Current Orthopaedics (2001) 15, 413^ 422

c 2002 Elsevier Science Ltd. All rights reserved. doi:10.1054/cuor.2001.0227 , available online at http://www.idealibrary.com on

MINI-SYMPOSIUM:TOTAL KNEE REPLACEMENTPRACTICAL CONSIDERATIONS

(iii) The valgus and varus knee

R.W . Parkinson and V . Bhalaik
Department of Orthopaedics, Arrowe Park Hospital, Wirral, Merseyside CH49 5PE, UK

KEYWORDS knee, valgus deformity, varus deformity, total knee replacement

Summary Arthritis of the knee commonly leads to valgus or varus deformity . The authors discuss the principles of management of these deformities withtotal knee replacement.Virtually any deformity can be corrected.The coronal plane deformity must be corrected for a satisfactory long-term outcome to be achieved, and it is mandatory for the surgeon to achieve correct alignment and soft tissue balance.The surgeon needs to understand the softtissue and bone abnormalitiesin the arthritic knee in order to make the appropriate bone cuts and softtissue releases to ensure thatthe prosthetic joint will c 2002 Elsevier Science Ltd. All rights reserved. function optimally .

INTRODUCTION
Arthritis of the knee is very common and when advanced disease occurs, total knee replacement (TKR) is often indicated to alleviate pain, correct deformity, restore function and improve quality of life. Advanced arthritis nearly always leads to deformity, which may occur in two planes. Coronal plane deformity causes varus (bow-leg) or valgus (knock-knee) (Fig. 1). Sagittal plane deformity causes xed exion; hyperextension (or recurvatum) is very rarely caused by arthritis alone. Coronal and sagittal deformities often occur together. Deformity occurs due to a combination of bone loss and soft tissue contracture. Correction of deformity is therefore achieved with a combination of bone cuts and soft tissue releases. The surgical correction of exion deformity is not considered.

at the ankle joint. The anatomical axis is a line, which runs down the centre of the femoral shaft to the centre of the knee and then to the centre of the talus.The angle sub-tended by those two axes is in a range of 4 ^ 81 (average 61) of valgus in the normal individual, usually towards

NORMAL ALIGNMENT
In order to appreciate deformity in the arthritic knee it is important to understand alignment in the normal knee. The mechanical axis of the weight-bearing lower limb is a straight line, which runs from the centre of the femoral head through the centre of the knee joint (or just medial to it) through to the centre of the talus
Correspondence to: RWP.Tel.: +44 151678511 1 ext. 2023; Fax: +44 151 6047023; E-mail: rwparkinson@ukgateway.net

Figure 1 Clinicalphotograph showing wind swept knee deformity .There is valgus deformity on the right and varus deformity on the left.

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the lower end of the range in males and the upper end in females (Fig. 2).

CLINICAL ASSESSMENT
Clinical assessment of varus and valgus is made on viewing the standing patient from in front and behind. Varus or valgus deformity is often increased when the patient weight-bears and the degree of deformity will often be underestimated if the patient is examined in the supine position alone.

The patient is examined walking to look for antalgic gait, lateral thrust (in varus knees) and general ease of mobility. Other signs may be demonstrated such as general unsteadiness, poor balance and neurological gaits. Appropriate use of walking aids can be assessed. An attempt should be made to quantify the degree of deformity with a goniometer, although signicant of observer error is to be expected.1 Deformity will be more accurately recorded radiographically. In a varus knee the medial soft tissue sleeve is tight and the lateral side is relatively lax. In a valgus knee the converse is true. The lateral soft tissues are tight and contracted; the medial soft tissues are lax (Fig. 3A and B).

Figure 2 Diagrammatic representation of anatomical and mechanical axes: (^ ^ ^) represents the anatomical axis. (Reproduced by kind permission of Zimmer Limited from the Intramedullary instrumentation surgical technique for cruciate retaining knees catalogue.)

Figure 3 (A) Diagram showing the softtissue balance in varus knee. (Reproduced by kind permission of Churchill Livingstone from ref.8; p.776,Fig. 26^65.) (B) Diagram showing the softtissue balance in valgus knee. (Reproduced by kind permission of Churchill Livingstone from ref. 8; p.776,Fig. 26^66.)

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Figure 4 Method of obtaining a exion weight-bearingradiograph so as to bring the weight-bearing portion of the femoral condyles into view and demonstrate subtle changes of jointspace narrowing. (Adapted by kind permission of RosenbergTD et al.2)

Figure 5 (A,B) AP X-rays of the knee showing varus and valgus deformity of the knee. Note the loss of joint space, osteophyte formation, and periarticular sclerosis.

The range of movement should be recorded. It is important to measure the xed exion deformity (FFD) on a rm examination couch with a goniometer. Assessment with a guesstimate on a soft bed will lead to an underestimate of the FFD. Varus and FFD often coexist, particularly in a male patient.

The use of long-leg weight-bearing lms is recommended (Table 1), particularly for preoperative templating.

RADIOGRAPHS
Radiographs should include weight-bearing antero-posterior (AP), lateral and skyline views. Rosenberg et al.2 suggested that postero-anterior (PA) views taken in 401 of exion will show tibiofemoral joint space narrowing better than AP views in full extension (Fig. 4). Radiological signs of osteoarthritis are loss of joint space, the presence of osteophytes, peri-articular sclerosis and cyst formation (Figs. 5A, B and 6). Arthroplasty is usually indicated when there is bone on bone or Outerbridge grade 4 disease.

T able 1 Reasons for performing long-leg radiographs for preoperative planning inTKR 1. Preoperative templating 2. Accurate measurement of anatomic and mechanical axis 3. Detection of hip or ankle problems (e.g. arthritis) 4. Detection of previous tibia or femur fracture with associated deformity 5. Identication of retained metalwork including IM nails, plates and hip implants (not always remembered by the patient) 6. Identication of a narrow intramedullary canal (useful if intramedullary alignment instrumentation is used)

Figure 6 Lateral X-ray of the knee showing signs of decreased joint space and osteophytes.

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PRINCIPLES
Varus deformity is much more common than valgus, in the authors experience in a ratio of 15:1. The varus knee is often associated with xed exion deformity, particularly in male patients with osteoarthritis (OA). Combined valgus and xed exion deformity is most commonly seen in inammatory arthritis. For TKR to be successful, alignment of the lower limb has to be restored to normal, i.e. between 41 and 81 of valgus. Failure to correctly align the knee will lead to early failure of the implant by polyethylene wear and loosening. Coronal plane deformity is corrected by a combination of appropriate bone cuts and soft tissue releases. Bone cuts are made using the alignment jigs provided by the implant manufacturer. The femoral cut is made perpendicular to the mechanical axis of the femur and on average 61 valgus to the anatomical axis. Intramedullary alignment is commonly used to make the distal femoral cut and a 4 ^ 81 cutting block is employed jigged from the anatomical axis (Fig. 7).The precise angle of cutting block can be decided by templating preoperative long-leg X-rays. The authors use a 61 cut in virtually every patient. The tibial cut is made perpendicular to the long axis of the tibia using either intra- or extramedullary alignment jigs (Fig. 8).

Figure 8 Diagram showing the alignment of the jig for the tibial cut perpendicular to the long axis of the tibia. (Reproduced by kind permission of Zimmer Limited from the Intramedullary instrumentation surgical technique for cruciate retaining knees catalogue.)

CHOICE OF ARTHROTOMY
The conventional surgical approach for TKR is a medial parapatellar arthrotomy for both varus and valgus knees.The arthrotomy is made in the quadriceps tendon and then carried distally, skirting the medial border of the patella and nishing just medial to the tibial tubercle. The proximal part of this arthrotomy can be made adjacent to vastus medialis in which case it is called the border cut. If the arthrotomy is made in the midsubstance of the tendon it is called the 25% or 50%cut depending on its exact location (Fig. 9). Homan3 popularized the subvastus approach, which preserves the extensor tendon mechanism by elevating the inferior border of the vastus medialis obliquus from the intermuscular septum and the adductor aponeurosis. This is not recommended in the obese patient due to difculty in everting the patella. For the same reason it is also contraindicated in revisionTKR. Faure et al.4 found in a comparison with the medial parapatellar approach that the subvastus approach offered a reasonable alternative and preserved greater quadriceps strength in the early postoperative period.

Figure 7 Diagram showing the jig alignment in relation to the femur. (Reproduced bykind permission of Zimmer Limited from the Intramedullary instrumentation surgical technique for cruciate retaining knees catalogue.)

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Figure 9 Diagram showing the incisions for the 50% parapatellar and the border cut parapatellar arthrotomy (VMFvastus medialis, QTFquadriceps tendon,VLFvastus lateralis, PFpatella, PTFpatellar tendon).

Figure 10 Diagram showing the incisions for the subvastus and the trivector arthrotomy (VMFvastus medialis, QTFquadriceps tendon, VLFvastus lateralis, PFpatella, PTFpatellar tendon).

Bramlett5 described the Trivector retaining arthrotomy and Engh6 describes the midvastus approach which are hybrid arthrotomies between the medial parapatellar and subvastus approach (Fig. 10). These two arthrotomies have been shown to lead to better patellar tracking and can be performed regardless of the body mass index. Keblish7 has described a lateral parapatellar arthrotomy for the valgus knee.The advantage is that the lateral retinacular patellar release is carried out with the arthrotomy, thus avoiding the need for a separate lateral release with a medial arthrotomy. In theory the risk of avascular necrosis of the patella is much reduced. The disadvantages of the lateral arthrotomy are that it is sometimes dicult to close the capsule distally, there is a risk of delayed wound healing, and the arthrotomy is unfamiliar to many surgeons as valgus deformity is less common.

ligament (PCL) is retained. Hence this approach may be more demanding (Fig.11). When the femur is cut rst a small amount of external rotation (usually 31) is built into the jigs to compensate for the conversion of a 31 varus slope on the normal tibia to a perpendicular cut. In practice, for xed bearing knees, it is probably not critical which bone, femur or tibia is addressed rst.

POSTERIOR TIBIAL SLOPE

The normal tibia has a posterior slope in the sagittal plane of 8 ^101 to aid posterior femoral roll back when

FEMUR OR TIBIA FIRST?

Opinion diers among orthopaedic surgeons as to whether the femur or tibia should be resected rst. Cutting the femur rst is technically easier and this method works well for many knee surgeons. However, proponents of tibia rst say that the anterior and posterior femoral cuts can be jigged more accurately from the cut tibial surface thus ensuring correct rotation of the femoral component.This may be more important in mobile bearing knees such as the LCS. The disadvantage is that surgical access to the tibia can be more dicult due to tight soft tissues, particularly if the posterior cruciate

Figure 11 Diagram showing the jig placement for the femoral cut, whenthe tibia is resected rst. (Reproduced bykindpermission of Deputy international Limited from the LCS surgical technique catalogue.)

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the knee goes into deep exion. There is debate as to how much posterior tibial slope there should be inTKR. Manufacturers provide jigs that provide 0 ^101 of posterior slope.The aim is the same as that in the normal knee, i.e. to allow femoral roll back as the knee exes. Too greater slope may cause instability in deep exion. The kinematics in TKR are not necessarily the same as the normal knee and a slope reproducing normal anatomy may not be needed. Another important disadvantage of a 101 posterior slope is that if the rotation of the tibial jig is not accurate then a complex cut will be made on the proximal tibia leading to a varus or valgus deformity. If the jig is internally rotated the tibial component will be in valgus. If the jig is externally rotated the implant will be in varus. When a 01 cut is used, the rotation of the tibial cutting block is not important as long as the tibial jig is parallel to the tibia in the sagittal plane. As a compromise between a 101 cut and a 01 many surgeons use a 3^ 41 posterior slope. This will allow some laxity in deep exion, but it will also be more forgiving if the rotation of the tibial cutting jig is not quite accurate. There is also a case for using a shallow tibial slope when there is a xed exion deformity, because a 101 posterior tibial slope will automatically produce a 101 xed exion deformity if the femur has been cut at 901 to its long axis. The authors use a 31 slope as a routine cut, and a 01 slope when xed exion deformity exceeds 151. Attention should always be paid to the manufacturers recommendations.

knee the exion and extension gaps are often trapezoid with the narrow side of the trapezium situated medially. After medial soft tissue release the exion and extension gaps should both be rectangular and symmetrical (Fig.12). In a valgus knee the lateral soft tissue sleeve is tight and a lateral release is required to equalize the exion/ extension gaps (Fig.13).

SOFT TISSUES
Varus knee
In the varus knee the primary area of bone loss is on the medial tibial condyle. There is a contracture of the med-

FLEXION^EXTENSION GAP
Understanding the concept of the exion/extension gap is crucial to alignment and ligament balance in TKR. Unless the exion and extension gaps are equalized theTKR will not be correctly balanced and a suboptimal outcome will result. It is very important that proper balance is obtained between the medial and lateral sides to distribute stress evenly and allow the knee to assume normal (61 valgus) alignment and thus a smooth arc of motion. An unbalanced knee will also cause premature wear and early failure of the implant due to edge loading and point contact of the femoral component on the polyethylene. The extension gap is the space created by the cut surface of the distal femur and the cut surface of the proximal tibia with the knee in extension. The exion gap is the space created between the cut posterior surface of the femur and the cut tibial surface with the knee in exion. Assuming that the bone cuts are made rst and the soft tissue releases are made second, in the varus

Figure 12 Diagram showing a symmetrical exion and extension gap.

Figure 13 Intraoperative view of exion gap in a valgus right knee showing trapezoidal exion gap prior to performing postero-lateral corner release.

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ial soft tissue sleeve and relative laxity of the lateral soft tissue sleeve. The medial soft tissue sleeve is mainly the medial collateral ligament (MCL), which has two components. The supercial MCL lies anteriorly and the deep portion of MCL (also called the posterior oblique ligament (POL)) which lies posteriorly. The hamstring tendons, which insert into the antero-medial aspect of the tibia as the pes anserinus (sartorius, gracilis and semitendinosus) may also be tight medially. The medial release for a varus knee is carried out as a sub-periosteal peel and can be performed with sharp dissection or cutting diathermy. The release can be continued postero-medially and distally in the same manner or with a curved osteotome. This medial peel was popularized by Insall and is sometimes referred to as the New York release (Figs.14 and 15).8 In most varus knees it is only necessary to release the anterior (supercial) portion of the MCL.The POL does not usually have to be divided except in severe varus deformity (201 or more). Whiteside9 has found that the POL is tight in extension and lax in exion (Fig. 16A and B), and thus the POL may need to be released if there is a xed exion deformity. The medial release should be performed sequentially, releasing small amounts at a time. It is much easier to continue a release if insucient release has been made initially than to tighten a structure that has been overlengthened.

Figure 15 The varus release completed. Only the supercial medial collateral ligament remains intact. Insall. (Reproduced by kind permission of Churchill Livingstone from ref. 8; p. 783, Fig. 26^75E.)

Figure 16 (A) Diagram showing medial side of the knee with the posterior oblique ligament tight in extension. (Reproduced by kind permission of Dr LA Whiteside, Missouri Bone and Joint Center,St Louis,Missouri.) (B) Diagram showing medial side ofthe knee with the posterior oblique ligament lax in exion. (Reproduced by kind permission of Dr LA Whiteside,Missouri Bone and Joint Center, St Louis,Missouri.)

Figure 14 The varus release. Subperiosteal stripping beneath the supercial medial collateral ligament begins the exposure. (Reproduced by kind permission of Churchill Livingstone from ref. 8; p.782,Fig. 26^75A.)

The proximal extent of the release is the medial joint line and can be extended distally as required. It can be carried to the midsagittal point on the tibia in virtually all knee replacements, whether varus or valgus. This amount of release is needed in any case to expose the proximal tibia. In many varus knees this release alone is sucient. Provided the knee has been correctly balanced and aligned at the time of surgery, there is no need

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to surgically reattach the medial soft tissue sleeve to the tibia at the end of the procedure. Late valgus instability in TKR is rare even with a most extensive medial release (unless the components become loose or worn). Engh6 has described a medial release on the femur using a medial femoral epicondylar osteotomy, but that is rarely required for primaryTKR. It is also important to remove the medial femoral and tibial osteophytes because they can tent the medial ligament. The osteophytes cleave o from bone easily along a visible tide-mark.

Valgus knee
The valgus knee is rarer than the varus knee and therefore it can be a more dicult surgical challenge.The primary area of bone loss is the lateral femoral condyle. Bone loss on the lateral tibial condyle is less than that on the femoral side, whereas in the varus knee the bone loss is primarily on the tibial condyle. The lateral soft tissue anatomy is more complex and variable than on the medial side and it is these structures (Table 2) that may require release. In order to realign and balance a valgus knee a sequential soft tissue release is performed, checking and rechecking after each release. The sequence in which the ligaments, tendons, muscles and capsule are released depends on the surgeons preference. In a mild valgus deformity correct alignment can usually be achieved by releasing the postero-lateral corner of the knee comprising the postero-lateral capsule and popliteus tendon alone. If the knee is still tight then the authors go on to release the lateral collateral ligament from its femoral origin followed by the lateral head of gastrocnemius taking care to stay close to bone at all times. If the knee is still tight, the next structure to be released or recessed is the PCL. If the PCL is excised completely then a posterior-cruciate sacricing prosthesis should be implanted (either a peg and cam mechanism or a tibial dish with an anterior lip) (Fig.17).

Figure 17 Photograph showing a posterior cruciate stabilized knee prosthesis with polyethylene peginterdigiting with a cam on the trial femoral component.

In extreme cases the knee may still not be balanced in which case the iliotibial band is separated from its attachment to Gerdys tubercle. Sometimes a Z-lengthening in the midsubstance is recommended. It can also be perforated with multiple small stab incisions. Release of the long head of biceps from the head of the bula is rarely necessary. Care must be taken to protect and preserve the lateral popliteal nerve, at risk in the correction of a valgus knee which inevitably stretches the nerve to some extent. The risk of neurapraxia leading to foot-drop must be included in the patients preoperative counselling and informed consent. The risk of foot-drop is greater when there is a combination of valgus and xed exion deformity. If foot-drop develops postoperatively most authorities recommend an expectant policy because there is often spontaneous recovery of the lesion. If the foot-drop has not recovered at 6 weeks then exploration and decompression or repair should be considered, but Nutton10 has suggested that the nerve lesion may be ischaemic and recommended immediate urgent exploration.

T able 2 Soft tissue structures that may be contracted and tight in a valgus knee and the order in which the authors prefer to perform a sequential release 1. Postero-lateral capsule (including arcuate and popliteobular ligaments) 2. Popliteus tendon 3. Lateral collateralligament 4. Lateral head of gastrocnemius 5. Posterior cruciate ligament 6. Iliotibial band 7. Biceps tendon

DEALING WITH BONE LOSS

Most varus and valgus knees can be dealt with using standard o-the-shelf modular knee systems supplied by the manufacturers. Occasionally bone grafts, augments or wedges are required to compensate for bone loss.Varus knees with severe deformity often have excessive loss of bone from the medial tibial condyle (Fig.18A).This can be addressed in four ways: 1. Resect more tibial bone down to a at surface and use a thicker insert. This means sacricing good lateral bone (Fig.18B).

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large defect however, then a distal lateral femoral augment should be used.

SPECIAL SITUATIONS
The vast majority of varus and valgus deformities can be addressed with conventional modularTKR systems.Very occasionally where there is exceptionally gross deformity or bone loss will special implants be required.Very unstable knees may need to be treated with a super-stabilized prosthesis or rotating hinge. Massive bone loss situations may need custom-made implants.

SUMMARY
Varus and valgus arthritic knees can be very successfully treated with TKR. Virtually any deformity can be corrected (Fig. 19). It is mandatory for the surgeon to achieve correct alignment and soft tissue balance. Coronal plane deformity must be corrected for a satisfactory long-term outcome to be achieved.The surgeon needs to understand the soft tissue and bone abnormalities in the arthritic knee in order to make the appropriate bone cut and soft tissue releases to ensure that the prosthetic joint will function optimally.

Figure 18 (A) Preoperative antero-posterior X-ray of a patient showing osteoarthritic changesin both knees.Thereisvarus deformity with considerableloss of bone on boththe medialtibial condyles. (B) Postoperative X-ray of the left knee of the same patient (Fig.18A) showing the use of generous at resection of the proximal tibia with no augment and a thicker insert to deal with medial tibial condyle bone loss. (C) Postoperative X-ray of right knee ofthe same patient (Fig.18A) showing one method of dealing with medial tibial condylar bone loss. It shows the use of 151 half medial wedge with 50 mm modular stem on the housing of the tibial componentto oset shear stresses.

2. Perform a more conservative bone cut and use a metal tibial augment on the medial side. Usually a slightly longer stem is required on the tibial component (Fig.18C). 3. Use autograft bone to ll the defect. The graft is usually held with a screw. If the graft fails to incorporate there is a risk of varus collapse. 4. Small residual bone defects (3 mm or less) can be lled with bone cement. It is unusual to require an augment for a valgus knee. A ush distal femoral cut and thicker insert to ll the exion/extension gap can compensate for the bone loss on the lateral femoral condyle. This has the eect of raising the joint line slightly (i.e. building up tibial height to compensate for femoral bone loss) but it seems to have little, if any adverse eect on clinical outcome. If there is a very

Figure 19 Clinical photograph showing right total knee replacement with correct alignment in 61 valgus. The left knee is in varus due to osteoarthritis.

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ACKNOWLEDGEMENTS
The authors would like to thank Mr Vishal Sahani, Department of Orthopaedics and Mr Paul Bannon, Department of Medical Illustration for their help in the preparation of illustrations for this manuscript. The authors would also like to thank Depuy International Limited and Zimmer limited for their help in the preparation of the article.

REFERENCES
1. Wagner J C.Observer error in medicine.Confessions of a reluctant measurer. Proc R Soc Med1968; 61: 449^ 451. 2. RosenbergT D, Paulos L E, Parker R D,Coward D B, Scott S M.The forty-ve degree posteroanterior exion weight-bearing radiograph of the knee. J Bone Joint Surg Am 1988; 70: 1479^1483. 3. Hofmann A A, Plaster R L, Murdock L E. Subvastus (Southern) approach for primary total knee. Clin Orthop 1991; 269: 70 ^77 . 4. Faure B T, Benjamin J B, Lindsey B, Volz R G, Schutte D. Comparison of the subvastus and paramedian surgical approaches in bilateral knee arthroplasty. J Arthroplasty1993; 8: 51 1^516.

5. Donnachie N J, Parkinson R W, Bramlett K W. Trivector retaining Arthrotomy. Presentation at the Annual Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, CA,1997 . 6. Engh G A. Medial epicondylar osteotomy: a technique used with primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity. Instr Course Lect 1999; 48: 153^156. 7 . Keblish P A.The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with two-year follow-up evaluation. Clin Orthop1991; 271: 52^ 62. 8. Insall J N. Surgical Techniques and Instrumentation in total knee arthroplasty. In: Insall J N, Windsor R E, Scott W N, Kelly M A, Aglietti P, (eds). Surgery of the Knee Vol. 2 2nd edn. New York, NY: Churchill Livingstone 1993; 739^ 804. 9. Whiteside L A, Saeki K, Mihalko W M. Ligament release in Total Knee Replacement of theVarus Knee. Presentation at the 67th Annual Meeting of the American Academy of Orthopaedic Surgeons, March15^19, 2000. 10. Nutton R W, Burnett R. Prevention of common peroneal nerve palsy after knee surgery for valgus deformity about the knee. Knee 2000; 7: 53.