The Valgus and Varus Knee | Knee | Human Anatomy

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 REPLACEMENTöPRACTICAL 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.

(Reproduced by kind permission of Churchill Livingstone from ref. Appropriate use of walking aids can be assessed. lateral thrust (in varus knees) and general ease of mobility.) Figure 3 (A) Diagram showing the softtissue balance in varus knee.Fig. In a valgus knee the converse is true. Other signs may be demonstrated such as general unsteadiness.8. 26^66. poor balance and neurological gaits. 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.776. p.1 Deformity will be more accurately recorded radiographically. (Reproduced by kind permission of Zimmer Limited from the Intramedullary instrumentation surgical technique for cruciate retaining knees catalogue. the medial soft tissues are lax (Fig. (Reproduced by kind permission of Churchill Livingstone from ref. An attempt should be made to quantify the degree of deformity with a goniometer. CLINICAL ASSESSMENT Clinical assessment of varus and valgus is made on viewing the standing patient from in front and behind.Fig. 8.) (B) Diagram showing the softtissue balance in valgus knee. The lateral soft tissues are ç tight and contracted.) . although signi¢cant of observer error is to be expected. Figure 2 Diagrammatic representation of anatomical and mechanical axes: (^ ^ ^) represents the anatomical axis. 2). p. 26^65. In a varus knee the medial soft tissue sleeve is tight and the lateral side is relatively lax.414 CURRENT ORTHOPAEDICS the lower end of the range in males and the upper end in females (Fig. The patient is examined walking to look for antalgic gait.776. 3A and B).

The use of long-leg weight-bearing ¢lms is recommended (Table 1). 4). Detection of hip or ankle problems (e. osteophyte formation. Preoperative templating 2.THE VALGUS ANDVARUSKNEE 415 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. particularly in a male patient. plates and hip implants (not always remembered by the patient) 6. Arthroplasty is usually indicated when there is ‘bone on bone’ or Outerbridge grade 4 disease. Identi¢cation 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. lateral and skyline views. and periarticular sclerosis. The range of movement should be recorded. particularly for preoperative templating. peri-articular sclerosis and cyst formation (Figs. RADIOGRAPHS Radiographs should include weight-bearing antero-posterior (AP). .B) AP X-rays of the knee showing varus and valgus deformity of the knee.g. Assessment with a ‘guesstimate’ on a soft bed will lead to an underestimate of the FFD. B and 6). 5A. T able 1 Reasons for performing long-leg radiographs for preoperative planning inTKR 1. Rosenberg et al. arthritis) 4. Detection of previous tibia or femur fracture with associated deformity 5. Varus and FFD often coexist. Accurate measurement of anatomic and mechanical axis 3. (Adapted by kind permission of RosenbergTD et al. It is important to measure the ¢xed £exion deformity (FFD) on a ¢rm examination couch with a goniometer. Identi¢cation of retained metalwork including IM nails. Note the loss of joint space. the presence of osteophytes. Radiological signs of osteoarthritis are loss of joint space.2) Figure 5 (A.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 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. which preserves the extensor tendon mechanism by elevating the inferior border of the vastus medialis obliquus from the intermuscular septum and the adductor aponeurosis. i. alignment of the lower limb has to be restored to normal. For the same reason it is also contraindicated in revisionTKR. 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. This is not recommended in the obese patient due to dif¢culty in everting the patella.416 CURRENT ORTHOPAEDICS PRINCIPLES Varus deformity is much more common than valgus. 9). in the author’s experience in a ratio of 15:1. Bone cuts are made using the alignment jigs provided by the implant manufacturer. Failure to correctly align the knee will lead to early failure of the implant by polyethylene wear and loosening. The femoral cut is made perpendicular to the mechanical axis of the femur and on average 61 valgus to the anatomical axis. 7). The authors use a 61 cut in virtually every patient.) CHOICE OF ARTHROTOMY The conventional surgical approach for TKR is a medial parapatellar arthrotomy for both varus and valgus knees. The varus knee is often associated with ¢xed £exion deformity. ’ 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. For TKR to be successful. Coronal plane deformity is corrected by a combination of appropriate bone cuts and soft tissue releases. (Reproduced by kind permission of Zimmer Limited from the Intramedullary instrumentation surgical technique for cruciate retaining knees catalogue. skirting the medial border of the patella and ¢nishing just medial to the tibial tubercle. 8). (Reproduced bykind permission of Zimmer Limited from the Intramedullary instrumentation surgical technique for cruciate retaining knees catalogue. Ho¡man3 popularized the subvastus approach. Faure et al.The arthrotomy is made in the quadriceps tendon and then carried distally. Combined valgus and ¢xed £exion deformity is most commonly seen in in£ammatory arthritis. The proximal part of this arthrotomy can be made adjacent to vastus medialis in which case it is called the ‘border cut. The tibial cut is made perpendicular to the long axis of the tibia using either intra. between 41 and 81 of valgus. Figure 8 Diagram showing the alignment of the jig for the tibial cut perpendicular to the long axis of the tibia. Figure 7 Diagram showing the jig alignment in relation to the femur.or extramedullary alignment jigs (Fig.e.) .The precise angle of cutting block can be decided by templating preoperative long-leg X-rays. particularly in male patients with osteoarthritis (OA).

VLFvastus lateralis. The disadvantage is that surgical access to the tibia can be more di⁄cult due to tight soft tissues. particularly if the posterior cruciate Figure 11 Diagram showing the jig placement for the femoral cut. QTFquadriceps tendon. 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. Keblish7 has described a lateral parapatellar arthrotomy for the valgus knee. PTFpatellar tendon). PTFpatellar tendon). QTFquadriceps tendon. femur or tibia is addressed ¢rst. for ¢xed bearing knees. In practice.This may be more important in mobile bearing knees such as the LCS. PFpatella.) .11). Hence this approach may be more demanding (Fig. Bramlett5 described the Trivector retaining arthrotomy and Engh6 describes the midvastus approach which are ‘hybrid’ arthrotomies between the medial parapatellar and subvastus approach (Fig. and the arthrotomy is unfamiliar to many surgeons as valgus deformity is less common. whenthe tibia is resected ¢rst. These two arthrotomies have been shown to lead to better patellar tracking and can be performed regardless of the body mass index. The disadvantages of the lateral arthrotomy are that it is sometimes di⁄cult to close the capsule distally. 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. there is a risk of delayed wound healing. (Reproduced bykindpermission of Deputy international Limited from the LCS surgical technique catalogue.The advantage is that the lateral retinacular patellar release is carried out with the arthrotomy. PFpatella. 10). ligament (PCL) is retained. In theory the risk of avascular necrosis of the patella is much reduced. 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 di¡ers among orthopaedic surgeons as to whether the femur or tibia should be resected ¢rst.THE VALGUS ANDVARUSKNEE 417 Figure 9 Diagram showing the incisions for the 50% parapatellar and the border cut parapatellar arthrotomy (VMFvastus medialis. However. it is probably not critical which bone. VLFvastus lateralis. Cutting the femur ¢rst is technically easier and this method works well for many knee surgeons. thus avoiding the need for a separate lateral release with a medial arthrotomy. Figure 10 Diagram showing the incisions for the subvastus and the trivector arthrotomy (VMFvastus medialis.

13). If the jig is internally rotated the tibial component will be in valgus. In a valgus knee the lateral soft tissue sleeve is tight and a lateral release is required to equalize the £exion/ extension gaps (Fig. Figure 13 Intraoperative view of £exion gap in a valgus right knee showing trapezoidal £exion gap prior to performing postero-lateral corner release. 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.12). but it will also be more forgiving if the rotation of the tibial cutting jig is not quite accurate. If the jig is externally rotated the implant will be in varus. . This will allow some laxity in deep £exion. Unless the £exion and extension gaps are equalized theTKR will not be correctly balanced and a suboptimal outcome will result. 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. knee the £exion and extension gaps are often trapezoid with the narrow side of the trapezium situated medially. Too greater slope may cause instability in deep £exion.The aim is the same as that in the normal knee. 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. i. There is debate as to how much posterior tibial slope there should be inTKR.418 CURRENT ORTHOPAEDICS the knee goes into deep £exion. 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. When a 01 cut is used. Attention should always be paid to the manufacturers recommendations. 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. The kinematics in TKR are not necessarily the same as the normal knee and a slope reproducing normal anatomy may not be needed. As a compromise between a 101 cut and a 01 many surgeons use a 3^ 41 posterior slope. 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. There is also a case for using a shallow tibial slope when there is a ¢xed £exion deformity. Assuming that the bone cuts are made ¢rst and the soft tissue releases are made second. 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. Manufacturers provide jigs that provide 0 ^101 of posterior slope.e. 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. After medial soft tissue release the £exion and extension gaps should both be rectangular and symmetrical (Fig. and a 01 slope when ¢xed £exion deformity exceeds 151. SOFT TISSUES Varus knee In the varus knee the primary area of bone loss is on the medial tibial condyle. in the varus Figure 12 Diagram showing a symmetrical £exion and extension gap. to allow femoral roll back as the knee £exes. The authors use a 31 slope as a routine cut.

In many varus knees this release alone is su⁄cient. The super¢cial MCL lies anteriorly and the deep portion of MCL (also called the posterior oblique ligament (POL)) which lies posteriorly. The hamstring tendons.) Figure 14 The varus release. (Reproduced by kind permission of Churchill Livingstone from ref. 26^75A.) (B) Diagram showing medial side ofthe knee with the posterior oblique ligament lax in £exion. 26^75E.THE VALGUS ANDVARUSKNEE 419 ial soft tissue sleeve and relative laxity of the lateral soft tissue sleeve. The release can be continued postero-medially and distally in the same manner or with a curved osteotome.The POL does not usually have to be divided except in severe varus deformity (201 or more). It can be carried to the midsagittal point on the tibia in virtually all knee replacements.Missouri Bone and Joint Center. Whiteside9 has found that the POL is tight in extension and lax in £exion (Fig. It is much easier to continue a release if insu⁄cient release has been made initially than to tighten a structure that has been overlengthened. (Reproduced by kind permission of Churchill Livingstone from ref.) The proximal extent of the release is the medial joint line and can be extended distally as required. Provided the knee has been correctly balanced and aligned at the time of surgery.14 and 15). This amount of release is needed in any case to expose the proximal tibia. releasing small amounts at a time. 16A and B). Fig. whether varus or valgus. p.Missouri. (Reproduced by kind permission of Dr LA Whiteside.) Figure 16 (A) Diagram showing medial side of the knee with the posterior oblique ligament tight in extension. Figure 15 The varus release completed. The medial release should be performed sequentially. This medial peel was popularized by Insall and is sometimes referred to as the New York release (Figs. St Louis.Missouri. there is no need . Missouri Bone and Joint Center. 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. 783. Subperiosteal stripping beneath the super¢cial medial collateral ligament begins the exposure.Fig. Insall.8 In most varus knees it is only necessary to release the anterior (super¢cial) portion of the MCL. which has two components. Only the super¢cial medial collateral ligament remains intact. p. and thus the POL may need to be released if there is a ¢xed £exion deformity. 8. 8. The medial soft tissue sleeve is mainly the medial collateral ligament (MCL). (Reproduced by kind permission of Dr LA Whiteside.782. gracilis and semitendinosus) may also be tight medially. which insert into the antero-medial aspect of the tibia as the pes anserinus (sartorius.St Louis.

Care must be taken to protect and preserve the lateral popliteal nerve. Occasionally bone grafts. checking and rechecking after each release. If the PCL is excised completely then a posterior-cruciate sacri¢cing prosthesis should be implanted (either a peg and cam mechanism or a tibial dish with an anterior lip) (Fig. In order to realign and balance a valgus knee a sequential soft tissue release is performed. 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. but that is rarely required for primaryTKR. The osteophytes cleave o¡ from bone easily along a visible ‘tide-mark’. 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. 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. Sometimes a Z-lengthening in the midsubstance is recommended.The primary area of bone loss is the lateral femoral condyle. The sequence in which the ligaments. augments or wedges are required to compensate for bone loss. Engh6 has described a medial release on the femur using a medial femoral epicondylar osteotomy. Postero-lateral capsule (including arcuate and popliteo¢bular ligaments) 2. Popliteus tendon 3. The risk of foot-drop is greater when there is a combination of valgus and ¢xed £exion deformity.Varus knees with severe deformity often have excessive loss of bone from the medial tibial condyle (Fig. muscles and capsule are released depends on the surgeon’s preference. Figure 17 Photograph showing a posterior cruciate stabilized knee prosthesis with polyethylene peginterdigiting with a cam on the trial femoral component. 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. but Nutton10 has suggested that the nerve lesion may be ischaemic and recommended immediate urgent exploration. Iliotibial band 7. This means sacri¢cing good lateral bone (Fig.420 CURRENT ORTHOPAEDICS to surgically reattach the medial soft tissue sleeve to the tibia at the end of the procedure. The risk of neurapraxia leading to foot-drop must be included in the patient’s preoperative counselling and informed consent. whereas in the varus knee the bone loss is primarily on the tibial condyle. Release of the long head of biceps from the head of the ¢bula is rarely necessary. Resect more tibial bone down to a £at surface and use a thicker insert. Posterior cruciate ligament 6. Lateral collateralligament 4. It can also be perforated with multiple small stab incisions. tendons.This can be addressed in four ways: 1. Valgus knee The valgus knee is rarer than the varus knee and therefore it can be a more di⁄cult surgical challenge. Bone loss on the lateral tibial condyle is less than that on the femoral side. In extreme cases the knee may still not be balanced in which case the iliotibial band is separated from its attachment to Gerdy’s tubercle. 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. Late valgus instability in TKR is rare even with a most extensive medial release (unless the components become loose or worn). It is also important to remove the medial femoral and tibial osteophytes because they can tent the medial ligament. If the foot-drop has not recovered at 6 weeks then exploration and decompression or repair should be considered. at risk in the correction of a valgus knee which inevitably stretches the nerve to some extent. If foot-drop develops postoperatively most authorities recommend an expectant policy because there is often spontaneous recovery of the lesion. . the next structure to be released or recessed is the PCL.18A).17). If the knee is still tight. Lateral head of gastrocnemius 5.18B).

Very unstable knees may need to be treated with a super-stabilized prosthesis or rotating hinge.18A) showing one method of dealing with medial tibial condylar bone loss.THE VALGUS ANDVARUSKNEE 421 large defect however.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.Thereisvarus deformity with considerableloss of bone on boththe medialtibial condyles. The left knee is in varus due to osteoarthritis. SPECIAL SITUATIONS The vast majority of varus and valgus deformities can be addressed with conventional modularTKR systems. It shows the use of 151 half medial wedge with 50 mm modular stem on the housing of the tibial componentto o¡set shear stresses. Figure 18 (A) Preoperative antero-posterior X-ray of a patient showing osteoarthritic changesin both knees. It is mandatory for the surgeon to achieve correct alignment and soft tissue balance. Perform a more conservative bone cut and use a metal tibial augment on the medial side. 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. 19). 3. (B) Postoperative X-ray of the left knee of the same patient (Fig. The graft is usually held with a screw. Virtually any deformity can be corrected (Fig. If the graft fails to incorporate there is a risk of varus collapse. 4.e.Very occasionally where there is exceptionally gross deformity or bone loss will special implants be required. Use autograft bone to ¢ll the defect. Usually a slightly longer stem is required on the tibial component (Fig. Massive bone loss situations may need custom-made implants. then a distal lateral femoral augment should be used. Small residual bone defects (3 mm or less) can be ¢lled with bone cement. 2. (C) Postoperative X-ray of right knee ofthe same patient (Fig. building up tibial height to compensate for femoral bone loss) but it seems to have little. It is unusual to require an augment for a valgus knee. This has the e¡ect of raising the joint line slightly (i.18C). . Coronal plane deformity must be corrected for a satisfactory long-term outcome to be achieved. if any adverse e¡ect on clinical outcome. SUMMARY Varus and valgus arthritic knees can be very successfully treated with TKR.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. If there is a very Figure 19 Clinical photograph showing right total knee replacement with correct alignment in 61 valgus.

2 2nd edn. 3. 48: 153^156. Benjamin J B.1997 . Schutte D. March15^19. Faure B T. Engh G A.Coward D B. 10. 6. 269: 70 ^77 . Presentation at the 67th Annual Meeting of the American Academy of Orthopaedic Surgeons. Burnett R. 739^ 804. Lindsey B. Trivector retaining Arthrotomy. 2. J Arthroplasty1993. Windsor R E. 8. 2000. Saeki K. 7 . Surgical technique and analysis of 53 cases with two-year follow-up evaluation. Kelly M A. In: Insall J N. 70: 1479^1483. Donnachie N J. (eds). 61: 449^ 451. J Bone Joint Surg Am 1988. Clin Orthop 1991. Murdock L E. Hofmann A A. Presentation at the Annual Meeting of the American Academy of Orthopaedic Surgeons. Insall J N. Scott W N. CA. San Francisco.Observer error in medicine.The lateral approach to the valgus knee. Parker R D. Bramlett K W. Instr Course Lect 1999. The authors would also like to thank Depuy International Limited and Zimmer limited for their help in the preparation of the article. Volz R G. Surgical Techniques and Instrumentation in total knee arthroplasty. NY: Churchill Livingstone 1993. Knee 2000. RosenbergT D. Parkinson R W. 7: 53. Subvastus (Southern) approach for primary total knee. 8: 51 1^516. Prevention of common peroneal nerve palsy after knee surgery for valgus deformity about the knee. 271: 52^ 62. Whiteside L A. Wagner J C. Ligament release in Total Knee Replacement of theVarus Knee. 4. 5. Surgery of the Knee Vol. Clin Orthop1991. REFERENCES 1.422 CURRENT ORTHOPAEDICS ACKNOWLEDGEMENTS The authors would like to thank Mr Vishal Sahani. Paulos L E. Nutton R W. Comparison of the subvastus and paramedian surgical approaches in bilateral knee arthroplasty. Plaster R L. Scott S M. 9. Proc R Soc Med1968. Department of Orthopaedics and Mr Paul Bannon. . Keblish P A.Confessions of a reluctant measurer. Department of Medical Illustration for their help in the preparation of illustrations for this manuscript. Medial epicondylar osteotomy: a technique used with primary and revision total knee arthroplasty to improve surgical exposure and correct varus deformity.The forty-¢ve degree posteroanterior £exion weight-bearing radiograph of the knee. Aglietti P. New York. Mihalko W M.

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