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Total Knee Arthroplasty in Total Knee Arthroplasty in Varus KneeVarus Knee
H.Makhmalbaf MDH.Makhmalbaf MDConsultant Orthopaedic & KneeConsultant Orthopaedic & Knee
SurgeonSurgeonGhaem Hospital Medical SchoolGhaem Hospital Medical School
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The most important factor in The most important factor in maintaining satisfactory long-term maintaining satisfactory long-term
outcome in TKA is anatomic outcome in TKA is anatomic alignmentalignment
This depends significantly on This depends significantly on ligamentous balanceligamentous balance
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The most favorable results are The most favorable results are observed with femorotibial angle observed with femorotibial angle
3-73-7oovalgus , valgus , the tibial component in neutral,& the tibial component in neutral,& the femoral component in 4-6the femoral component in 4-6oo
valgusvalgus
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The typical patientThe typical patient
• Severe varus deformity
• Some varus alignment since childhood
• H/O medial menisectomy
• Gradually progresses
• Lateral subluxation of the tibia on the femur
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ExposureExposure
• Standard medial parapatellar arthrotomy
• Resect medial meniscus
• Release deep MCL
• Resect ACL
• Externally rotate & deliver the tibia
• Remove all osteophytes
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Mediolateral BalancingMediolateral Balancing
• Ligament balance in flexion & extention are interrelated (unlike valgus knee)
• In a varus knee , the knee should be balanced in extention first then in flexion
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Shift & resect techniqueShift & resect technique
• Tibia is delivered in front of the tibia
• Initial conservative tibial resection
• Based on the intact lateral side
• 10mm lateral resection
• Angle of resection is perpendicular to the long axis of the tibia & 3-5o posterior slope
• Choose tibia one size smaller
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Shift & resectShift & resect
• Choose tibia one size smaller &
• Shifted laterally to the edge of tibia
• Align tibial rotation with tibial tubercle
• Outline the nucapped portion of tibia
• Free the MCL from bone
• Resect bone perpedicular
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Formal MCL release Formal MCL release from the tibiafrom the tibia
• Release deep MCL
• Posteromedial capsule
• Remove osteophytes
• Release PCL
• Resect PCL & put PS knee
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Distal femoral resectionDistal femoral resection
• Pre-op X-ray
• Varus in the femoral shaft ?
• Usually 5-7deg.cut
• More resection of medial fem. condyle
• The amount of resection depends on the thickness of metallic femoral component
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Femoral component rotationFemoral component rotation
• Establish a balanced, symmetric flexion gap to maximize flex. Stability
• In varus knee balance in ext.1st
• Use the Whiteside line or trans epi.
• 30 external rotation
• Then posterior condyles in flexion
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Tibial bone stock deficiencyTibial bone stock deficiency
• Medial tibial plateau is always deficient in varus knee
• Resect enough bone not too much
• Bone graft
• Cement & screws
• Metal wedges
• Allograft
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Residual lateral laxityResidual lateral laxity
• How much laxity is acceptable
• The bony alignment should not be in varus
• The lateral should not gap open on the tab
• Correct significant laxity
• More medial release
• Fibula head advancement?
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summarysummary
• Tibia is responsible for varus • Release MCL, remove osteopytes• Bone resection, undersize, sift• Balance flexion gap• PCL retention in severe varus?• Release PCL ?• Accept some residual laxity if• Fill bony defects in tibia
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Thank youThank you