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Total Knee Arthroplasty for Severe Valgus Deformity

Amar S. Ranawat, Chitranjan S. Ranawat, Mark Elkus, Vijay J. Rasquinha, Roberto Rossi and Sushrut Babhulkar
J Bone Joint Surg Am. 87:271-284, 2005. doi:10.2106/JBJS.E.00308

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COPYRIGHT © 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

Total Knee Arthroplasty for

Severe Valgus Deformity
Surgical Technique
By Amar S. Ranawat, MD, Chitranjan S. Ranawat, MD, Mark Elkus, MD, Vijay J. Rasquinha, MD,
Roberto Rossi, MD, and Sushrut Babhulkar, MD
Investigation performed at the Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 2671-2676, December 2004

INTRODUCTION
Approximately 10% of patients requiring total knee arthroplasty have ABSTRACT
a valgus deformity (defined as an anatomic valgus of >10°). Correc-
BACKGROUND:
tion of the valgus deformity has posed technical challenges and has
In 1985, the senior author
produced variable clinical results in terms of correction of the defor- (C.S.R.) developed a new soft-
mity, instability, and the overall results. The valgus deformity may be tissue release technique to
caused by rheumatoid arthritis, posttraumatic arthritis, osteoarthritis, balance valgus knees to avoid
or metabolic bone disease. unacceptably high rates of late-
The valgus deformity consists of two components: an element of onset instability and the need
bone loss with metaphyseal remodeling, primarily from the lateral for primary constrained im-
plants. This report describes the
femoral condyle and lateral tibial plateau, and a soft-tissue contracture soft-tissue release technique
consisting of tight lateral structures, such as the iliotibial band, lateral and its long-term results when
collateral ligament, popliteus tendon, posterolateral capsule, and ham- performed in primary total knee
string muscles1. arthroplasty in patients with a
Multiple surgical techniques have been described to balance the severe valgus knee deformity.
soft tissues after correction of a severe valgus deformity during total
METHODS:
knee replacement. The following guide describes the “inside-out
Four hundred and ninety consec-
technique.”
utive total knee arthroplasties
were performed by one surgeon
SURGICAL TECHNIQUE between January 1988 and
Preoperative Radiographic December 1992. In this group,
Evaluation seventy-one patients (eighty-five
Weight-bearing anteroposterior, lateral, and sunrise radiographs of knees) had a valgus deformity of
10°. Thirty-two patients (thirty-
the knee should be assessed for overall coronal alignment in conjunc-
six knees) died, and four pa-
tion with an anteroposterior radiograph of the pelvis. The valgus knee tients (seven knees) were lost to
has been classified into three types. A type-I deformity has minimal follow-up, leaving thirty-five pa-
valgus and medial soft-tissue stretching. A typical type-II fixed valgus tients (forty-two knees) followed
deformity has a more substantial deformity (>10°) with medial soft- for a minimum of five years.
tissue stretching, as shown in Figures 1 and 2, and shall be the focus of continued
this technique guide. A type-III deformity is a severe osseous defor-

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ABSTRACT | continued

These twenty-seven women and

eight men had a mean age of
sixty-seven years at the time of
the index operation. The tech-
nique included an inside-out
soft-tissue release of the pos-
terolateral aspect of the cap-
sule 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 radio-
graphic evaluations were per-
formed at one, five, and ten
years postoperatively.

RESULTS:
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° both
preoperatively and postopera-
tively. The mean coronal align-
ment was corrected from 15°
of valgus preoperatively to 5°
of valgus postoperatively. Three
patients underwent revision
surgery because of delayed in-
fection, premature polyethylene
wear, and patellar loosening in FIG. 1
one patient each. There were no
Radiograph of a type-II valgus deformity.
cases of delayed instability.

CONCLUSIONS: mity after a prior osteotomy should be aware of distal femo-

The inside-out release technique with an incompetent medial
to correct a fixed valgus defor- soft-tissue sleeve, which is best
mity in patients undergoing pri- managed with a constrained or
mary total knee arthroplasty is
hinged total-knee design.
reproducible and provides excel-
lent long-term results.
Attention should always be
focused on both the osseous and
soft-tissue deformities. One
ral hypoplasia, posterior femoral
condylar erosion, unusual proxi-
mal femoral neck-shaft angles,
and metaphyseal remodeling of
both the femur and the tibia,
which can lead to malalignment
or malrotation of the femoral

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FIG. 2

Preoperative clinical photograph of

the knee shown in Figure 1.

component. Full-length stand-

ing radiographs of the lower ex-
tremity can help to avoid these
problems.
Fixed flexion contractures
and the amount of medial joint-
space opening may influence the
amount of osseous resection nec-
essary to correct the deformity.
Generally speaking, in type-II
fixed valgus deformities in which
the medial joint space on stand-
ing anteroposterior radiographs
is >1 cm, less bone than is typi-
cally removed should be resected
from both the distal part of the
femur and proximal part of the
tibia in order to allow for soft-
tissue balancing without elevat-
ing the joint line or creating an
extension gap that is too large.
The amount of osseous resection
can be templated on the radio- FIG. 3
graphs prior to surgery. Templating
of the pre-
Templating operative
Anteroposterior Radiograph (Fig. 3) radiograph.

1. A vertical line is drawn down

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FIG. 5

The alignment rod is centered over the medial third of the tibial tu-
bercle proximally and the mid-talus distally.
FIG. 4

Photograph of the PFC Sigma posterior stabilized

fixed-bearing total knee prosthesis.

the center of the femoral and tib- 3. On the femoral side, a proximal tibial cut and a distal
ial shafts. line is drawn at the level of the femoral cut performed in 3° of
2. On the tibial shaft, a line lateral aspect of the distal por- valgus to the anatomical axis.
is drawn perpendicular to the tion of the femur that is in 3° of This is done, as opposed to the
first line at the level of the more valgus in relation to the vertical typical 5° to 7° of valgus used for
involved lateral tibial plateau. line that was drawn in Step 1. a varus knee, in order to protect
This will be used to give an idea This line gives an idea of the against undercorrection of the
of the tibial resection that will be amount of osseous resection underlying deformity.
performed. The relative amount needed from the medial and lat-
of the osseous resection as well as eral femoral condyles. Coronal Lateral Radiograph
the ratio of lateral-to-medial re- correction with the “inside-out 1. On the lateral radiograph, any
section can be determined. technique” is based on a 90° posterior osteophytes should be

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identified and outlined with a

marker. During the procedure,
these osteophytes should be re-
moved as they may hinder the
range of motion as well as the
soft-tissue balance.
2. The lateral radiograph is
used for sizing the femoral com-
ponent, as magnification of the
femoral condyle is greater (by
5% to 7%) on the anteroposte-
rior radiograph.

Preoperative Selection
of Implant
The goals of total knee replace-
ment are to restore the alignment
of the knee, the joint line, the sta-
bility of the joint, and the range
of motion; to assure proper pa-
tellofemoral tracking; and to ap-
ply proper fixation techniques.
While these goals can be accom-
plished with any total knee re-
FIG. 7
FIG. 6
The femoral alignment rod is set at 3° of valgus during the rough anterior cut and the dis-
tal femoral cut.
placement design, we believe that the use of a posterior stabilized
there are inherent advantages to design when correcting the val-
gus deformity (Fig. 4). First, the
posterior stabilized design is in-
herently more stable than a cru-
ciate-retaining design as a result
of the post-cam mechanism and
joint surface conformity. Thus, it
is applicable to most deformi-
ties. Second, the posterior stabi-
lized design allows for greater
lateralization of the femoral and
tibial components, which greatly
improves patellar tracking and
minimizes the need for lateral
retinacular releases. Finally, this
technique involves complete
resection of the posterior cru-
ciate ligament, obviating any
advantage offered by a cruciate-
retaining design.

A spacer block is used to check knee ligamentous stability. Patient Positioning

After spinal anesthesia has been

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CRITICAL CONCEPTS
with use of an osteotome or
electrocautery to create a small
INDICATIONS: medial sleeve of tissue. The pa-
Type-I and II valgus deformities tella is then everted after releas-
of the knee with severe arthritis ing the patellofemoral ligament,
and the knee is fully flexed to
CONTRAINDICATIONS: expose the cruciate ligaments
Type-III valgus deformities
and the menisci. Use of a poste-
continued
rior stabilized implant requires
release of both cruciate liga-
ments at this point. The me-
nisci are excised, and the tibia is
maximally flexed and externally
rotated to expose the entire tib-
ial plateau. The knee is stabi-
lized in flexion by placing the

administered, the patient is

positioned supine on the oper-
ating table. A tourniquet is
placed high on the thigh, and
the knee is shaved if needed. A
lateral thigh post, positioned at
the level of the tourniquet, can
help to stabilize the knee when
it is placed in flexion with the
aid of a bump placed under the
foot and taped securely to the
table.

Approach and Exposure

After positioning, the extremity
is prepared and draped. With
the knee in extension, a straight
midline incision is planned.
The knee is then hyperflexed,
and a straight midline incision
is made starting approximately
5 to 10 cm proximal to the su-
perior pole of the patella and
continuing an equal distance
distal to its inferior pole. The
incision is carried down to
the deep fascial layer to expose
the quadriceps tendon, vastus
medialis obliquus, patella, and
patellar tendon. Undermining
of the skin flaps is avoided. A
standard medial arthrotomy is
made. FIG. 8
The medial soft tissues are Schematic of a valgus deformity before the “inside-out” release. Note the trapezoidal ex-
released subperiosteally from tension gap.
the proximal part of the tibia

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foot on the previously installed resection will vary, depending
bump. on the preoperative evaluation
of the deformity and ligamen-
Tibial Resection tous laxity. In type-II valgus de-
The proximal portion of the formities, one should remember
tibia should be resected at 90° to to resect less bone than normal,
its long axis. The exact level of i.e., generally, 6 to 8 mm should
be resected from the medial
side. Before the tibial cuts are
made, alignment should be con-
firmed with the alignment
guide. The distal portion of the
alignment device should align
with the center of the talus on
the anteroposterior radiograph.
On the lateral radiograph, the
alignment rod should run paral-
lel with the tibial crest. Once the
cutting jig is secured in place,
the proximal tibial resection is
performed.
Next, the trial tibial inset is
used to determine the size of
the tibial tray needed on the
basis of the anteroposterior
diameter of the lateral condyle.
An alignment rod is used to
check the alignment of the cut
tibial surface once again (Fig.
5). One should remember that,
when using this technique, a
varus tibial cut causes the fem-
oral component to be inter-
nally rotated during the flexion
gap evaluation.

Femoral Resection
The femoral canal is first en-
tered with use of a gouge to as-
sist in drill passage. The entry
point is the intersection of the
patellofemoral and the tibio-
femoral articular surfaces on the
lateral and medial femoral
condyles. The canal should be
entered with a drill, and then
the entry point should be en-
larged by rotating the drill be-
FIG. 9 fore sinking it completely. With
a correct entry point, the drill
Schematic after release of the posterolateral capsule and “pie-crusting” of the iliotibial
band. Note the symmetrical extension gap. LCL = lateral collateral ligament, and PCL = should not come into contact
posterior cruciate ligament. with the cortices of the femoral
shaft.

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Next, the intramedullary

femoral rod is inserted into the
hole and a femoral cutting jig is
aligned with the distal aspect of
the femur. The valgus angle with
the appropriate “right” or “left”
designation is set and placed on
the front of the locating device.
With a valgus knee, the jig is set
to cut in 3° of valgus to compen-
sate for metaphyseal-diaphyseal
valgus remodeling that has usu-
ally taken place and to avoid un-
dercorrection of the underlying
deformity (Fig. 6).
The cutting block is then
rotated until it is roughly paral-
lel to the cut surface of the tibia
with the knee in 90° of flexion. FIG. 10
The anterior rough cut is made, A spacer block is placed in the extension gap.
and then the distal femoral cut
is made, resecting no more
than 10 mm of bone from the balanced valgus knee. Next, a trally in the gap. If the knee is
medial side while only remov- lamina spreader is placed cen- unbalanced, this should mani-
ing 1 to 2 mm from the lateral
side.
At this point, the knee is
extended and a spacer block is
placed into the extension gap.
The limb is exsanguinated, and
the tourniquet is inflated. The
patella is then prepared for
resurfacing.

Evaluation of the
Extension Gap
Attention can now be directed
to the extension gap. With an
appropriately sized spacer block
in place, the mediolateral stabil-
ity of the knee is evaluated in
full extension by applying both
a varus and a valgus stress (Fig.
7). The application of stress FIG. 11

should demonstrate lateral side Applying a varus stress. Note the opening on the lateral side.
soft-tissue tightness in an un-

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CRITICAL CONCEPTS | continued

PITFALLS:
• With this technique, a varus
tibial cut can lead to internal
rotation of the femoral
component.

• While performing the “inside-

out” release of the posterior
capsule, one should use
electrocautery to avoid iatro-
genic injury to the peroneal
nerve.

• While pie-crusting of the ili-

otibial band is performed,
caution should be taken to
avoid puncturing through the
skin on the lateral side of
FIG. 12 the knee.

Applying a valgus stress. Note the equal amount of opening on the medial side. This • The surgeon should ensure
knee is balanced. that the knee is indeed bal-
anced in extension before as-
sessing the flexion gap.

continued

sary to fractionally lengthen the

lateral side (Figs. 8 and 9).

The Steps of the “Inside-Out”

Technique
1. Remove peripheral
osteophytes.
2. Extend the knee and
distract with a lamina spreader.
3. Irrigate and dry the joint.
4. Palpate the posterior
cruciate ligament, posterolat-
eral corner, and iliotibial band
with a finger or with a small
FIG. 13
Cobb elevator to determine
Preliminary placement of the anteroposterior cutting block on the distal aspect of the femur. tight structures.
5. Release any remnant of
fest as a trapezoidal gap. The is trapezoidal, soft-tissue the posterior cruciate ligament.
goal is to achieve a rectangular balancing with use of the 6. Release the posterolat-
extension gap. When the gap “inside-out” technique is neces- eral capsule intra-articularly

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with use of electrocautery at the

level of the tibial cut surface
from the posterior cruciate liga-
ment to the posterior border of
the iliotibial band. (Electrocau-
tery is used to avoid injury to the
peroneal nerve, which is usually
located <1 cm from the articu-
lar side.)
7. Preserve the popliteus if
possible, unless it is too tight.
8. The iliotibial band is
lengthened as necessary from the
inside with multiple transverse
stab incisions a few centimeters
proximal to the joint line with
use of the so-called pie-crusting
technique2.
9. Repeat these steps FIG. 14
after manual stress-testing if
Evaluation of the flexion gap with a lamina spreader.
necessary.
The knee should now be
balanced in extension. The ap- side can lead to internal rota- with use of this technique.
plication of a varus and valgus tion of the femoral component The knee is placed in 90° of
stress to the knee with a spacer
block in place should allow for
a “springy” give of 2 to 3 mm
on both the medial and lateral
sides (Figs. 10, 11, and 12). The
retention of at least one or two
of the lateral stabilizers is im-
portant for stability. If instabil-
ity is detected after the releases
have been performed, then use
of a constrained component is
considered.

Evaluation of the
Flexion Gap
Once the knee is balanced in ex-
tension, the flexion gap can be
addressed. One should not at-
tempt flexion gap balance until
the extension gap has been bal- FIG. 15
anced. One should remember Evaluation of the flexion gap with a spacer block in place.
that overrelease of the medial

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FIG. 16
Intraoperative view of the knee after all bone cuts have been made.
flexion, and an anteroposterior
cutting block of the same size as
the tibial component is prelimi-
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
Many different surgical tech-
niques and approaches have been
described for correcting the valgus
knee2-17. However, the results are
generally inferior and the com-
plication rates are generally higher
when correcting a valgus defor-
mity compared with its varus
counterpart.
These outcomes are due, in part, to
the technically demanding nature of
soft-tissue balancing in the valgus
knee. This, in turn, has led some
surgeons to accept the use of con-
strained implants when instability
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S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
narily fixed to the distal aspect
of the femur roughly parallel to
the cut tibial surface (Fig. 13).
could not be prevented with balanc-
ing techniques alone. Other sur-
geons have promoted medial
collateral ligament tightening re-
constructions or lateral parapatel-
lar approaches to deal with these
inherent instabilities. It is our opin-
ion that these techniques are not
only unnecessary but also techni-
cally difficult and fraught with the
potential for wound and extensor
mechanism complications.
In an effort to deal with these is-
sues, the technique described
herein was adopted by the senior
JBJS . ORG
(Bone cuts are used to balance
the knee in flexion, whereas
controlled soft-tissue lengthen-
ing is used to balance the
knee in extension.) A lamina
spreader is placed into the flex-
ion gap, and the medial and lat-
eral flexion gaps are measured
(Fig. 14). If the gaps are un-
equal, the block can be rotated
and/or raised or lowered to cre-
ate a symmetric gap. The size of
the gap should be the same as
the extension gap or even 2 mm
less. The same spacer block that
was used in the extension gap
can be placed into the flexion
gap, prior to cutting the poste-
rior condyles, to assess flexion
stability. It should create a snug
fit with no visible medial or lat-
eral opening during internal and
external rotation of the leg (Fig.
15). If, at any time, rotational
malalignment is suspected, align-
ment can be checked by referenc-
ing the cutting block with respect
author (C.S.R.) in 1985 to addres
inherent instabilities noted with his
earlier technique, originally de-
scribed in 1979, with the total
condylar knee replacement1,2,9,18.
With use of the “inside-out” tech-
nique and the PFC Sigma posterior
stabilized total knee system (DePuy
Orthopaedics, Warsaw, Indiana), no
problems with late-onset instability
or neurovascular injury have been
noted (Figs. 17 through 20). There-
fore, we recommend this technique
for the correction of all valgus type-I
and II deformities.
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FIG. 17 FIG. 18

Clinical photograph of a bilateral valgus deformity before Clinical photograph of a bilateral valgus deformity after total
total knee replacement. knee replacement with use of the “inside-out” technique.

to the anteroposterior axis of should first be assessed with the ment is allowed to polymerize.
Whiteside or the transepicondy- tourniquet deflated. If the com- The capsule is closed in flexion
lar axis3. ponents are well aligned and a over a drain.
The final anterior and pos- release is deemed necessary,
terior flexion cuts can now be pie-crusting of the lateral reti- Postoperative Management
made. Box and chamfer cuts can naculum usually suffices and The patient is evaluated closely
then be made allowing for later- avoids the complications of per- for any signs of peroneal nerve
alization of the femoral compo- forming a full longitudinal lat- compromise. If any sign of nerve
nent (Fig. 16). Trial components eral release. compromise develops, the knee
can be inserted to test the knee The knee is irrigated and is placed in flexion. If the com-
for stability through a full range the bone is dried. The compo- promise does not improve, the
of motion and for adequate pa- nents are cemented into place. bandage is then loosened. Physi-
tellar tracking. Excess cement is removed dur- cal therapy and continuous pas-
Maltracking of the patella ing pressurization, and the ce- sive motion are initiated on the

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FIG. 20

Radiograph after total knee replacement with a PFC Sigma

posterior stablized fixed-bearing design.
FIG. 19

Radiograph of a valgus deformity before total knee replacement.

first postoperative day after the Department of Orthopedic Surgery, Lenox Hill Hos-
pital, 130 East 77th Street, William Black Hall,
drain has been removed. Pa- 11th Floor, New York, NY 10021. E-mail address
tients are progressed to weight- for A.S. Ranawat: aranawat@rocinnyc.com
bearing as tolerated. The authors did not receive grants or outside fund-
ing in support of their research or preparation of
Amar S. Ranawat, MD this manuscript. One or more of the authors
Chitranjan S. Ranawat, MD received payments or other benefits or a commit-
Mark Elkus, MD ment or agreement to provide such benefits from a
Vijay J. Rasquinha, MD commercial entity (C.S. Ranawat is a consultant
Roberto Rossi, MD for DePuy). No commercial entity paid or directed,
Sushrut Babhulkar, MD or agreed to pay or direct, any benefits to any
research fund, foundation, educational institu-
tion, or other charitable or nonprofit organization
with which the authors are affiliated or associated.
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
(biomedart@haderermuller.com).
doi:10.2106/JBJS.E.00308
REFERENCES
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