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      Total knee arthroplasty for a valgus deformity angle of >90° : A case report

      case-report

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          Abstract

          Rationale:

          Valgus knees are relatively rare in the clinic. Treatments for valgus deviations >90° represent a surgical challenge to achieve a balance between the soft tissue and bone and prevent nerve damage.

          Patient concerns:

          A 63-year-old woman with valgus deviations >90° in both knees complained that she had been unable to walk for 50 years.

          Diagnoses:

          Congenital malformation valgus deformity.

          Interventions:

          Bilateral total knee arthroplasty (TKA) was performed using a rotating hinge knee instrument from Endo-Model for axial correction and stabilization of the joint.

          Outcomes:

          The patient fully recovered 3 months after surgery. At the follow-up 6 years after the operation, the function of the knee joint clearly improved. The knee society score (KSS) increased from 35 to 90.

          Lessons:

          Constrained implants are commonly used to stabilize the joint and correct the bone axis in patients with severe ligamental instability, gross deformity, bone loss, and extreme deviation of the straight leg axis. Intraoperative exploration of the common peroneal nerve and the postoperative flexed position of the knee joints could help prevent nerve injuries.

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          Most cited references20

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          Total knee arthroplasty for severe valgus deformity.

          In 1985, the senior author (C.S.R.) developed a new soft-tissue release technique to balance valgus knees to avoid unacceptably high rates of late-onset instability and the need for primary constrained implants. This report describes the soft-tissue release technique and its long-term results when performed in primary total knee arthroplasty in patients with a severe valgus knee deformity. Four hundred and ninety consecutive total knee arthroplasties were performed by one surgeon between January 1988 and December 1992. In this group, seventy-one patients (eighty-five knees) had a valgus deformity of 10 degrees . Thirty-two patients (thirty-six knees) died, and four patients (seven knees) were lost to follow-up, leaving thirty-five patients (forty-two knees) followed for a minimum of five years. These twenty-seven women and eight men had a mean age of sixty-seven years at the time of the index operation. The technique included an inside-out soft-tissue release of the posterolateral aspect of the capsule with pie-crusting of the iliotibial band and resection of the proximal part of the tibia and distal part of the femur to provide a balanced, rectangular space. Cemented, posterior stabilized implants were used in all knees. Clinical and radiographic evaluations were performed at one, five, and ten years postoperatively. The mean modified Knee Society clinical score improved from 30 points preoperatively to 93 points postoperatively, and the mean functional score improved from 34 to 81 points. The mean range of motion was 110 degrees both preoperatively and postoperatively. The mean coronal alignment was corrected from 15 degrees of valgus preoperatively to 5 degrees of valgus postoperatively. Three patients underwent revision surgery because of delayed infection, premature polyethylene wear, and patellar loosening in one patient each. There were no cases of delayed instability. The inside-out release technique to correct a fixed valgus deformity in patients undergoing primary total knee arthroplasty is reproducible and provides excellent long-term results.
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            Total knee arthroplasty in the valgus knee.

            Valgus knee deformity is a challenge in total knee arthroplasty (TKA) and it is observed in nearly 10% of patients undergoing TKA. The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation. Bone tissue variations consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodelling. Soft tissue variations are represented by tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of the gastrocnemius and iliotibial band. Complete pre-operative planning and clinical examination are mandatory to manage bone deformities and soft tissue contractions/elongations and to decide if a higher constrained prosthesis is necessary. Two different approaches have been described to perform TKA in a valgus knee: the anteromedial approach and the anterolateral one. In valgus knee deformity bone cuts can be performed differently in order to correct low-grade deformities and reduce great deformities. There is still debate in the literature on the sequence of lateral soft tissue release to achieve the best alignment without any instability. The aim of this article is to review the anatomical variations underlying a valgus knee, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. We will also review the main approaches and surgical techniques both for bone cuts and soft tissue management. Finally, we will report on our experience and technique.
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              The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation.

              Valgus deformity correction poses a major challenge in total knee arthroplasty (TKA). The standard medial approach has many technical limitations and disadvantages that include patellofemoral maltracking and subsequent patellar problems. The lateral approach has been developed and utilized successfully in 79 cases (53 with over two-year follow-up evaluation) since 1980. The biomedical rationale of the approach is sound, and addresses the pathologic anatomy of fixed valgus deformity. Surgical technique is direct, anatomical, more physiologic, and maintains soft-tissue integrity. The "lateral release" is performed as part of the approach. Patellofemoral tracking and alignment stability are optimized and medial blood supply preserved. Clinical experience has shown the approach to be more aesthetic and results objectively superior. Scores have been good/excellent in 94.3% of cases. Knee stability is enhanced with the use of nonconstrained prostheses in this difficult group of patients. The lateral approach is recommended as the "approach of choice" for fixed valgus deformity in TKA.
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                Author and article information

                Journal
                Medicine (Baltimore)
                Medicine (Baltimore)
                MEDI
                Medicine
                Wolters Kluwer Health
                0025-7974
                1536-5964
                June 2019
                07 June 2019
                : 98
                : 23
                : e15745
                Affiliations
                [a ]Department of Joint Surgery, Honghui Hospital, Xi’an Jiaotong University
                [b ]Institute of Geriatrics, Xijing Hospital, The Air Force Medical University
                [c ]Department of Pathology, Worker's Hospital of Aecc Xi’an Aero–Engine LTD, Xi’an, P. R. China.
                Author notes
                []Correspondence: Yakang Wang, Honghui Hospital, Xi’an Jiaotong University, Xi’an, 710054, P. R. China (e-mail: wangyakangde@ 123456163.com ).
                Article
                MD-D-18-02823 15745
                10.1097/MD.0000000000015745
                6571272
                31169673
                324a5096-8d0d-4c82-b19c-f68909eb2e40
                Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

                History
                : 31 October 2018
                : 14 April 2019
                : 29 April 2019
                Categories
                7100
                Research Article
                Clinical Case Report
                Custom metadata
                TRUE

                total knee arthroplasty,valgus deformity,hinge knee
                total knee arthroplasty, valgus deformity, hinge knee

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