Case Report Hip Knee J.
Vol.
No.
2, 2023, pp.
p-ISSN: 2723-7818 e-ISSN: 2723-7826 http://dx.
org/10.
46355/hipknee.
TOTAL KNEE ARTHROPLASTY IN SEVERE VALGUS DEFORMITY OF KNEE
OSTEOARTHRITIS WITH NON-CONSTRAINED IMPLANT: A CASE REPORT
Suyenci Limbong.
Asep Santoso.
D2.
Iwan Budiwan Anwar.
Tangkas Sibarani.
Ismail Mariyanto.
Fellow of Indonesia Hip and Knee Society.
Orthopaedic Surgery Department.
Dr.
Soetomo General Hospital.
Surabaya.
Indonesia
2,3,4,5
Consultant of Orthopaedic Surgery Department.
Prof.
DR.
Soeharso Orthopaedic Hospital.
Surakarta.
Indonesia
ABSTRACT
Osteoarthritis (OA) is main cause of musculoskeletal disability all over the world.
The incidence and prevalence of OA increase with aging .
The treatment for grade four of knee osteoarthritis (OA) as classified by Kellgren and Lawrence is knee replacement.
Approximately 10% of patient need TKA have valgus deformity and 15% of it is severe deformity.
In type-i deformity .
evere osseous deformit.
with an incompetent medial softtissue sleeve is best managed with a constrained or hinged total-knee design, but it is not always available due to insurance limitation.
In this case we choosed to manage the type i deformity using non constrained or hinged total knee design and achieve knee balancing by a soft tissue procedure (MCL tightenin.
Reporting female patient Mrs.
S, a 61-year-old with painful and valgus deformity on the right knee.
Her range of motion preoperatively was 5-100A with 30A fixed valgus deformity on the right knee.
We performed total knee arthroplasty used non-constraint implant with additional soft tissue procedure to gain ligament balance by shifted MCL origin with its bone .
picondyle ) superior and anteriorly.
Intra operative we were able to correct valgus deformity and achieved 5-90A range of motion.
Total knee arthroplasty is a procedure that contains two main steps, bone cut and soft tissue balancing.
In valgus knee tightness found at lateral site with loosening at medial site.
In its severe condition medial collateral ligament may be found disfunctioned .
Selective soft tissue release was effective to achieve good ROM and aligment without prosthetic constraint needed which was helped to manage patient when the constraint implant was not accessible.
after 3 month post operative we found patient was able to stand and walk without pain and device with 080A range of motion, stable and corrected valgus deformity.
Keywords: Osteoarthritis, disability, valgus deformity This is an open access article under the CCAeBY-SA license.
Article History:
Corresponding Author:
Submission Revision Accepted : September 12th, 2022 : December 6th, 2022 : August 26th, 2023 Suyenci Limbong.
Fellow of Indonesia Hip and Knee Society.
Orthopaedic Surgery Department.
Dr.
Soetomo General Hospital.
Surabaya.
Indonesia liliosanci@gmail.
TOTAL KNEE ARTHROPLASTY IN SEVERE VALGUS DEFORMITY OF KNEE OSTEOARTHRITIS WITH NONCONSTRAINED IMPLANT: A CASE REPORT
INTRODUCTION
Osteoarthritic (OA) is the most common form of arthritis.
It is a chronic, degenerative change of the joint.
Primary OA is caused by mechanical wear and tear that naturally occur to the articular cartilage with aging.
OA progression, more joint tissues changed, there are seen in the subchondral bone synovium, synovial fluid, joint capsule and ligaments .
Osteoarthritis (OA) is the main cause of musculoskeletal disability all over the The incidence and prevalence of OA increases with aging.
The patient complaints of pain and swelling as the result of decreased joint mobility .
The treatment for grade four knee osteoarthritis (OA) as classified by Kellgren and Lawrence is knee replacement.
Approximately 10% of patient need TKA have valgus deformity and 15% of it is severe deformity .
The primary goals of therapy are to improve function without pain of the knee .
The valgus deformity has bone loss with metaphyseal remodeling, from lateral PRESENTATION OF CASE Female patient Mrs.
S is a 61-year-old, with progressive painful deformity of her right knee for three years before she came to the hospital and worsened this last one year.
She has no trauma history.
The pain was increased by weight bearing activity such as She Nonsteroidal Anti-Inflammatory Drugs (NSAID) medication and physiotherapy for three months and no improvement.
From physical examination the patient was found Copyright A 2023 the author.
| http://thehipkneejournal.
to have valgus deformity and difficulty to stand and walk due to pain on her right knee (Figure .
she was able to bend the knee for 100A with condyle and lateral tibial plateau and soft tissue contracture consisting tight lateral structure such as iliotibial band, lateral collateral ligament, popliteus tendon, posterolateral capsule and hamstring muscle .
According to Ranawat classification valgus deformity has been classified into three A type-I deformity has minimal valgus and medial soft-tissue stretching.
typical type-II fixed valgus deformity has a more substantial deformity (>10A) with medial soft tissue stretching A type-i deformity is severe.
osseous deformity after a prior osteotomy with an incompetent medial soft-tissue sleeve, which is best managed with a constrained or hinged total knee design .
In this case we choose to manage patients with type i deformity using non constrained or hinged total knee design due to its unavailability with additional soft tissue procedure (MCL tightenin.
to achieve the balance.
5A less of knee The radiological result showed 30A valgus deformity with joint space narrowing, sclerotic of subchondral bone, lateral subluxation and osteophytes (Figure The patient agreed for total knee arthroplasty, and it was performed by the For osteoarthritis knee with severe valgus deformity 30A.
The choice of implant is constraint implant but due to limitation of insurance coverage the patient was treated with non-constrained implant and soft tissue balancing procedure by tightening MCL to achieve the balance.
TOTAL KNEE ARTHROPLASTY IN SEVERE VALGUS DEFORMITY OF KNEE OSTEOARTHRITIS WITH NONCONSTRAINED IMPLANT: A CASE REPORT
sterile manner.
We used medial parapatellar approach.
Skin incised started midline 5cm above patella and one third medial in patella and stop just medial site of tibial tubercle.
(A)
(B)
(C)
Figure 1.
Pre operative clinical condition A.
Front.
Behind.
Lateral .
ource: internal (A) (B) Figure 3.
Imbalance was found between lateral and medial site intra operative in flexion and extension A.
Before used implant.
After using implant.
(B)
(C)
(D)
(A)
Figure 2.
Pre operative radiology showed right knee joint line narrowing, lateral subluxation, sclerotic, osteophytes and severe valgus deformity A.
Full lower limb, lateral view.
Posterior View.
ource: internal documentatio.
We performed surgery with a patient in supine position, under spinal anesthesia.
Prophylactic antibiotic administered 30 minutes prior to incision and before torniquet inflated.
Patient then draped in Copyright A 2023 the author.
| http://thehipkneejournal.
(A)
(B)
Figure 4.
(A).
Clamp marks of the medial collateral ligament.
(B).
Elongation of medial collateral ligament.
Figure 5.
(A).
Exposure of medial collateral ligament (B).
Tightening of MCL by osteotomy of medial femoral condyle and shifted to superior and anterior femur until it tightened and balanced and fixated with TOTAL KNEE ARTHROPLASTY IN SEVERE VALGUS DEFORMITY OF KNEE OSTEOARTHRITIS WITH NONCONSTRAINED IMPLANT: A CASE REPORT kistner wire and cortical screw.
internal documentatio.
Arthrotomy was performed at half centimeter medial of quadriceps tendon down to medial site of patella, patellar tendon and stop on the medial site of tibial We started with femoral bone cut in 6A valgus.
Tibial bone cut performed perpendicular with joint line.
The extension and flexion gap balancing were evaluated.
We found imbalance between lateral and medial site, tight on the lateral and loose in medial site (Figure 3.
A,B).
After removed all the osteophyte on the lateral and posterolateral site we performed lateral release by step incision using 15 blades on the iliotibial band and postero lateral After lateral release we found lateral site was tighter than medial site and there was a MCL elongation on the medial site (Figure 4.
A,B).
Tightening on the medial site was done after implant and insert has been installed.
used primary total knee implant from implantcast with insert 12,5 mm thick.
performed osteotomy of MCL insertion at medial femoral condyle and shifted it to proximal and anterior fixated with 3.
cortical screw and kistner wire 2.
0 (Figure 5 A,B) that made as staple.
After the capsule had been closed, we found the potential range of motion for this patient was 5-90A.
The wound was closed layer by layer.
With adequate analgetic the patient started the range of motion exercise in first day and started to walk using walker in second day.
The valgus was corrected and ROM in third day post operation was 5-65 A.
Two months after surgery the patient was able to walk Copyright A 2023 the author.
| http://thehipkneejournal.
without pain and didnAot need device for ambulation with knee range of motion improved 5-80A and reach 0-80A range of motion at three months after surgery.
(A)
(B)
Figure 6.
post operative right knee with painless, stable and corrected valgus deformity A.
Alignment view.
X-ray view.
DISCUSSION