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Total knee replacement with intra-articular resection of bone after malunion of a femoral fracture CAN SAGITTAL ANGULATION BE CORRECTED?

Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Centre, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung Hsiang, Kaohsiung, Taiwan 83305, Republic of China.
The Bone & Joint Journal (Impact Factor: 2.8). 10/2010; 92(10):1392-6. DOI: 10.1302/0301-620X.92B10.24551
Source: PubMed

ABSTRACT Intra-articular resection of bone with soft-tissue balancing and total knee replacement (TKR) has been described for the treatment of patients with severe osteoarthritis of the knee associated with an ipsilateral malunited femoral fracture. However, the extent to which deformity in the sagittal plane can be corrected has not been addressed. We treated 12 patients with severe arthritis of the knee and an extra-articular malunion of the femur by TKR with intra-articular resection of bone and soft-tissue balancing. The femora had a mean varus deformity of 16° (8° to 23°) in the coronal plane. There were seven recurvatum deformities with a mean angulation of 11° (6° to 15°) and five antecurvatum deformities with a mean angulation of 12° (6° to 15°). The mean follow-up was 93 months (30 to 155). The median Knee Society knee and function scores improved from 18.7 (0 to 49) and 24.5 (10 to 50) points pre-operatively to 93 (83 to 100) and 90 (70 to 100) points at the time of the last follow-up, respectively. The mean mechanical axis of the knee improved from 22.6° of varus (15° to 27° pre-operatively to 1.5° of varus (3° of varus to 2° of valgus) at the last follow-up. The recurvatum deformities improved from a mean of 11° (6° to 15°) pre-operatively to 3° (0° to 6°) at the last follow-up. The antecurvatum deformities in the sagittal plane improved from a mean of 12° (6° to 16°) pre-operatively to 4.4° (0° to 8°) at the last follow-up. Apart from varus deformities, TKR with intra-articular bone resection effectively corrected the extra-articular deformity of the femur in the presence of antecurvatum of up to 16° and recurvatum of up to 15°.

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    • "As with navigation, these instruments are based on direct mechanical alignment without using the anatomical axes [3] [4]. Extra-articular deformities have always been a challenge to obtain alignment either by corrective osteotomy or by intra-articular correction of the axis [4] [11] [15] [16]. For these special cases, navigation has proven to be of added value [1] [3] [4] [12] [17]. "
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    • "In terms of extra-articular femoral deformity in sagittal plane, Wang et al. reported intra-articular correction with TKA for femoral deformity of up to 15° recurvatum and up to 16° antecurvatum in sagittal plane [15]. In our first case, the sagittal angulation was 23° antecurvatum. "
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    ABSTRACT: Total knee arthroplasty (TKA) for osteoarthritis (OA) patients with extra-articular deformity is still challenging because angular deformity, canal sclerosis, or the retained hardware that precludes the use of the traditional intramedullary guide. In addition, atypical bone cut for intra-articular correction leads to imbalanced soft tissue gap. Furthermore, corrective osteotomy should be considered for severe deformity or para-articular deformity cases. Recently, navigation-assisted TKA has been reported to increase the accuracy of prosthetic positioning and limb alignment. This system can calculate mechanical axis regardless of extra-articular deformity, canal sclerosis, or retained hardware. Accordingly, navigation surgery has been considered to be a powerful option especially in TKAs with extra-articular deformity cases. Here, we report 3 successful navigation-assisted TKAs for osteoarthritis with extra-articular deformities and/or retained hardware. Navigation-assisted TKA is an effective and reliable alternative for patients with extra-articular deformities.
    09/2013; 2013:174384. DOI:10.1155/2013/174384
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    • "As with navigation, these instruments are based on direct mechanical alignment without using the anatomical axes [3] [4]. Extra-articular deformities have always been a challenge to obtain alignment either by corrective osteotomy or by intra-articular correction of the axis [4] [11] [15] [16]. For these special cases, navigation has proven to be of added value [1] [3] [4] [12] [17]. "
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    ABSTRACT: Restoring function and alignment when treating knee arthritis with a total knee arthroplasty (TKA) in patients who have an extra-articular deformity (EAD) from a malunion or with retained femoral hardware is a challenge. The normal anatomical landmarks are hard to find and difficult to use to obtain correct alignment. The procedure will be further challenged by angular deformity of the femur or tibia. A retrospective study was performed on a case series of patients with EAD or obliteration of the canal treated with patient-specific instruments (PSI). A multicenter retrospective review of 10 patients with multiplanar deformities in which the knee components were aligned with patient-specific instruments was performed. Outcome and alignment were studied. At a mean follow-up of 3.4years, function improved from preoperative as evidenced by a mean increase in the KS pain score of 53 points, KS function score of 48 points and Oxford Score of 28 points (P<0.05). Flexion improved from 94° +/- 11° to 112° +/- 15° (P<0.05). Limb alignment was restored with a mean Hip-Knee-Ankle angle of 179.3° +/- 1.3° (P<0.05). Maximum outliers were 177° to 181°. An average tourniquet time of 75 +/- 9minutes (range, 62-83min) was observed. The use of patient-specific instrumentation systems to perform TKA in patients without access to the intramedullary canal because of EAD or fixation devices, improved function and restored limb alignment. Mechanical alignment can easily be obtained with this technique by intra-articular correction of deformities under 20°. Level IV.
    The Knee 07/2013; 20(6). DOI:10.1016/j.knee.2013.07.001 · 1.70 Impact Factor
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