total knee arthroplasty in valgus knee h.makhmalbaf md consultant knee surgeon mashad university
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Total Knee Arthroplasty in Total Knee Arthroplasty in Valgus kneeValgus knee
H.Makhmalbaf MDH.Makhmalbaf MD
Consultant Knee surgeonConsultant Knee surgeon
Mashad UniversityMashad University
The Typical patientThe Typical patient
Sever valgus deformitySever valgus deformity
Elderly woman in7th or8th decadeElderly woman in7th or8th decade
Has had “knock knees” Has had “knock knees”
Also had patellofemoral problemsAlso had patellofemoral problems
Valgus deformity progressesValgus deformity progresses
Loss of lateral joint spaceLoss of lateral joint space
Attenuation of MCLAttenuation of MCL
The typical patientThe typical patient
PFJ involvement & patella dysplasia on PFJ involvement & patella dysplasia on X-RayX-Ray
Patella subluxation & concave patellaPatella subluxation & concave patella
Patella alta & a very thin patellaPatella alta & a very thin patella
Chondrocalcinosis & calcification of Chondrocalcinosis & calcification of meniscimenisci
Long leg film of tibia shows valgus bowLong leg film of tibia shows valgus bow
The typical patientThe typical patient
The valgus tibia is problematic if using The valgus tibia is problematic if using intramedullary guide intramedullary guide
The long leg film is necessary to templateThe long leg film is necessary to template
The diagnosis is usually OA or RAThe diagnosis is usually OA or RA
Hypermobile knee or hyperextentionHypermobile knee or hyperextention
In RA might have stiff knee & flexion cont.In RA might have stiff knee & flexion cont.
Clinical features of valgus vs varusClinical features of valgus vs varus
Valgus knees tolerate significant damageValgus knees tolerate significant damage
In windblown knees varus knee is more In windblown knees varus knee is more symptomaticsymptomatic
Varus knee should be operated on 1Varus knee should be operated on 1stst
Source of deformity is also differentSource of deformity is also different
Medial tibial plateau is deficient & tibial Medial tibial plateau is deficient & tibial joint line in sever varus in varus kneesjoint line in sever varus in varus knees
The femoral joint line is still in 5-7 valgusThe femoral joint line is still in 5-7 valgus
Valgus vs varus kneeValgus vs varus knee
In valgus knees, is from the femurIn valgus knees, is from the femur
The tibial joint line usually in neutralThe tibial joint line usually in neutral
The femoral joint line is in marked valgusThe femoral joint line is in marked valgus
Deformity due to hypoplasia of lat.femoral Deformity due to hypoplasia of lat.femoral condylecondyle
Both distally & posteriorlyBoth distally & posteriorly
The tibial defect in valgus is containedThe tibial defect in valgus is contained
Variants of valgusVariants of valgus
Based on degree of deformityBased on degree of deformity
Status of MCL, osseous deficiency &Status of MCL, osseous deficiency &
The amount of release must be performedThe amount of release must be performed
Variant I: mild & correctable deformityVariant I: mild & correctable deformity
Variant II: greater deformity ,intact soft Variant II: greater deformity ,intact soft tissuetissue
Variant III: stretched MCL, Marked bone Variant III: stretched MCL, Marked bone loss & deformity & lateral contractureloss & deformity & lateral contracture
Type of prosthesisType of prosthesis
In variant I: P CR or PS may be usedIn variant I: P CR or PS may be used
In variant II: may require a PS implantIn variant II: may require a PS implant
Invariant III: a PSC (constrained) should Invariant III: a PSC (constrained) should be usedbe used
Complete set of instruments if preferred Complete set of instruments if preferred
Lateral femoral condyle hypoplasiaLateral femoral condyle hypoplasia
Is present in sever valgus deformityIs present in sever valgus deformityExists both distally & posteriorlyExists both distally & posteriorlyIn distal femoral resection don’t cut to the In distal femoral resection don’t cut to the defectdefectThe deficiency must be augmentedThe deficiency must be augmentedIf not, causes large extension gapIf not, causes large extension gapAnd elevation of joint lineAnd elevation of joint lineAnd mid-flexion laxity, distorting kinematicAnd mid-flexion laxity, distorting kinematic
The angle of DF cutThe angle of DF cut
5 degree is preferred5 degree is preferred
7 degree cut is better for balance but?7 degree cut is better for balance but?
55oo or less to overcorrect the deformity or less to overcorrect the deformity
Less tension on MCL on WBLess tension on MCL on WB
But needs more lateral releaseBut needs more lateral release
Distal metaphyseal bow Distal metaphyseal bow
More medial point of entrance in the notch More medial point of entrance in the notch
Balancing the knee in flex.& Balancing the knee in flex.& extensionextension
Create symmetric flexion extension gapsCreate symmetric flexion extension gaps
Valgus knees could be balanced in flexion Valgus knees could be balanced in flexion & extension independently& extension independently
In flexion the tissues are not tightIn flexion the tissues are not tight
Nor the medial tissues are lax in flexionNor the medial tissues are lax in flexion
Draw Whiteside line & transepicondylar axDraw Whiteside line & transepicondylar ax
In sever valgus int rotation of femoral In sever valgus int rotation of femoral component is necessarycomponent is necessary
Flexion extension balanceFlexion extension balance
Lateral release, after bone cutsLateral release, after bone cuts
Put spacers, varus & valgus testsPut spacers, varus & valgus tests
Inverted cruciform releaseInverted cruciform release
LCL, poplliteal, & Biceps tendon releaseLCL, poplliteal, & Biceps tendon release
PS in sever valgus & CR in mild onePS in sever valgus & CR in mild one
Surgical approachSurgical approach
SummarySummary
Associated with PFJ diseaseAssociated with PFJ disease
Lat femoral condyle hypoplasiaLat femoral condyle hypoplasia
Medial laxity, a valgus tibial bowMedial laxity, a valgus tibial bow
Conservative bone cutsConservative bone cuts
Cruciform release of ITB & capsuleCruciform release of ITB & capsule
Protect peroneal nerveProtect peroneal nerve
PS or CR kneePS or CR knee
Thank youThank you
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