International Orthopaedics

https://doi.org/10.1007/s00264-021-05039-9

ORIGINAL PAPER

Finite element analysis of biomechanical effects of residual varus/

valgus malunion after femoral fracture on knee joint
Kai Ding1,2 · Weijie Yang1,2 · Haicheng Wang1,2 · Shi Zhan3 · Pan Hu1,2 · Junsheng Bai1,2 · Chuan Ren1,2 · Qi Zhang1,2 ·
Yanbin Zhu1,2 · Wei Chen1,2,4

Received: 14 December 2020 / Accepted: 6 April 2021

© SICOT aisbl 2021

Abstract
Objective Post-operative femoral shaft fractures are often accompanied by a residual varus/valgus deformity, which can
result in osteoarthritis in severe cases. The purpose of this study was to investigate the biomechanical effects of residual
varus/valgus deformities after middle and lower femoral fracture on the stress distribution and contact area of knee joint.
Methods Thin-slice CT scanning of lower extremities and MRI imaging of knee joints were obtained from a healthy adult
male to establish normal lower limb model (neutral position). Then, the models of 3°, 5°, and 10° of varus/valgus were
established respectively by modifying middle and lower femur of normal model. To validate the modifying, a patient-specific
model, whose BMI was same to former and had 10° of varus deformity of tibia, was built and simulated under the same
boundary conditions.
Result The contact area and maximum stress of modified models were similar to those of patient-specific model. The con-
tact area and maximum stress of medial tibial cartilage in normal neutral position were 244.36 ­mm2 and 0.64 MPa, while
those of lateral were 196.25 ­mm2 and 0.76 MPa. From 10° of valgus neutral position to 10° of varus, the contact area and
maximum stress of medial tibial cartilage increased, and the lateral gradually decreased. The contact area and maximum
stress of medial meniscus in normal neutral position were 110.91 ­mm2 and 3.24 MPa, while those of lateral were 135.83
­mm2 and 3.45 MPa. The maximum stress of medial tibia subchondral bone in normal neutral position was 1.47 MPa, while
that of lateral was 0.65 MPa. The variation trend of medial/lateral meniscus and subchondral bone was consistent with that
of tibial plateau cartilage in the contact area and maximum stress.
Conclusion This study suggested that varus/valgus deformity of femur had an obvious effect on the contact area and stress
distribution of knee joint, providing biomechanical evidence and deepening understanding when performing orthopedic
trauma surgery or surgical correction of the already existing varus/valgus deformity.

Keywords Femur fractures · Varus/valgus deformity · Finite element analysis · Biomechanical effect · Knee arthritis

Introduction whole body fracture in adults [1]. Fractures are often com-
bined with soft tissue injuries, resulting in massive blood
Femoral shaft fracture is one of the most typical long shaft loss and even mortality [2, 3]. As was estimated, in-hospital
fractures caused by high-impact trauma mechanisms (espe- mortality for high-energy injuries (including femoral shaft
cially traffic accident), accounting for about 4.6% of the fracture) in the elderly reached 12.3% [4]. In most cases,
femoral shaft fracture requires emergency surgery for inter-
nal fixation to stabilize the medical conditions [5].
Kai Ding, Weijie Yang and Haicheng Wang contributed equally to In the last several decades, with advances in surgical tech-
this work. niques and continued improvements in fixation materials, most
of patients with such fractures have a good prognosis and are
* Yanbin Zhu
zhuyanbin111@126.com able to return to their pre-fracture functional state [6–9]. How-
ever, there are still some reports about complications, espe-
* Wei Chen
surgeonchenwei@126.com cially the bone-related complications, like malunion or non-
union, with an incidence of 10% and 5%, respectively [10–12].
Extended author information available on the last page of the article

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The former complication often requires a second corrective
surgery, significantly increasing the burden on the patient’s
family and the cost of expenditure of medical resources.
Sasha et al. [11] analyzed the therapeutic effect of interlock-
ing intramedullary nail fixation for femoral shaft fractures, and
found that the incidence of post-operative deformity with angle
greater than 5° was up to 10% and with angle greater than 10°
up to 1.6%, respectively. William et al. [13] retrospectively
collected 374 patients with femoral shaft fractures fixed with
intramedullary nail, and reported that post-operative deform-
ity occurred in 9% of patients overall, with 30%, 2%, and 12%
for the proximal, middle, and distal parts, respectively. These
deformities, including valgus and varus deformities, will
undoubtedly alter the mechanical axis of lower extremity,
resulting in knee pain and development of knee osteoarthritis
(OA) if they exist for a long term [14, 15]. Kettelkamp et al.
[14] followed up 14 patients with femoral or tibial coronal
deformities and found them all developing knee osteoarthritis
after a mean follow-up of 32 years. Moreover, even if joint
replacement is performed in some severe OA cases, the uncor-
rected deformity will accelerate the wear of prosthetic con-
stituents [14], thereby, leading to prosthesis failure.
By far, researchers have done extensive work to investi-
gate the pathogenesis of knee OA and the effects of different
interventions [16]. However, there have been few studies
biomechanically quantifying the effects of femoral deform-
ity on the medial and lateral compartments of the knee, and
most of them have used in vitro testing [17, 18], which was
unable to fully show the changes of stress with varied extent
of the deformity. On the other hand, the specimen in previ-
ous studies included only a portion of the lower extremity
near the knee and could only be fixed according to the ana-
tomical axis of the femur, which was somewhat different
from mechanical axis. In fact, mechanical axis and anatomi-
cal axis have a physiological intersection valgus angle of
about 6°, and possibly this could induce a medial tilt of the
femur, increasing the stress on the medial aspect of the knee.
Given above, we designed this full-length finite element
(FE) model of a living human lower limb anatomy consisting
of bones, cartilage, meniscus, and knee ligaments, with aims
to (i) identify the relationship between extent of femoral
deformity and contact area as well as stress of medial and
lateral cartilage, meniscus and proximal tibia and (ii) quan-
titatively evaluate the effect of femoral deformity on knee
joint, so as to guide clinical treatment.
Materials and methods
Three‑dimensional (3D) models
After obtainment of their informed consent, a healthy vol-
unteer (male, 30 years old, height 170 cm, body weight
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60 kg) without a history of lower extremity injury and a
patient (male, 45 years old, height 170 cm, body weight
60 kg) with tibia varus deformity were scanned by computed
tomography scanner (SOMATOM Definition AS Siemens,
Germany) with a slicing distance of 0.625 mm from hip
joint to the ankle joint. MRI scans of the volunteers’ knee
joints were performed, and a total of 160 layers of MRI
images (MAGNETOM AVanto 1.5 T Siemens, Germany)
were obtained. Then, all these images, in DICOM format,
were imported into Mimics 17.0 software (Materialise, Leu-
ven, Belgium). The two-dimensional image data were trans-
formed into three-dimensional model by gray value adjust-
ment, region growth, and other commands. The apparent
density (ρ), Young’s modulus (E), and Poisson’s ratio of
each element were assigned based on the Hu value in the CT
scans according to the following formula [19], which made
a distinction between cancellous and cortical bone:
𝜌 g∕cm3 = 0.000968∗ HU + 0.5
( )
If 𝜌 < 1.2g∕cm3 , E = 2014𝜌2.5 , (MPa), v = 0.2
If 𝜌 > 1.2g∕cm3 , E = 1763𝜌3.2 , (MPa), v = 0.32
STL geometric models including femur, tibia, fibula, and
meniscus were obtained, then were imported into Geomagic
Studio13.0 software (Geomagic Company, USA). The non-
uniform rational basis spline (NURBS) surface of the model
was reconstructed, the nails were eliminated, the surface was
smoothed, and then the surface was materialized, and each
part was saved in STEP format. The normal lower extremity
model was imported into the UG NX 9.0 software (Siemens
Product Life cycle Management Software Inc., USA), and
the mechanical axis of the lower extremities was determined
on the three-dimensional model according to the method
proposed by Moreland et al. and Whitesid et al. [20, 21].
The distal and middle femoral fracture models were created.
There were 6 models of femoral varus and valgus deformi-
ties, each at 3°, 5°, or 10° respectively (Fig. 1.1).
Material properties and boundary conditions
The normal lower extremity model was imported into
Hypermesh14.0 software (Altair Company, USA) for mesh-
ing. All models were meshed with C3D4 elements.
The models were exported into the finite element analysis
software Abaqus6.12 (Simulia Corp., Providence, RI). All
models were assumed to behave with homogeneous, iso-
tropic, and linear elastic behaviour. According to the exist-
ing literature [22–24], articular cartilage, ligaments, and
meniscus were assigned a Young’s modulus (E) of 5 MPa,
215.3 MPa, and 59 MPa, respectively, and the Poisson’s
ratios were 0.46, 0.46, and 0.49, respectively.
The connection between the meniscus and the tibial
plateau was replaced by a one-dimensional linear spring
International Orthopaedics

Fig. 1  (1) Diagram of varus/valgus deformities of middle and lower femur; (a) valgus 10°; (b) valgus 5°; (c) valgus 3°; (d) neutral position 0°;
(e) varus 3°; (f) varus 5°; and (g) varus 10°. (2) Diagram of contact area distribution

element [25]. Ten spring elements were connected from
anterior and posterior horn of the meniscus to the tibial pla-
teau, and the spring stiffness was set at 200 N/mm.
In the assembled model, 4 contact relationships were
established for getting the contact area. The contact area
between the medial femoral condylar cartilage and the
medial meniscus was defined as surface 1, between the
lateral femoral condylar cartilage and the lateral menis-
cus as surface 2, between the medial femoral condylar
cartilage and the medial tibial plateau cartilage as sur-
face 3, and area between the lateral femoral condylar
cartilage and the lateral tibial plateau cartilage as sur-
face 4. The contact relationship was set as “hard contact
between surface and surface,” and the contact surface was
set as nonlinear “frictionless finite sliding,” which was
used to simulate the finite sliding state of the knee joint.
Ligaments and springs were bound to the corresponding
regions. Binding constraints were used for malunited sites
(Fig. 1.2).
In this experiment, distributed coupling constraints were
used to apply loads. A reference point was established, and
then the reference point was coupled to the reference surface.
A concentrated force load of 600 N was applied at the refer-
ence point, i.e., vertically above the femoral head, according
to the standing position of the human body. The distal tibi-
ofibula was fixed at 6 different settings based on deformity
extent (3°, 5°, 10° at varus and valgus, respectively).
Validation of finite element models
established. For comparison with previous studies,
2400 N [17] and 1000 N [28] loads were respectively
applied to the femoral head of neutral model to generate
the values on contact area and maximum contact stress of
medial and lateral cartilage (Table 2). Moreover, in order
to validate the deformed model (varus/valgus) based on
neutral model, a patient-specific model with 10° angle
tibia varus was also created. In this study, the stress val-
ues and contact area of tibial cartilage and meniscus in
neutral normal position were compared with the reported
results [17, 28] and the patient-specific model to evaluate
the effectiveness of modeling. The results of comparison
showed that our modeling method was appropriate to be
used on the next research, and the difference was not sig-
nificant (Figs. 2 and 3).
Results
Stress distribution of the medial and lateral
compartments of the knee joint under the femoral
varus and valgus deformities
The contact area, mean stress, and maximum stress of
medial tibial cartilage in normal neutral position were
244.36 ­m m 2, 0.33 MPa, and 0.64 MPa, while those of
lateral were 196.25 ­mm2, 0.24 MPa, and 0.76 MPa. From
neutral position to 10° of varus, the contact area, mean

The von Mises stress on the bone, articular cartilage, and Table 1  Amounts of nodes and elements of five components
meniscus of the intact lower extremities was tested to ana- Components Nodes Elements
lyze the mesh convergence. The convergence criterion used
Femur 6759 32,898
was a change of < 5%. The long bone mesh was set to 3 mm,
Femoral articular cartilage 1640 25,057
and the meniscus and cartilage mesh was set to 1 mm [26,
Meniscus 2883 11,957
27] (Table 1).
Tibial articular cartilage 5854 16,858
Complete finite element models of the lower
Tibia and fibula 23,610 94,440
extremities in neutral, varus, and valgus position were

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Table 2  Comparisons of contact area as well as stress of this study and previous studies
Study Contact area(cm2) Maximum stress(MPa)
Applied load (N) Medial compartment Lateral compartment Medial compartment Lateral compartment

Present study 2400 5.46 4.78 6.35 7.64

McKellop et al. [17] 2400 7.9 5.9 4.1 4.6
Present study 1000 4.01 3.75 5.37 6.65
Morimoto et al. [28] 1000 5.95 ± 1.54 4.44 ± 1.07 4.76 ± 1.2 5.24 ± 1.0

stress, and maximum stress of medial tibial cartilage Discussion

increased to 264.61 ­mm2, 0.49 MPa, and 1.16 MPa, and
the lateral gradually decreased to 31.32 m ­ m2, 0.03 MPa,
and 0.35 MPa. From the normal neutral position to 10°
of valgus, the contact area, mean stress, and maximum
stress of medial plateau cartilage gradually decreased to
24.58 ­mm2, 0.06 MPa, and 0.27 MPa, while those of lat-
eral increased to 215.46 m ­ m2, 1.03 MPa, and 2.08 MPa.
(Figs. 4, 5, and 6).
The maximum stress of medial tibia subchondral bone
in normal neutral position was 1.47 MPa, while that of lat-
eral was 0.65 MPa. From neutral position to 10° of varus,
the maximum stress of medial tibia subchondral bone
increased to 3.79 MPa, and the lateral gradually decreased to
0.41 MPa. From the normal neutral position to 10° of valgus,
the maximum stress of medial tibia subchondral bone gradu-
ally decreased to 0.64 MPa, while that of lateral increased
to 1.67 MPa (Fig. 4).
The contact area and maximum stress of medial meniscus
in normal neutral position were 110.91 m ­ m2 and 3.24 MPa,
2
while those of lateral were 135.83 m ­ m and 3.45 MPa. From
neutral position to 10° of varus, the contact area and maxi-
mum stress of medial meniscus increased to 117.91 m ­ m2
and 5.97 MPa, and the lateral gradually decreased to 38.99
­mm2 and 1.63 MPa. From the normal neutral position to 10°
of valgus, the contact area and maximum stress of medial
meniscus gradually decreased to 2.19 ­mm2 and 2.53 MPa,
while those of lateral increased to 215.46 ­mm2 and 5.87 MPa
(Figs. 4 and 5).
Lower extremity deformity is one of the major post-oper-
ative complications in orthopedic trauma field. Review of
literature showed that the lower extremity varus and valgus
deformities were closely related to the occurrence and pro-
gression of knee arthritis [15, 29]. Our results showed that
the femoral deformities did cause changes of the stress of
medial and lateral cartilage, subchondral bone, and menis-
cus, which, from the perspective of basic biomechanics,
added the evidences to support the association of femoral
deformity and potential knee arthritis.
The results showed that with the increasing varus
deformity degree, the stress and contact area of medial
knee cartilage, meniscus, and proximal tibia gradu-
ally increased, while those of the lateral compartment
decreased gradually. It was the opposite when that was in
setting of valgus deformity. The increase of stress in the
medial and lateral compartments can destroy the normal
structure of cartilage, meniscus, and proximal tibia. Femo-
ral deformities alter the balance of the medial and lateral
compartments of the knee. The varus and valgus deformi-
ties of lower extremities are closely related to the occur-
rence and development of knee joint medial and lateral
compartment arthritis, especially in obesity and overweight
groups [15, 30, 31]. The femoral deformity can cause the
mechanical axis of the lower extremities to move in/out. In
addition, the effect of femoral valgus and varus deformities

Fig. 2  Von Mises stress dis-

tribution on the lower extrem-
ity under the normal natural
position; (a) the compete lower
extremity; (b) the tibial plateau
cartilage

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Fig. 3  Comparison between the real varus tibia model and the artificial varus tibia model; (a) the medial tibial plateau cartilage; (b) the lateral
tibial plateau cartilage; (c) the medial meniscus; (d) the lateral meniscus
on knee joint is not symmetrical. The maximum stress of
10° valgus in lateral compartment is 2.75 times of normal
value, 41% of normal value in medial compartment. The
maximum stress of 10° varus in lateral compartment is
46% of normal value, 1.82-time of normal value in medial
compartment. This change is related to the existence of
anatomical mechanical angle of the femur. Furthermore,
the existence of anatomical mechanical angle of the femur
influences criteria for distal femoral osteotomy. In Martin’s
study [32], the 10° valgus deformity was corrected 5°, 10°,
and 15° osteotomy of distal femur. It was found that 15°
osteotomy was closer to the normal state.
Knee osteoarthritis is often manifested as narrowing of
joint space, sclerosis of subchondral bone, and so on, and
the initial cause can also be traced back to the unbalanced
stress on the medial and lateral plateau of tibia bone [33].
In this study, our findings demonstrated this point. First
of all, femoral deformity will correspondingly change the
stress magnitude and caused its skewed distribution on
the medial and lateral tibial cartilage. Femoral varus and
valgus deformities can increase the load of medial and
lateral cartilage respectively, which thereby increase the
odds of cartilage injury. Secondly, femoral deformity may
damage and destroy the structure of meniscus and cruciate
ligament, affecting the stability of the knee joint. Rajgopal
et al. [34] believed that varus deformity would cause dam-
age to ACL during exercise, and the deformities with or
without injury of the anterior cruciate ligament are incon-
sistent in the location and mode of cartilage wear. Zamber
et al. [35] and Irvine et al. [36] found that the destruction
of cruciate ligament could cause cartilage and meniscus
damage. In this experiment, we studied the model in the
standing position. A large prospective study showed that
knee valgus could lead to lateral meniscus and cartilage
injury over time [30]. Regarding meniscal injuries, we
speculate that stress concentration and joint relaxation
may damage the structure of the meniscus. Meniscus
injury will damage the stress distribution, contact area,
and buffering capacity of the knee joint [37, 38]. Finally,
subchondral bone osteosclerosis is an important part of
imaging changes in knee arthritis. It was reported that the
morphological changes of subchondral bone and cartilage
occur at the same time in patients with knee arthritis, even
the change of subchondral bone was faster than that of car-
tilage [39]. This is consistent with our experimental results
of the effect of femur deformity on the stress distribution
in the proximal tibia.
The lasting effect of abnormal stress and other external
effects can damage the structure of cartilage, meniscus, cru-
ciate ligament, and subchondral bone. We speculate that the
varus and valgus deformity of the lower extremities will
cause a variety of injuries to the normal tissue structure of
the knee joint, and a variety of structures will interact with
each other, which will lead to an increase in the incidence
of knee arthritis. Therefore, femoral deformities have an
important “initial action” in the process of osteoarthritis.
The influence on knee joint is increasing gradually over
time, and early treatment of deformity can avoid knee joint
injury. Except femoral deformities, we need to pay extra
attention to the injury of knee cartilage, meniscus, proximal
tibia, and cruciate ligament.
According to the results, femoral varus and valgus
deformities significantly alter the loading status of the
medial and lateral compartments of the knee [40]. At
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Fig. 4  Overall von Mises stress distribution on the tibial plateau cartilage, meniscus and the proximal tibia under the condition of varus and val-
gus deformities of femur; (a) valgus 10°; (b) valgus 5°; (c) valgus 3°; (d) neutral position 0°; (e) varus 3°; (f) varus 5°; and (g) varus 10°

Fig. 5  Overall the contact area

under the condition of varus and
valgus deformities of femur; (a)
valgus 10°; (b) valgus 5°; (c)
valgus 3°; (d) neutral position
0°; (e) varus 3°; (f) varus 5°;
and (g) varus 10°

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Fig. 6  Overall mean stress
of tibial cartilage under the
condition of varus and valgus
deformities of femur; (a) valgus
10°; (b) valgus 5°; (c) valgus
3°; (d) neutral position 0°; (e)
varus 3°; (f) varus 5°; and (g)
varus 10°
present, osteotomy has become a consensus for patients with
varus and valgus deformities of lower extremities greater
than 5°. Na et al. [41] believed that even for patients with
less than 5°, if these patients met the symptoms, functional
status, meniscus, and other conditions, patients could still
benefit through osteotomy to reduce the deformity degree.
Therefore, whether it is necessary to intervene in the lower
extremities not only needs to take into account the degree
of deformity but also needs to carefully evaluate the knee
joint. If measures are taken to correct the deformity and the
mechanical axis before the injury of the knee joint, the inter-
vention measures can be reduced and the knee joint function
can be preserved to the maximum extent. Bode et al. [42]
performed high tibial osteotomy combined with autologous
chondrocyte implantation and simple high tibial osteotomy
for patients with knee deformity less than 5° with cartilage
defect, and the prognosis of the former was significantly
better than that of the latter. This reflects the higher require-
ment of corrective surgery for varus and valgus deformities
and the emphasis on the structural integrity of the knee joint.
For patients, the integrity of the surrounding structure of the
knee joint and the residual function of the knee joint should
be carefully evaluated before operation, and corresponding
measures should be taken during the operation to maximize
preservation of the function of the knee joint and delay the
progression of knee arthritis.
Although our results revealed the biomechanical effects
of residual varus/valgus malunion on knee joint by finite
element analysis, limitations of this study exist. First, the
material properties of the cortical bone and cancellous were
assumed to be isotropic, linearly elastic, and homogeneous.
Nevertheless, all the models were set the same that the bias
would not be generated in comparison of models. Second,
we simplified the model without considering the impact of
muscle when the model was built, which may cause errors.
However, when standing position was chosen, the influence
of muscle is very small and can be ignored.
In summary, femoral deformities can change significantly
the stress distribution and contact area of knee joint. Resid-
ual varus/valgus deformity should be avoided. In the treat-
ment of femoral deformities, orthopedic surgeons should
correct the deformities early and pay extra attention to integ-
rity of knee joint for reducing the risk of traumatic arthritis
in the long term.
Author contribution W. C. and Y. Z. designed the study. W. C. and Y.Z.
searched relevant studies. K. D., W. Y., S. Z., C. R., Y. B., Q. Z., and
P.H. analyzed and interpreted the data. K. D., W. Y., and H. W. wrote
the manuscript and contributed equally to this work. W. C., Y. Z., and
S.Z. contributed most in the revision of this manuscript. All authors
approved the final version of the manuscript.
Funding This study was supported by the Support Program for the
National Natural Science Foundation of China (Grant No. 82072447,
81401789) and the Hebei National Science Foundation-Outstanding
Youth Foundation (Grant No. H2017206104). The funding source
has no role in study design, conduction, data collection, or statistical
analysis.
Declarations
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors. This study
conforms to the provisions of the Declaration of Helsinki and has been
reviewed and approved by the Institutional Review Board of The Third
Hospital of Hebei Medical University.
Informed consent Informed consent to participate and publish was
obtained from the volunteer individual in the study.
Conflict of interest The authors declare no competing interests.
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Authors and Affiliations

Kai Ding1,2 · Weijie Yang1,2 · Haicheng Wang1,2 · Shi Zhan3 · Pan Hu1,2 · Junsheng Bai1,2 · Chuan Ren1,2 · Qi Zhang1,2 ·
Yanbin Zhu1,2 · Wei Chen1,2,4
1
Kai Ding Trauma Emergency Center, the Third Hospital of Hebei
2805279748@qq.com Medical University, No. 139 Ziqiang Road, Qiaoxi District,
Shijiazhuang 050051, People’s Republic of China
Weijie Yang
2
2975087821@qq.com Key Laboratory of Biomechanics of Hebei Province,
Orthopaedic Research Institute of Hebei Province, No.139
Haicheng Wang
Ziqiang Road, Qiaoxi District, Shijiazhuang 050051, Hebei,
1569647282@qq.com
People’s Republic of China
Shi Zhan 3
Department of Orthopedic Surgery and Orthopedic
zhanshi4890966@yeah.net
Biomechanical Laboratory, Shanghai Jiao Tong University
Pan Hu Affiliated Sixth People’s Hospital, No. 600 Yishan Road,
panhu_1989@163.com Xuhui District, Shanghai 200233, People’s Republic of China
4
Junsheng Bai NHC Key Laboratory of Intelligent Orthopeadic Equipment
979744844@qq.com (The Third Hospital of Hebei Medical University),
Shijiazhuang, People’s Republic of China
Chuan Ren
rc18511859860@163.com
Qi Zhang
zq_19865@163.com

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