Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function

Graef, Frank; Falk, R.; Tsitsilonis, Serafeim; Perka, Carsten; Zahn, R.; Hommel, Hagen

doi:10.1007/s00167-019-05812-9

Cited by 13 publications

(19 citation statements)

References 36 publications

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“…It is of upmost importance to appreciate the influence of the correction on the adjacent hip joint to prevent the occurrence of an unwanted effect. Given that pain disorders of the ankle have also been reported as a result of realignment of the knee, it can only be underlined that there is a true need of deepening the understanding of limb realignment with particular emphasis on further developing planning tools [1,5,10]. Figure 5 represents an example of the above concept in a patient who was referred to the outpatient clinic with severe hip pain that has occured after having undergone a high tibial osteotomy for the treatment of medial knee gonalgia.…”

Section: Discussionmentioning

confidence: 99%

The ischiofemoral space of the hip is influenced by the frontal knee alignment

Ahmad

Kerber

Konrads

et al. 2021

Knee Surg Sports Traumatol Arthrosc

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Purpose The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD. Methods A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD. Results Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (β-0.4, confidence-interval − 0.5 to − 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment. Conclusion These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints. Level of evidence IV.

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Section: Discussionmentioning

confidence: 99%

The ischiofemoral space of the hip is influenced by the frontal knee alignment

Ahmad

Kerber

Konrads

et al. 2021

Knee Surg Sports Traumatol Arthrosc

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“…Nineteen patients complained about increased ankle pain after TKA. Thirteen of these 19 patients had a preoperative mTFA > 15°, corresponding to the cut-off values previously reported for varus osteoarthritis [5]. Kim et al performed a prospective study on 55 patients, who presented with varus osteoarthritis of the knee and underwent TKA.…”

Section: Discussionmentioning

confidence: 84%

Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms

Graef

Hommel

Falk

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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The aim of this study was to assess the mid-term clinical outcome of the ankle joint after total knee arthroplasty (TKA) in high-grade valgus osteoarthritis. Methods In this case-control study, n = 36 patients with a preoperative mechanical tibiofemoral angle (mTFA) ≥ 15° who underwent TKA between December 2002 and December 2012 were included. The control group (mTFA < 15°) of n = 60 patients was created using case matching. Radiological [mechanical tibiofemoral angle (mTFA) and ankle joint orientation to the ground (G-AJLO)] and clinical parameters [Foot Function Index (FFI), Knee Society Score, Forgotten Joint Score, and Range of Motion (ROM)] were analysed. The mean follow-up time was 59 months (IQR [56, 62]). Results The degree of correcting the mTFA by TKA significantly correlated with the postoperative FFI (R = 0.95, p < 0.05), although the knee and ankle joint lines were corrected to neutral orientations. A cut-off value of 16.5° [AUC 0.912 (0.85-0.975 95% CI), sensitivity = 0.8, specificity = 0.895] was calculated, above which the odds ratio (OR) for developing ankle symptoms increased vastly [OR 34.0 (9.10-127.02 95% CI)]. ROM restrictions of the subtalar joint displayed a strong significant correlation with the FFI (R = 0.74, p < 0.05), demonstrating that decreased ROM of the subtalar joint was associated with aggravated outcomes of the ankle joint. Conclusions In this study, higher degrees of leg axis correction in TKA were associated with increased postoperative ankle symptoms. When TKA is performed in excessive valgus knee osteoarthritis, surgeons should be aware that this might trigger the onset or progression of ankle symptoms, particularly in cases of a stiff subtalar joint. Level of evidence III.

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“…Enough range of motion in this region might not be given in patients with an ankle arthrodesis by a nail. In patients with indication for osteotomy around the knee and primary or secondary arthritis of the ankle joints, we would recommend performing the osteotomy around the knee first and then treat the ankle afterwards-especially when indicating ankle arthrodesis [22][23][24][25][26][27]. With this sequence of surgeries, the surgeon can sustainably accomplish a correct foot position when performing the ankle arthrodesis.…”

Section: Discussionmentioning

confidence: 99%

Osteotomies around the knee lead to corresponding frontal realignment of the ankle

Konrads

Eis

Ahmad

et al. 2021

Eur J Orthop Surg Traumatol

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Introduction Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation. Materials and methods Long-leg standing radiographs of 154 consecutive patients undergoing valgisation or varisation osteotomy around the knee in 2017 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip knee ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), the mechanical medial proximal tibia angle (mMPTA) and five angles around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann–Whitney test. Results One hundred fifty-four patients (96 males, 58 females) underwent osteotomies around the knee for coronal realignment. The mean age was 51 ± 11 years. Correction osteotomies consisted of 73 HTO, 54 DFOs, and 27 double level osteotomies. Of all osteotomies, 118 were for valgisation and 36 for varisation. For valgisation osteotomies, the mean HKA changed from 5.8° ± 2.9° preoperatively to − 0.9° ± 2.5° postoperatively, whereas the mMPTA changed from 85.9° ± 2.7° to 90.7° ± 3.1° and the malleolar-horizontal-orientation-angle (MHA) changed from 16.4° ± 4.2° to 10.9° ± 4.2°. For varisation osteotomies, the mean HKA changed from − 4.3° ± 3.7° to 1.1° ± 2.2° postoperatively, whereas the mLDFA changed from 85.7° ± 2.2° to 89.3° ± 2.3° and the MHA changed from 8.8° ± 5.1° to 11.2° ± 3.2°. Conclusion Osteotomies around the knee for correction of coronal limb alignment not only lead to lateralization or medialization of the weight-bearing line at the knee but also lead to a coronal reorientation of the ankle. This can be measured at the ankle using the MHA. When planning an osteotomy around the knee for correction of genu varum or valgum, the ankle should also be appreciated—especially in patients with preexisting deformities, ligament instabilities, or joint degeneration around the ankle.

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Correction of excessive intraarticular varus deformities in total knee arthroplasty is associated with deteriorated postoperative ankle function

Cited by 13 publications

References 36 publications

The ischiofemoral space of the hip is influenced by the frontal knee alignment

The ischiofemoral space of the hip is influenced by the frontal knee alignment

Correction of severe valgus osteoarthritis by total knee arthroplasty is associated with increased postoperative ankle symptoms

Osteotomies around the knee lead to corresponding frontal realignment of the ankle

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