Current surgical strategies for total arthroplasty in valgus knee

Table 1 Results reported in the literature on total knee arthroplasty in valgus knee

Ref.	No knees	Valgus deformity	Technique	Implant Selection	Results	Follow-up
Ranawat et al[1]	85	> 10˚	Inside-out soft-tissue release of PLC with pie-crusting of the ITB Resection of proximal part of tibia and distal part of femur to provide a balanced, rectangular space	PS	Knee Society Score improved from 30 to 93 points; mean functional score improved from 34 to 81 points; mean ROM 110° 3 patients underwent revision No cases of delayed instability	10 yr
Apostolopoulos et al[3]	33	> 10˚	Lateral parapatellar arthrotomy, in combination with TTO ITB is elevated from Gerdy’s tubercle Pie-crust technique in LCL and PLC if needed	CR, PS, VVC or CCK (> 20 ˚)	Mean IKS score improved from 44 points preoperatively, to 91 points postoperatively, at the last follow-up In terms of alignment parameter, only 2 knees had a residual valgus deviation greater than 7°	11.5 yr
Karachalios et al[5]	51	> 20˚	Medial or lateral parapatellar arthrotomy; balancing non referred	CR or PS	Bristol knee score 84.3% excellent to good results; 15.7% fair to poor Some deformity persisted in 14/51 patients. These patients had a significantly poorer mean clinical outcome Lateral dislocation or subluxation of the patella was found in 4 knees, with VD > 30˚	5.5 yr
Elkus et al[9]	85	> 10˚	Inside-out soft-tissue release of PCL with pie-crusting of the ITB and resection of the proximal part of the tibia and distal part of the femur to provide a balanced, rectangular space	PS	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 post- ROM was 110˚ No cases of delayed instability	5 yr
Krackow et al[10]	99	Type I and II Ranawat	Type I: Lateral soft tissue release Type II: Medial capsular ligament tightening	CR	Knee Society post-operative knee score was 87.6 (± 10.6) and mean post-operative functional score was 52.3	2 yr
Keblish[11]	79	Type 2 and 3 Ranawat	Lateral approach ITB, PLC release	Non-constrained	Scores have been good/excellent in 94.3% of cases	> 2 yr
Whiteside[26]	135	91: 8˚-15˚ 25: 16˚-25˚ 19: > 25˚	Lateral approach < 15˚: LCL release < 25˚: + ITB > 25 ˚: + POP + Lat. Head gastrocnemius	CR	Neither alignment nor varus-valgus stability deteriorated during the six-year follow-up period, but the knees with greater than 25 degrees deformity had a tendency to increase posterior laxity Patellar subluxation and dislocation occurred in less than 1% of the cases	6 yr
Burki et al[27]	61	> 10˚	Lateral approach with TTO LCL release	CR	Good or excellent in 45 (88%) patients, fair in four (8%), and poor in two (4%) No postoperative tibial fractures, no delayed unions, and no nonunions at the site of the osteotomy were seen	1 yr
Stern et al[31]	134	> 10˚	Medial approach and lateral release	118 PS, 8 VVC, 4 KSS, 4 CR	95 knees (71%) rated as excellent, 27 knees (20%) as good, eight knees (6%) as fair, and four knees (3%) as poor Postoperatively, 76% of the knees had a tibiofemoral alignment between 5 degrees and 9 degrees valgus with an overall average of 7 degrees valgus	2-10 yr (mean 4.5 yr)
Miyasaka et al[30]	108	> 10˚	Medial approach Releasing the lateral retinaculum and ITB, followed when necessary by detaching the PCL and POP tendon from the femur	PS	Mean Knee Society knee score was 88.7 and the mean functional score was 69.2. Postoperative knee alignment averaged 4.5 degrees with 75% of the knees corrected to between 2 degrees and 7 degrees valgus. Postoperative flexion averaged 101 degrees	10-20 yr
Sekiya et al[32]	47	6°-24°	All cases required ITB release at Gerdy's tubercle, 83% ITB at joint level, 21% LCL, 17% POP in medial approach group, and 88% ITB at Gerdy's tubercle, 46% ITB at joint level, 13% LCL, 4% POP in lateral approach group	PS	Pre/postoperative alignment, surgical time, lateral laxity, and preoperative ROM had no significant in two groups; however, postoperative flexion was superior in lateral approach group 123.8°, 109° in medial approach group	43 mo
Chalidis et al[51]	57	Type II Ranawat	Lateral approach and TTO	PS	Significant improvement in knee extension (P = 0.002), flexion (P = 0.006), Knee Society Pain and Function Scores (P < 0.001) and WOMAC Osteoarthritis Index (P < 0.001) The tibiofemoral angle changed from a preoperative median value of 11° (10 to 17) to a postoperative value of 3.75° (0 to 9)	20-98 mo
Hadjicostas et al[52]	15	17°-24°	Osteotomy of the lateral femoral condyle and computer navigation	CR	All the knees were corrected to a mean of 0.5° of valgus (0 to 2) Flexion of the knee had been limited to a mean of 85° (75 to 110) pre-operatively and improved to a mean of 105° (90 to 130) after operation The mean Knee Society score improved from 37 (30 to 44) to 90 points (86 to 94)	24-60 mo

CR: Cruciate retaining; TTO: Tibial tubercle osteotomy; PS: Posterior stabilize; VVC: Varus-valgus constrained; CCK: Constrained condylar knee; ITB: Iliotibial band; LCL: Lateral collateral ligament; POP: Popliteus tendon; PLC: Posterolateral corner.