophies. - tumor in the area of the epiphyseal cartilage. At insufficient stability in a hip joint at insufficiently expressed roof of an acetabulum of rotational deformation of a neck of a hip, for prevention of a coxarthrosis and normalization of a ratio of articular ends operation detorsion-varying subvertebral corticotomy of a femur is shown. Conclusions. The operation is minimally invasive, with accesses of 5–6 mm, anatomical and topographical features are taken into account, which will eliminate damage to tissues, nerve trunks and the circulatory system

Management of a knee with valgus deformities has always been considered a major challenge. Total knee arthroplasty requires not only correction of this deformity but also meticulous soft tissue balancing and achievement of a balanced rectangular gap. Bony deformities such as hypoplastic lateral condyle, tibial bone loss, and malaligned/malpositioned patella also need to be addressed. In addition, external rotation of the tibia and adaptive metaphyseal remodeling offers a challenge in obtaining the correct rotational alignment of the components. Various techniques for soft tissue balancing have been described in the literature and use of different implant options reported. These options include use of cruciate retaining, sacrificing, substituting and constrained implants. Purpose. This presentation describes options to correct a severe valgus deformity (severe being defined as a femorotibial angle of greater than 15 degrees) and their long term results. Methods. 34 women (50 knees) and 19 men (28 knees) aged 39 to 84 (mean 74) years with severe valgus knees underwent primary TKA by a senior surgeon. A valgus knee was defined as one having a preoperative valgus alignment greater than 15 degrees on a standing anteroposterior radiograph. The authors recommend a medial approach to correct the deformity, a minimal medial release and a distal femoral valgus resection of angle of 3 degrees. We recommend a sequential release of the lateral structures starting anteriorly from the attachment of ITB to the Gerdy's tubercle and going all the way back to the posterolaetral corner and capsule. Correctability of the deformity is checked sequentially after each release. After adequate posterolateral release, if the tibial tubercle could be rotated past the mid-coronal plate medially in both flexion and extension, it indicated appropriate soft tissue release and balance. Fine tuning in terms of final piecrusting of the ITB and or popliteus was carried out after using the trial components. Valgus secondary to an extra-articular deformity was treated using the criteria of Wen et al. In our study the majority of severe valgus knees (86%) could be treated by using unconstrained (CR, PS) knee options reserving the constrained knee / rotating hinge options only in cases of posterolateral instability secondary to an inadequate large release or in situations with very lax or incompetent MCL. Results. The average follow up was 10 years (range 8 to 14 years). The average HSS knee scores improved from 48 points preoperatively (range 32 to 68 points) to 91 points (range 78 to 95 points) postoperatively. The average postoperative range of motion measured with a goniometer was 110 degrees (range 80 to 135 degrees) which was a significant improvement over the preoperative levels (average 65 degrees). None of the patients were clinically unstable in the medioloateral or anteroposterior plane at the time of final follow up. The average preoperative valgus tibiofemoral alignment was 19.6 degrees (range 15 degrees to 45 degrees). Postoperatively the average tibio-femoral alignment was 5 degrees (range 2 degrees to 7 degrees) of valgus. No patient in the study was revised. Conclusion. Adequate lateral soft tissue release is the key to successful TKA in valgus knees. The choice of implant depends on the severity of the valgus deformity and the extent of soft tissue release needed to obtain a stable knee with balanced flexion and extension gaps. The most minimal constraint needed to achieve stability and balance was used in this study. In our experience the long term results of TKR on severe valgus deformities using minimal constrained knee have been good

Introduction. Valgus knee deformity is associated especially with differences in anatomy between medial and lateral femoral condyles. Vertically smaller lateral condyle and more distally located medial condyle cause valgus deformity in extension. The anteroposterior dimensions of both condyles influence the knee axis in flexion. In a „true“ valgus knee there is a mismatch between both condyles in both the vertical and anteroposterior dimensions, the lateral condyle is generally smaller. In a „false“ valgus knee there is no mismatch between anteroposterior dimensions of both condyles, the knee axis changes from valgus into varus with increased degree of flexion and lateral soft tissue structures are that's why not so contracted as in „true“ valgus knee deformity, where the knee stays in valgus deviation during the whole range of motion. The aim of the study was to preoperatively identify and analyse patterns of passive movement of osteoarthritic valgus knees with imageless navigation system to optimise surgical approach and intra-operative tissue handling during subsequent total knee replacement (TKR) surgery. Material and Methods. TKR were prospectively performed in 50 valgus knees. Cases with severe bony destruction and enormous soft tissue laxity were excluded from the study. The kinematic navigation system used was OrthoPilot® (Aesculap, Tuttlingen, Germany). It is designed to produce a numerical output of varus/valgus deviation of the knee against the degree of flexion. Before skin incision for TKR surgery, active markers were attached percutaneusly to the femur and the tibia with bicortical screws to create two ‘rigid bodies’. After the registration process the kinematic analysis was performed by passive movement of the knee. The mechanical axis was recorded at 0°, 30°, 60°, 90°, and 120° of flexion. The valgus deformity persistent through the whole range of motion was called „true“ and the valgus deformity passing into varus with flexion was called „false“. In „true“ valgus knees the lateral approach according to Keblish was used, in „false“ valgus knees we used standard medial parapatellar approach. Results. The pre-operative valgus deformity in extension ranged from 13° to 4° (mean 7,8°). We observed „true“ valgus type deformity during passive range of movement in 34 cases (68 %) and „false“ type of kinematics in 16 cases (32 %). The average value of valgus deviation in extension in „true“ group was 7,9° (range, 13° to 4°) and in „false“ group 7,5° (range, 9° to 6°), without statistically significant difference. In the „true“ valgus deviation group the value of deformity gradually decreased with flexion in all cases. The mean difference between axis deviation in 0° and 120° of flexion was 5,5° (range, 10° to 1°) in this group. In the „false“ valgus group the varus deviation was observed either already in 60° of flexion or in most cases in 90° of flexion. The mean difference between axis deviation in 0° and 120° of flexion in this group was much more significant – 12,0° (range, 14° to 10°) – there was statistically significant difference between both groups. The mean time necessary for data collection before surgery was 6 minutes (range, 4 to 11 minutes); afterwards, tha navigation was used for TKR implantation. No complications were observed regarding to the navigation usage. Subsequently correct soft tissue balance was achieved in all TKRs using this method. Conclusions. Computer navigation assistance can easily and fast help to identify the character of valgus deformity („true“ or „false“) just before skin incision. In „true“ valgus deviation lateral structures (iliotibial band, vastus lateralis tendon, lateral collateral ligament, and the popliteus muscle) are tight and lateral approach according to Keblish may be necessary for appropriate release and soft tissue balancing during TKR surgery. Mostly used standard medial parapatellar approach is always sufficient in „false“ valgus knees. Computer navigation can help surgeon to choose the appropriate parapatellar approach (medial or lateral) just before the surgery without significant time lost

Background. Total knee arthroplasty has been performed even for severe valgus knee. All ligaments around knee must be balanced to obtain good clinical results. Especially medial collateral ligament plays a role as a stabilizer. For severe valgus knee, however, deep medial collateral ligament (dMCL) located closely to the articulating tibial surface [Fig. 1] can be damaged by bone resection in standard tibial osteotomy which may leads to progress valgus deformity. Purpose. There are no report of dMCL preserved total knee arthroplasty for sever valgus knee. Thus it was evaluated the clinical outcomes of total knee arthroplasty for severe valgus knees using dMCL preservation technique. Methods. Twenty six knees of 18 osteoarthritis and 8 rheumatoid arthritis with severe valgus deformity (from 10° to 56°) underwent TKA between January 2006 and January 2014 was reviewed retrospectively. All surgeries were conducted by lateral parapatellar approach. Additional four mm resection was conducted on distal femur. Resection level at tibia was one to three mm below the medial joint line to preserve dMCL. GENESIS II PS with high flex insert (Smith and Nephew) was used for 25 knees. One knee with 56° valgus deformity that had no end point of MCL was required Rotating Hinge Prosthesis (Link). Mean follow up time was four years (range one to nine years). Results. Mean Japanese Orthopaedic Association (JOA) score and femorotibial angle was improved from 53°±12.6 to 84°±7.6 and from 159°±9.3 preoperatively to 172.6°±2.3 postoperatively, respectively (both P<0.001). Mean extension range of motion were improved significantly from −14.8°±13.1 to −2.3°±4.7 (P<0.001). Mean flexion range of motion, however were not changed significantly from 115.8°±25.9 to 121.3°±20.8 (P>0.05). No patient had any postoperative complications including deep infection, peroneal palsy, loosening of the implant and pulmonary embolism. Every valgus knee underwent total knee arthroplasty using dMCL preservation technique had static end point of MCL at the last follow up. No progress of the valgus deformity was found and revision surgery for every case in this study. No potential COI to disclose

In a „true“ valgus knee the lateral femoral condyle is smaller in both the vertical and anteroposterior dimensions and lateral soft tissue structures are contracted. In a „false“ valgus knee there is no mismatch between anteroposterior dimensions of both condyles. The aim of the study was to preoperatively analyse patterns of passive movement of valgus knees with imageless navigation system to optimise surgical approach during subsequent total knee replacement (TKR). TKR were prospectively performed in 50 valgus knees. After the data registration process, the kinematic analysis was performed by passive movement of the knee. The mechanical axis was recorded at 0°, 30°, 60°, 90°, and 120° of flexion. The valgus deformity persistent through the whole range of motion was called „true“ and the valgus deformity passing into varus with flexion was called „false“. The pre-operative valgus deformity in extension ranged from 13° to 4° (mean 7.8°). We observed „true“ valgus type deformity during passive range of movement in 34 cases (68%) and „false“ type of kinematics in 16 cases (32%). The average value of valgus deviation in extension in „true“ group was 7.9° (range 13° to 4°) and in „false“ group 7.5° (range 9° to 6°). The mean difference between axis deviation in 0° to 120° range of flexion was 5.5° (range 10° to 1°) in the „true“ valgus group. In the „false“ valgus group the varus deviation was observed in 90° of flexion in all cases and mean difference between axis deviation in 0° to 120° range of flexion was 12.0° (range 14° to 10°). Computer navigation can easily help to identify the character of valgus deformity („true“ or „false“) just before skin incision. In „true“ valgus deviation lateral approach may be necessary for appropriate soft tissue balancing during TKR surgery

Background. We have performed total knee arthroplasties for valgus and varus in the knees of one person and investigate the clinical characteristics of these patients and the relationship between the kind of deformity and postoperative result. Methods. From March 2002 to February 2010, 25 patients who had simultaneous varus and valgus knee deformities underwent total knee arthroplasties and followed more than 12 months were included. The average age was 66.9 years and the average follow-up period was 61.1 months. Follow-up imaging assessments were taken and clinical outcome were evaluated using HSS score at last follow-up. Results. 11 cases had more pain in varus knee and 8 cases had more pain in valgus knee preoperatively. In 11 cases, degenerative scoliosis were associated with the knee deformity and among the cases, 10 cases had valgus deformities in concave side of scoliosis. In three cases, hip deformities were noted in ipsilateral side of the valgus deformity. One case showed both hip deformities with ankylosing spondylitis. Preoperative mean valgus angle was 11.4 degree and varus angle was 7.5 degree. Postoperative valgus and varus angle improved to 6.3 and −5.7 degree. HSS score improved from 64.3 to 84.7 point in valgus deformities and from 62.1 to 85.1 point in varus deformities. Postoperative patellar clunk syndrome was identified in one valgus knee, but resolved by arthroscopic debridement. And postoperatively, one case showed out-toeing gait caused by equinovarus deformity in varus knee, but resolved by correction of foot deformity. Conclusions. Simultaneous or staged total knee arthroplasties in patients with simultaneous varus with contralateral valgus knee deformities brought satisfactory outcomes with regard to objective orthopedic criteria such as radiographic and clinical results. Concave aspect of scoliosis and hip deformity correlate with valgus knee in statistically. But rheumatoid factor and VDRL do not correlate with valgus deformity. And we found no significant difference between the kind of deformity and postoperative result

INTRODUCTION. In patients presenting with significant ligamentous instability/insufficiency and/or significant varus/valgus deformity of the knee, reproduction of knee alignment and soft tissue stability continues to be a difficult task to achieve. These complex primary total knee arthroplasty (TKA) candidates generally require TKA systems incorporating increasing levels of constraint due to the soft-tissue and/or bone deficiencies. In addition, achievement of “normal” gap symmetry through physiologic kinematics is challenging due to the complexity of the overall correction. Advancements in TKA design have not fully addressed the negative consequences of the increased forces between the degree of component constraint, the femoral box, and the tibial post. The purpose of this early feasibility study was to introduce the design characteristics of a primary TKA system that incorporates progressive constraint kinematics using a low profile trapezoidal femoral box, and to assess the short-term clinical and radiographic results of this patient cohort. METHODS. We retrospectively evaluated 22 consecutive, non-selected, complex primary TKA patients with a minimum of 3-years follow-up and varus deformity of > 20 degrees or valgus deformity of >15 degrees. The Progressive Constraint Kinematics® Knee System (PCK, MAXX Orthopedics, Norristown, PA) was used and provides a variable constraint profile, from high constraint in extension to less constraint in flexion through a novel trapezoidal femoral box. We evaluated patient demographics, pre- and post-operative serial radiography, range of motion (ROM), and total Knee Society Score (KSS – total score). General descriptive statistics and paired t-Test to assess the difference between means at p <0.05 level of significance. RESULTS. The average time to most recent follow-up was 40.5 ±3.5 months (range: 36.0 to 44.0 months). The PCK knee system had 100% survival rate at the most recent follow-up, with no reports of adverse events, subsequent corrective surgery, or revision. The average total KSS improved from 72.7 ±3.2 (range: 68 to 81) pre-operatively to 92.3 ±2.1 (range: 88 to 96) post-operatively (p < 0.001). Full post-operative arc of motion was 0 – 130° and there was no radiographic evidence of composite degradation, aseptic loosening or component malalignment. DISCUSSION/CONCLUSION. The PCK Knee System utilizes a trapezoidal shaped femoral box, where the narrower end is located anteriorly, allowing a valgus/varus tilt of 1–4 degrees and internal/external rotation of 2–7 degrees during flexion, while maintaining necessary soft-tissue constraint during extension. This variable constraint profile allows for fully tensed collaterals in extension, with a slight reduction in collateral tension through flexion. Furthermore, the combination of the condylar anatomy, trapezoidal femoral box and tibial post allows for adequate clearance through full flexion, while facilitating slightly progressive increases in tilt and rotation, thereby maintaining knee kinematics while dampening forces transmitted through the prosthetic composite. From this feasibility study we report promising short-term clinical and radiographic results in the absence of biomechanical failure in complex primary TKA cases. We recommend continuation of the use and further research of the PCK Knee System for complex primary TKA with the ultimate goal of further determining cost effectiveness and intermediate to long-term clinical relevance

In arthritic knees with severe valgus deformity Total Knee Arthroplasty (TKA) can be performed through medial or lateral parapatellar approaches. Many orthopaedic surgeons are apprehensive of using the lateral parapatellar approach due to lack of familiarity and concerns about complications related to soft tissue coverage and vascularity of the patella and the overlying skin. However surgeons who use this approach report good outcomes and no added complications. The purpose of our study was to compare outcomes following TKA performed through a medial parapatellar approach with those performed through a lateral parapatellar approach in arthritic knees with severe valgus deformity. We conducted a retrospective review of patients from two consultants using computer navigation for all their TKAs. All patients with severe valgus deformities (Ranawat 2 & 3 grades) operated on between January 2005 and December 2011 were included. 66 patients with 67 TKAs fulfilled the inclusion criteria. Patients were group by approach; Medial = 34TKAs (34 patients) or Lateral = 33 TKAs (32 patients). Details were collected from patients' records, AP hip-knee-ankle (HKA) radiographs and computer navigation files. Outcome measures included lateral release rates, post-operative range of knee movements, long leg mechanical alignment measurements, post-operative Oxford scores at six weeks and one year, patient satisfaction and any complications. Comparisons were made between groups using t-tests. The total cohort had a mean age of 69 years [42–82] and mean BMI of 29 [19–46]. The two groups had comparable pre-operative Oxford scores (Medial 41[27–56], Lateral 44 [31–60]) and pre-operative valgus deformity measured on HKA radiographs (Medial 13° [10°–27.6°], Lateral 12° [6°–22°]). Three patients in the Medial group underwent intra-operative lateral patellar release to improve patellar tracking. Seven patients in the Lateral group had a lateral condyle osteotomy for soft tissue balancing (one bilateral). There was no statistically significant difference between groups at one year follow up for maximum flexion (Medial 100° [78°–122°], Lateral 100° [85°–125°], p=0.42), fixed flexion deformity (Medial 1.2° [0°–10°], Lateral 0.9° [0°–10°], p=0.31) or Oxford score (Medial 23 [12–37], Lateral 23 [16–41], p=0.49). Similarly there was no difference in the patient satisfaction rates between the two groups at one year follow up. However there was a statistically significant difference in the mean radiographic post-operative alignment angle measurement (Medial 1.8° valgus [4° varus to 10° valgus], Lateral 0.3° valgus [5° varus to 7° valgus], p=0.02). One patient in the Medial group had a revision to hinged knee prosthesis for post-operative instability. There was no wound breakdown or patellar avascular necrosis noted in either of the groups. The lateral parapatellar approach resulted in slightly better valgus correction on radiographs taken six weeks post-operatively. We found no major complications in the Lateral parapatellar approach group. Specifically we did not encounter any difficulties in closing the deep soft tissue envelope around the knee and there were no cases of patellar avascular necrosis or skin necrosis. Hence we conclude that lateral parapatellar approach is a safe and reliable alternative to the medial parapatellar approach for correction of severe valgus deformity in TKA

Background:. The origin of a valgus deformity affects the algorithmic and individualized approach used in total knee arthroplasty in valgus knees. We developed a new physical examination technique, the swing test, to evaluate whether valgus malalignment is present when the knee flexes. Methods:. We performed the swing test on 44 valgus knees in 44 consecutive patients, and we conducted traditional malalignment analysis on each patient's long-film radiographs and computed tomography images to evaluate origin of valgus deformity. We did a diagnostic test to compare the results of the swing test with those of traditional malalignment analysis. Results:. For the swing test, there were positive findings in 22 cases and negative findings in the other 22 cases, whereas for traditional malalignment analysis, there were positive findings in 26 cases and negative findings in 18. The sensitivity, specificity, and accuracy for the swing test were 84.6%, 100%, and 90.9%, respectively. Conclusions:. The swing test is an effective technique in evaluating whether valgus deformity exists when the knee is flexed. Level of Evidence: Level III. See Instructions to Authors for a complete description of levels of evidence

It is a well-known fact that total knee arthroplasty is a soft tissue operation. Soft tissue balancing is the key to success in total knee arthroplasty. It is paramount importance to preserve the maximal amount of bone on both the femur and tibial side. In Indian scenario, majority of the patients present relatively late with varus or valgus deformity. Adding to this problem is poor bone quality due to osteoporosis. Our technique of Posterior cruciate ligament (PCL) retaining TKA with tibial end plate resection facilitates soft tissue balancing, preserves PCL and maximizes bone preservation on both tibial and femoral side achieving good results in minimum seven year follow up. We retrospectively analyzed seven year outcomes of 120 knees (110 patients), mean age was 65 years (range 55 to 75 years), who received contemporary cruciate-retaining prostheses with tibial end plate resection technique. The diagnosis was osteoarthritis in 96%, Rheumatoid arthritis in 2% and posttraumatic arthritis in 2% cases. There were more number of flexible varus knees as compared to flexible valgus knees. All the patients were followed up for minimum of 84 months with average follow up of 96 months. They were followed up at 3mths, 6mths, 1,3,5,7,9 and 10 years. The functional assessment was done using knee society knee and function scores. Radiographic analysis was done to rule out subsidence and aseptic loosening. The statistical significance was assessed using chi square test. Survival analysis was done using the Kaplan Meier analysis with revision taken as the endpoint. The average ROM was 100 degrees preoperatively and 120 degrees at last follow-up. The average knee society knee score improved from 45 points preoperatively to 90 points at last follow-up. The average knee society functional score improved from 48 points preoperatively to 84 points at last follow-up (p<0.05). Radiolucency was observed in 20 knees but all except four were non-progressive lesions smaller than 2 mm. None of the implants were revised for subsidence or aseptic loosening of tibial component. The technique of PCL retaining total knee arthroplasty with tibial end plate resection in arthritic knees with flexible varus or valgus deformity yields good functional outcome in medium term follow up with relatively low incidence of subsidence of the tibial implant. This technique appears promising for total knee arthroplasty in osteoporotic bones where retaining the strong subchondral bone increases the longevity of the implant

Computer navigation has been advocated as a means to improve limb and component alignment and reduce the number of outliers after total knee arthroplasty (TKA). We aimed to determine the alignment outcomes of 1500 consecutive computer-assisted TKAs performed by a single surgeon, using the same implant, with a minimum 1 year follow-up, and to analyze the outliers. Based on radiographic analysis, 112 limbs (7.5%) in 109 patients with mechanical axis malalignment of > 3° were identified and analyzed. The indication for TKA was osteoarthritis in 107 patients and rheumatoid arthritis in 2 patients. Fifty-eight patients (53%) had undergone simultaneous bilateral TKA and 13 patients (12%) had a BMI >30. Preoperative varus deformity was seen in 100 limbs and valgus deformity in 12 limbs. Thirty limbs (27%) had an extra-articular deformity (2 post HTO limbs, 3 malunited fractures, 1 stress fracture, 21 severe femoral bowing and 3 tibial bowing) and 21 limbs (19%) had severe lateral laxity or subluxation. Thirty-eight limbs (34%) had a preoperative deformity of =10° and 24 limbs (21.5%) had varus or valgus deformity of >20°. Postoperatively, 11 limbs were malaligned at ±3°, 74 limbs at ±4°, 22 limbs at ±5°, 2 limbs at ±6°, and 2 limbs at ±7°. Coronal plane malalignment of > ±3° of the femoral component was seen in 28 limbs, tibial component in 32 limbs, and both femoral and tibial components in 13 limbs. Twenty-six limbs with preoperative varus deformity had a postoperative valgus alignment of >183° and 3 limbs with valgus deformity had a postoperative varus alignment of <177°. The incidence of outliers for postoperative limb alignment was low at 7.5% with the tibial component showing a higher incidence of coronal malalignment. Malalignment may be more common in cases of simultaneous bilateral procedures, preoperative limb alignment of =10°, limbs with extra-articular deformities and severe lateral instability. There was a tendency towards over-correction of the hip-knee-ankle axis in both varus- and valgus-deformed knees. Further detailed statistical analysis of the data will be presented. This is the largest single-surgeon series of consecutive navigated TKAs and consequently the largest analysis of outliers that highlights which knees are likely to fall outside the +3 degrees of acceptable alignment and which therefore behoove the surgeon to exercise greater caution

Backgrounds. Most of in vivo kinematic studies of total knee arthroplasty (TKA) have reported on varus knee. TKA for the valgus knee deformity is a surgical challenge. The purposes of the current study are to analyze the in vivo kinematic motion and to compare kinematic patterns between weight-bearing (WB) and non-weight-bearing (NWB) knee flexion in posterior-stabilized (PS) fixed-bearing TKA with pre-operative valgus deformity. Methods. A total of sixteen valgus knees in 12 cases that underwent TKA with Scorpio NRG PS knee prosthesis operated by modified gap balancing technique were evaluated. The mean preoperative femorotibial angle (FTA) was 156°±4.2°. During the surgery, distal femur and proximal tibia was cut perpendicular to the mechanical axis of each bone. After excision of the menisci and cruciate ligaments, balancer (Stryker joint dependent kinematics balancer) was inserted into the gap between both bones for evaluation of extension gap. Lateral release was performed in extension. Iliotibial bundle (ITB) was released from Gerdy tubercle then posterolateral capsule was released at the level of the proximal tibial cut surface. If still unbalanced, pie-crust ITB from inside-out was added at 1 cm above joint line until an even lateral and medial gap had been achieved. Flexion gap balance was obtained predominantly by the bone cut of the posterior femoral condyle. Good postoperative stability in extension and flexion was confirmed by stress roentgenogram and axial radiography of the distal femur. We evaluated the in vivo kinematics of the knee using fluoroscopy and femorotibial translation relative to the tibial tray using a 2-dimentional to 3-dimensional registration technique. Results. The average flexion angle was 111.3°±7.5° in weight-bearing and 114.9°±8.4° in non-weight-bearing. The femoral component demonstrated a mean external rotation of 5.9°±5.8° in weight-bearing and 7.4°±5.2° in non-weight-bearing (Fig.1). In weight-bearing, the femoral component showed medial pivot pattern from 0° to midflexion and a bicondylar rollback pattern from midflexion to full flexion (Fig2). Medial condyle moved similarly in non-weight-bearing condition and in weight-bearing condition. Lateral condyle moved posterior in slightly earlier angle during weight-bearing condition than during non-weight-bearing condition (Fig.3). Discussion. Numerous kinematic analyses of a normal knee have demonstrated greater posterior motion of the lateral femoral condyle relative to the medial condyle, leading to a mean external rotation and a bicondylar rollback motion with progressive knee flexion. A kinematic analysis of valgus knee was reported to show a different kinematic pattern from a physiological knee motion. Many valgus knees showed paradoxical anterior translation from extension to mid-flexion and greater posterior translation in the medial condyle than in the lateral condyle. Kitagawa et al. reported that this non-physiologic pattern wasn't completely restored after TKA using medial pivot knee system. In the present study, we showed kinematic patterns of the TKA performed on the valgus knee to be similar to the normal knee for the first time, even though the magnitude of external rotation was small. Conclusions. We conclude that the medial pivot pattern followed by posterior rollback motion can be obtained in TKA with modified gap balancing technique for the preoperative valgus deformity

Objectives. The approach in total knee arthroplasty (TKA) with severe valgus deformity is controversial. The lateral parapatellar approach has been proposed for several years, but surgical technique of this approach was unusual and difficult. Therefore, we have consistently been selected medial parapatellar approach (MPP) for all cases. In this study, we investigated the short term results of TKA for severe valgus deformity with MPP about clinical and radiographic assessment. Methods. Seven knees in seven cases of severe valgus knees with stand femorotibial angle (FTA) less than 160 degrees were enrolled. Osteoarthritis were 6 cases, hemophilic arthropathy was 1 case and no rheumatoid arthritis case. There were 6 female and 1 male, and mean age was 63.6 years (41–75 years). Duration of follow up ranged 3 months to 22.5 months, with mean of 10.9 months. We compared alignment on standing radiograph, range of motion (ROM), the Japanese Orthopaedic Association (the JOA) score for osteoarthritic knee pre/postoperatively, and examined post operative complication retrospectively. Results. Significant changes of the range of motion pre- and postoperation were not obtained. The mean JOA score improved 50.0 preoperatively to 76.7 postoperatively. The mean stand FTA was corrected 149 degrees preoperatively to 174 degrees postoperatively (p0.001). Postoperative complications occurred in two cases. Aseptic loosening of tibial component due to pyoderma gangrenosum was one case, and peroneal nerve palsy was another. In the former case, revision TKA with varus-valgus constrained prosthesis were performed after a year from primary surgery. In the latter case, weakness of the extensor hallucis longus muscle was fully recovered 4 months later. Conclusion. The medial parapatellar approach was beneficial for TKA of severe valgus knee over the short term

In primary TKA, non- or semi-constrained TKA implants might have their limitations in the absence of collateral ligaments, severe deformity, large osseous defects and gross flexion-extension instability. Although most primary TKA indications can be solved with modular, non-hinged implants, an adequate balancing might require a relevant soft tissue release. This consequently adds complexity and operative time with less predictable results in the elderly patient. The current literature reporting on short- to mid-term results of rotating hinged implants in primary osteoarthritis shows some quite diverse results and consequently different interpretations of this implant type in primary knee arthroplasty. Although some authors were able to show good and excellent clinical results in 91% of patients and consequent survival rates of a rotating hinge implant after 15 years up to 96% in primary indications, others found high complication rates of up to 25% of all operated patients, which remains unclear for us and is inconsistent with our clinical results in primary and revision TKA in over 30 years of experience with the ENDO-Model rotating hinge implant. Our potential indications in the elderly for a rotating or pure hinged implant in primary TKA include: Complete MCL instability; Severe varus or valgus deformity (>20 degrees) with necessary relevant soft tissue release; Relevant bone loss including insertions of collaterals; Gross flexion-extension gap imbalance; Ankylosis; One staged implantation with specific antibiotics after PJI. Due to general limited soft tissues or hyperlaxity, patients with neuropathic joints, or lack of extensor mechanism should be considered for a complete hinged implant. The ENDO-model hinge has only been minimally adapted since its development in the 70´s, including fully cemented long stems, in modular and non-modular versions. We strictly reserve a rotational hinge in primary indications for patients >70 years with a combined varus alignment, whereas in severe valgus deformities, a complete hinged implant version should be used for our implant design

Aim. In surgeries on patients with advanced ligament instabilities or severe bone defects modern-generation of rotating hinged knee prostheses are one of the main options. The objective of our study is to evaluate the mid-term functional results and complications of several surgeries using this form of prosthesis. Material and Method. The rotating hinged knee prosthesis (RHKP) was applied to 208 knees of 204 patients in primary surgeries between September 2009 and December 2017, the minimum followup was 15 months (mean, 65 months; range, 15–115 months). Of the total number of female patients there were 152 (74.5%), men − 52 (25.5%). The average age of the patients was 64,6 years (from 32 to 85). The main indications for using RHKP were severe varus deformity with flexion contracture in 107 knees (51,4%), severe valgus deformity (from 20 to 50 degrees) in 54 knees (26,0 %), severe ligamentous deficiencies in 24 knees (11,5%) and ankylosis in the flexion position in 23 cases (11,1%). Patients were evaluated clinically (Knee Society score) and radiographically (positions of components, signs of loosening, bone loss). Results. The average Knee Society Knee Scores, and Knee Society Functional Scores were 27, and 18, respectively, before the surgery; and 86, and 77 in the final post-surgery follow-ups. In addition, the average range of motion increased from the pre-operative level of 46 to 104 degrees at the final evaluation. Four patients (2%) had various complications after the surgery : two patients had deep infection, in one case took place fracture of the hinge mechanism and in one - post-operative rupture of the patellar tendon. Conclusions. Primary knee arthroplasty using RKHP can be successful in cases with advanced ligament instability or severe bone defects. Modern-generation of the kinematic rotating-hinge total knee prostheses allow to achieve in difficult primary cases the same consistently good results as commonly used constructions in standard situations

Background and Purpose of Study. The Valgus knee in total knee Arthroplasty, is considered a more demanding procedure, often with ligament balance a greater challenge than seen with neutral or Varus knees. It has also frequently been suggested that prostheses with higher levels of constraint be used to avoid late-onset instability. Various lateral release techniques have also been suggested in the literature. This study is aimed at assessing the outcomes of an unconstrained, rotating platform designed prosthesis, the LCS, using our technique, in the management of severe valgus deformity. Methods. 44 knees in 42 patients with a pre-operative valgus deformity of more than 10 degrees were included in our retrospective series. We analyzed the radiographs for the degree of correction, the angle of tibial tray implantation, and femoral implantation angle, tibial slope, as well as the presence (or degree) of lift off and any complications were noted. In this group, 7 had a Valgus deformity of greater than 25 degrees, with a mean Valgus deformity of 17,36 degrees. The mean age at operation was 65. Clinical and radiological analysis was done Pre-hospital discharge and again post-operatively 6 weeks. Results. The mean coronal alignment was corrected from 17,36 degrees to 5 degrees of Valgus post operatively. 2 knees were corrected past neutral to varus alignment. There was 1 case of bearing spin out experienced early on in the series. The mean tibial implant angle was 1,7 degrees from neutral. Lift off in the early post-operative X-rays was seen in 6 patients, however at 3 month follow up the knees appeared to be well balanced. There were no infections or revisions for wear, one re-operation for bearing dislocation, and no cases of loosening in our series. There were no cases of delayed instability. Patient satisfaction was 86 %. Conclusions. The rotating platform, mobile bearing prosthesis, using our technique, provided a reproducible correction of deformity in Valgus knees, a well-balanced knee, a low complication rate, and an excellent degree of patient satisfaction. NO DISCLOSURES

In primary TKA, non- or semi-constraint TKA implants might have their limitations in the absence of collateral ligaments, severe deformity, large osseous defects and gross flexion - extension instability. Although most primary TKA indications can be solved with modular, non-hinged implants, an adequate balancing might require a relevant soft tissue release. This consequently adds complexity and operative time with less predictable results in the elderly patient. The current literature reporting on short to mid-term results of rotating hinged implants in primary osteoarthritis shows some quite diverse results and consequently different interpretations of this implant type in primary knee arthroplasty. Although some authors were able to show good and excellent clinical results in 91% of patients and consequent survival rates of a rotating hinge implant after 15 years up to 96% in primary indications, others found high complication rates of up to 25% of all operated patients, which remains unclear for us and is inconsistent with our clinical results in primary and revision TKA in over 30 years of experience with the Endo-Model rotating hinge implant. Our potential indications in the elderly for a rotating- or pure-hinged implant in primary TKA include: Complete MCL instability, Severe varus or valgus deformity (>20 degrees) with necessary relevant soft tissue release, Relevant bone loss including insertions of collaterals, Gross flexion-extension gap imbalance, Ankylosis, One staged implantation with specific antibiotics after PJI. Due to general limited soft tissues or hyper laxity, patients with neuropathic joints, or lack of extensor mechanism should be considered to a complete hinged implant. The ENDO-model hinge has only been minimal adapted since its development in the 70's, including fully cemented long stems, in modular and non-modular versions. We strictly reserve a rotational hinge in primary indications for patients >70 years with a combined varus alignment, whereas in severe valgus deformities, a complete hinged implant version should be used for our implant design

Methods. There were 106 men and 94 women (mean age 65 years; 22 - 85). 69 patients had inflammatory arthritis and 131 osteo-arthritis. 27 patients (13 B-P, 14 STAR) had a pre-operative varus/valgus deformity greater than or equal to 20 degrees. Mean follow-up was 48 months (36-72). Results. Ten patients had died from unrelated cause with satisfactory final outcome assessment. Thirteen ankles (4 STAR, 9 B-P) required revision surgery. The causes of failure were: early deep infection (1 STAR), recurrent deformity (1 STAR, 4BP) aseptic loosening (1STAR, 4 BP), implant failure (1STAR, 1 BP). Six revised ankles (5BP, 1STAR) had pre-operative varus/valgus deformity of 20 degrees or more. AOFAS score for pain improved from 0 to 35 and for function from 30 to 43. There was no difference between the two groups. Pre-operative range of movement was predictive of the final range of movement. Radiographic assessment showed that 30 patients (17BP, 13 STAR) had recurrent deformity (edge loading) as shown by the UHMWPE insert no longer articulating congruently with the metallic components. 14 ankles (8BP, 6 STAR) from this group had pre-operative deformity of 20 degrees or more. Conclusion. Patients with severe pre-operative deformity had a significant evidence of edge loading and failure resulting in revision surgery. BP replacements failed more frequently than STAR replacements but most BP failures were in ankles with severe pre-operative deformity