Total knee replacement with intra-articular resection of bone after malunion of a femoral fracture

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°.

Total Knee Arthroplasty with Extra- or Intra-Articular Correction Technique for Arthritic Knees with Extra-Articular Deformity of the Femur or Tibia: A Report of Three Cases

“…[4][5][6][7][8] The intra-articular correction technique through bone resection to compensate for the deformity followed by excessive soft tissue release is appropriate for an extra-articular deformity of the femur <20º, and of the tibia <30º in the coronal plane and <15º in the sagittal plane. [9][10][11] The extra-articular correction technique using an extended incision or an extended stem is appropriate for deformities close to the joint line, beyond the scope of intra-articular correction technique, or when the distal femoral cut may violate the collateral ligament attachment, or when the intramedullary axis of the tibia passes outside the proximal tibial plateau. 12,13 A deformity or retained hardware may preclude the use of an intramedullary guide because of distorted anatomic landmarks.…”

Management of Extra-articular Deformity in the Setting of Total Knee Arthroplasty

“…Other authors have reported the successful intra-articular correction of sagittal plane deformity of up to 15°for either recurvatum or procurvatum. 21 Although no absolute degree of sagittal malalignment exists, generally guidelines suggest that when the sagittal deformity (either procurvatum or recurvatum) is greater than 20°, an osteotomy should be performed before TKA. In the setting of a sagittal deformity that is combined with a coronal plane deformity, hexapod frames are a useful tool that can be used to gradually correct the deformity in multiple planes 22,23 (Figure 4).…”

Navigation-Assisted Total Knee Arthroplasty for Osteoarthritis with Extra-Articular Femoral Deformity and/or Retained Hardware

“…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.…”