total knee arthroplasty in varus knee.pptx

Varus knee deformity is very common, and it can be classified according to the severity and reducibility of the deformity. Pre-operative planning is mandatory to obtain a good result. Both clinical and radiological planning should be carefully performed, particularly focused on collateral ligament deficiency. In most of the cases, a postero-stabilized implant is necessary, but in the presence of a varus thrust, a midlevel constrained (MLC) implant may be necessary. Rarely, if a severe extra-articular deformity is present, a femoral osteotomy and a high constrain implant may be necessary. In most of the cases, a standard midline approach can be performed. Soft tissue balancing is crucial, avoiding excessive releases of the medial collateral ligament (MCL). In the presence of severe deformity, more aggressive procedure such as tibial reduction osteotomy or sliding medial epicondyle osteotomy can be performed. In literature, good outcomes are reported for total knee arthroplasty (TKA) in varus deformity. In this manuscript, the available literature on TKA in varus deformity is analyzed, and the preferred surgical techniques of the authors are describedreduction osteotomy can be used to achieve deformity correction in varus arthritic knees in a predictable manner, especially in knees with < 15° varus deformity, and will help the surgeon in avoiding or minimizing medial soft tissue release. However, the surgeon needs to be careful in knees in which the varus deformity is correctible to < 5° or highly correctable deformities in which performing a reduction osteotomy may lead to excessive slackening of soft tissue medially and overcorrection.
note whether varus/valgus deformities are fixed vs flexible;
- it is important to distinguish between a fixed varus knee and a knee w/ pseudolaxity due to loss of the medial joint space;
- in the later case, the MCL may be attenuated and can easily be "overstripped" during the initial exposure (when this happens, a
larger spacer is needed to restore stability);
- w/ a fixed varus knee, further capsular elevation may be required;
Reduction osteotomy can achieve deformity correction in a predictable manner in a 2 mm for 1° pattern in most varus arthritic knees during TKA. It is an effective soft tissue-sparing step when performed early on during TKA to achieve deformity correction

1. TOTAL KNEE ARTHROPLASTY in Varus knee Presenter- Dr Manojit Basak Moderator- Prof. Dr Rehan Ul Haq.

2. Varus Knee Understanding Anatomy Classification Preoperative Planning Bone Management Soft Tissue Management Tips Tricks and Traps

3. Defining Varus Maquet Line Load Bearing Axis, Passes from centre of Femoral head to Centre of Talus

4. Pre operative planning

5. Classification

6. INTRA ARTICULAR DEFORMITY(Type 1A) 1 .Reducible AMOA with an intact ACL 2. Reducible PMOA with a deficient 3. Fixed varus deformity without lateral laxity. 4. Fixed varus with lateral laxity. METAPHYSEAL DEFORMITY (TYPE M; WITHIN 5 CM OF JOINT LINE) Either at the femoral (f) or tibial (t) level 1. Metaphyseal involvement because of wear (bone defects). 2. Metaphyseal involvement because of changed joint line obliquity. DIAPHYSEAL DEFORMITY (TYPE D; AT LEAST 5 CM AWAY FROM JOINT LINE) 1. Deformity at the tibial level. 2. Deformity at the femoral level. 3. Deformity at the tibial and femoral level combined.

7. Intraarticular

8. Metaphyseal

9. PAGODA deformity

10. Extra articular

11. Medial Structures

12. MCL Attachments

13. Algorithmic approach Think in terms of anatomy & Classify Decide in terms of Soft tissue & Bone deformity Execute with tips tricks and traps of special techniques.

14. PRINCIPLES OF SOFT TISSUE BALANCING Measured resection-femoral cut by fixed bony landmarks(Transepicondylar axis,whiteside’s line, 3 ° external rotation of the zig) Gap Balancing- Soft tissue tensioning after tibial cut and femoral cut accordingly. Combined

15. Concept of clock, triangle & layers Art of medial release during TKR in Varus knee from 6 o’clock to 10 o’clock anti clockwise from level 1-3 from inside out Concept of Reduction osteotomy.

16. Basic Principles Medial Release Removal of Osteophytes Metaphys e al Bumpectomy Quadrant of deformity & Bone Loss management Avoid Over release

17. Medial releases A sequential release is performed until the medial structures reach a length equalizing that of the lateral structures. Create a Medial Sleeve - medial parapatellar approach is preferred .

18. Creating Medial Sleeve The periosteal elevator is passed deep to the superficial MCL Elevation should start 3 – 4 cm from the medial tibial plateau where the tibial metaphysis merges with the diaphysis Bent Homan is inserted to create the sleeve

19. Creating Medial Sleeve

20. Order of Medial Release Deep MCL Posterior capsule Superficial MCL Posterior oblique ligament Semimembranosus tendon Pes tendon Popliteus tendon

21. Medial Release

22. Semi Membranous release

23. Posterior Oblique Lig

24. Osteophyte removal Remove all osteophytes from Femur & Tibia as they can tent the medial soft tissue sleeve & shorten the MCL

25. Osteophyte Removal Remember to check the Posterior femoral condyle and Posteromedial tibia , as they tighten extension gap.

26. Cruciate's For severe deformities- it may be better to use PS type Knees PCL may prevent complete correction Non functioning PCL with CR knees —> loss of roll back functioning —> anterior opening and loosening

27. PCL

28. Posterior Release 15mm or ¾ “ osteotome is used to release the posterior capsule and remove the osteophytes. By doing this maneuver not only the flexion deformity is corrected, it also releases the medial head of gastrocnemius improving the varus deformity medially

29. Check the Gaps

30. Shift & Resect In case of severe deformities where the gap is still not balanced, it may be a good idea to undersize and lateralize the tibia and remove the medial sclerotic bone (reduction osteotomy) After the cuts, an undersized trial tibial implant is placed & medial boundaries of the implant are marked with methylene blue. Excess bone removed with saw or an osteotome

31. Shift And Resect

32. Shift & Resect

33. Shift & Resect

34. Pie Crusting lengthen soft tissue under tension use 16 G needle

35. Medial Structures

36. Dealing - Residual laxity Lateral laxity post balancing can be an issue IT band is dynamic stabilizer Medial release can be increased and thicker poly can be used LCL advancement is an alternative

37. Take Home Assess & Plan Create Medial Sleeve Do complete removal of osteoph y t es & lumpectomy Sequential Release Shift & Resect Pie Crust ing