varus scenarios in indian knee

Varus Scenarios, in Indian KneesDr L.Prakash M.S., M.Ch.Institute for Special Orthopaedics Chennai.

A varus knee can vary in degrees

A varus knee may be somewhat like this

Or like this

Or even like this

But before thatBut why Varus scenario in Indian knees?Are our knees different?Is there a racial variation in coronal deviation of the knee joint?

Apparently yes. Apart from my studies I have found two references. One for adults and one for children.Varus and valgus deformities in knee osteoarthritis among different ethnic groups (Indian, Portuguese and Canadians) within an urban Canadian rheumatology practice

Raman Joshi1, Nimu Ganguli2, Christopher Carvalho3, Faye de Leon4, Janet Pope5Significantly more varus deformity was noted in the Indian-born group than the Canadian-born group (P = 0.002), and more valgus deformity was noted in the Portuguese-born than Canadian-born group (P = 0.009).

Conclusions: Patient populations differed significantly in terms of varus and valgus deformities at the knee.

I could locate one study, in childrenNormal development of the knee angle in healthy Indian children: a clinical study of 215 childrenUttam Chand Saini, Kamal Bali, Binoti Sheth, Nitesh Gahlot, and Arushi Gahlot

Normal development of the knee angle in healthy Indian children: a clinical study of 215 childrenThe overall pattern of development might be slightly different in Indian children, especially in Indian girls, with early reversal of physiological varus (

Knee varus in Indian populationThere have been few demographic or anthropometric studies of the Indian knees in adult population.No study has been done on long term measurements of knee saggital deviation with an increase in age.

My anthropological study of Indian knee saggital and coronal positionsStudy conducted in prisonConducted over 12 yearsFourteen thousand Indian Males were studied

MethodsInstruments used were a Galton calliper, Long scale, Wall, Pencil and long sheets of paper.

MethodsPatient stood with back to the wall.Second toe faced straight towards the observerLine drawn from hip centre to knee centre was allowed to bisect the line from centre of ankle to centre of knee.

MaterialAll subjects were maleConvict and under-trial prisoners.Age from 18 to 91Only 9% complained of any problemsExcept for Sex, they represented the average Indian population

Results Saggital plane

Total Knees studied14,321Varus alignment7642Valgus alignment1387Neutral alignment5292

Varus kneesTotal kneesNeutral kneesValgus knees

Relationship between age and Varus

Correlation between symptoms of medial compartment OA and knee varus

Progression of varus with age1640 subjects over 40 years of age were progressively followed up for ten years or longer.Average rate of progression of varus was two degrees per year and increased exponentially with age.

Varus progresses with age and the progress is more rapid in obese individualsWhile less than 15% of those in twenties had varus knees, over 60% of those above 70 had varus knees.Varus progressed most rapidly between the ages of 60 to 80.Once a knee gets into varus disposition, it continues to progress till the patients death.

Important observationMore than 50% Indian knees had a varus disposition, though not all varus knees had symptoms of medial compartment OA.Severity of symptoms had a direct correlation to the degree of varus, and after 30 degrees, all knees were symptomatic.Varus of the knee gradually and progressively increases with age.

Limitations of the studyNo facilities for radiographic co-relationIt was only a clinico-anthropometric study.Large numbers give the findings credibilityStudy will be published soon.

We must rememberTKR is not always the only choiceIf you do embark on replacement, correcting VARUS (or every other deformity) is of paramount importance.

Varus Deformity of KneeThis not an isolated saggital plane deformity.There is a distinct coronal plane element.And a rotational element too.

Prakashs classification of Varus deformitiesType 1 : Primarily medial compartment OA. Lateral and PF joints near normal.Type 2: Bi or tri compartmental OA without subluxation.Type 3: Wobbly, lax, or destroyed knee with primary varus

Prakashs classification of Varus deformitiesType 1: Primarily medial compartment OA. Lateral and PF joints near normal.Type 2: Bi or tri compartmental OA without subluxation.Type 2: Wobbly, lax or destroyed knee with primary varus

Prakashs classification of Varus deformitiesType 1:Primarily medial compartment OA. Lateral and PF joints near normal.Type 2: Bi or tri compartmental OA without subluxation.Type 3: Wobbly, lax or destroyed knee with primary varus

This classification is superior to Thienpont E1, Parvizi J2.s classification of 2016

What would you do in this case?56 year old gyaenacologistAdvised TKR by six surgeons.Severe pain on walking, no rest pain.

Pre and post surgery

PFO, something newAccidental discovery in 2004Based on my experiences in prisonAn out of the box method which produces remarkable and startling results both functionally and radiologically.

How??Prison riots happen infrequently.Wardens are instructed to hit rioting prisoners with a Lathi, Below the knees, to avoid grievous injuries.Fracture proximal fibula is an usual consequence.

Unique aspects of practicing orthopaedics in the prisonEvery single inmate has to come to you if he breaks a bone. Most orthopaedic problems come to you.There are absolutely no facilities available.But for a pure scientist, this is a wonderful opportunity for study.And these are my studies that lead to PFO

OA knee is very common in India.

About 6% of above 70yrs old are considered essential candidates for TKR, due to the bad state of their knees.Its natural that a prison too would have its share of ideal TKR candidates on their waiting list.Unfortunately a convict prisoner seldom gets any surgery except for life threatening conditions

It is only natural that a few of these ripe candidates for TKR would indulge in riots and break their fibula.

Miraculously, in all these patients, the symptoms of OA disappeared immediately after fractured fibula.

Those waiting for surgery refused a knee replacement as their symptoms had disappeared!

Fractures below fibular neck cured pain from severe medial compartment OAHow does it work?The single versus triple cortex theory.Whatever be the theory, it really works well in most patients.

Anatomical studies

The first patient

PFO, indications

PFO, Surgical steps

Small 2cm incision, 6 to 8 cm below fibular head.1.5 cm fibula is excised.Patient walks and climbs stairs the same day.Can be well done as an outpatient procedure

PFO, a day care procedure

PFO, observations so far

Effective in all patients, even those with patellofemoral OAPatient remains pain free for three years or longer.My first patient operated in 2004, is still happy and refuses knee replacement.A multi-centre trial is being conducted presently and about 1800 surgeries have been done in the last one year.

PFO, the first case, nine years follow up

PFO, other references

PFO, other referencesZong-You Yang, MD; Wei Chen, MD; Cun-Xiang Li, MD; Juan Wang, MD; De-Cheng Shao, MD; Zhi-Yong hou, MD; Shi-Jun gao, MD; Fei Wang, MD; Ji-Dong Li, MD; Jian-Dong hao, MD; Bai-Cheng Chen, MD; Ying-Ze Zhang, MDIt is a safe, simple, and effective procedure that is an alternative to total knee arthroplasty for medial compartment OA of the knee joint. Care must be taken to avoid potential nerve injuries.Proximal fibular osteotomy may reduce knee pain significantly in the varus osteoarthritic knee and improve the radiographic appearance and functional recovery of the knee joint.

Type two varus deformitiesType 2: Bi or tri compartmental OA without subluxation.These need a replacement by an implant of your choice, after proper soft tissue releases!

Choice of implants and techniqueCR vs CSCemented versus cementlessFixed versus modular bearings.Snap on versus rotating bearings.Gap balance versus bone resection methodsNavigation versus open surgery

Makes absolutely no difference at 10 to 15 years

I follow the gap balance methodAll soft tissue releases before the first bone cut.Complete resection and nibbling of all osteophytes.Sequential release as the limb is externally rotated.Use of gap balancing and soft tissue balancing instruments.Flexion and extension gaps have to be absolutely equal.

The freeman technique for soft tissue balancing in varus kneesMedial structures are released as one single sub periosteal sleeve

The freeman technique for soft tissue balancing in varus kneesComplete resection and nibbling of all osteophytes, and sequential release as the limb is externally rotated.

The freeman technique for soft tissue balancing in varus kneesExternal rotation and anterior translation of tibia will expose posterior osteophytes which have to be removed.

The freeman technique for soft tissue balancing in varus kneesThe limb can be straightened to a 6 degree values at this stage.

The freeman technique for soft tissue balancing in varus kneesDistal femur and proximal tibia are cut with instruments of your choice.

Prakash instruments for these cutsDistal femur and proximal tibia are cut with instruments of your choice.

The freeman technique for soft tissue balancing in varus kneesFreeman gap balancer and tissue tensioner

The gap balance methodFlexion and extension gaps should be equal

Knee is stable through the entire range of motion

Case three

What should be done?Level of upper tibial cut??Soft tissue techniques?? Gap balancing??What if flexion gap opens up suddenly after releasing the PCL?Does the level of femoral cut matter here?How will you manage the tibial defect?Is a stemmed tibia needed here?Bilateral surgery in one sitting or one by one??

Case three

41 year old female with polyarticular rheumatoid arthritisWind swept/ Varus - Valgus knees.

Fixed flexion deformity

QuestionsDo you expect the posterior cruciate to be intact? Is there a possibility to use a cruciate retaining prosthesis?What problems do you anticipate in equalising the flexion and extension gaps?What is the importance of the level of distal femoral cut here?Any tricks to equalise the flexion and extension gaps?

Both cruciates are gone. So there is no possibility of using a CR implant

I always use a dynamic gap balancer

Here i could do both in the same sitting

Type 3: Wobbly, lax or destroyed knee with primary varusTwo approaches Biological and Mechanical.I follow the biological approach

Biological Versus Mechanical Methods.Biological methodsGood soft tissue releasesMinimal tibial cut, to the level of defect on Lateral tibial plates.Defect is augmented by grafts from femoral cut.Screw, graft and cement make the biological wedge augment.Tibial bearing is usually 8 mm and no stem is used.

Mechanical methodsCut is a little lower.Defect is augmented by metal wedges attached to the stem.A thick insert is used usually 12 mm or thicker.PCL is usually sacrificed.Tibial stems are often used.

Biological Versus Mechanical Methods.

I usually follow the gap balance method, so my method is always biological.

Biological method

Take home messages

Over 50% of Indian knees present with Varus deformities.Children who have valgus knees gradually develop varus as they grow old.Not all Varus knees have symptomatic medial joint OA

Take home messages

There is a direct correlation between increasing varus, and symptomatic medial compartment OA.All knees with over 30degrees varus have painful medial compartment OA

Take home messages

Type of implant used doesn't matter, but surgical technique does. A gardeners approach is preferable to a carpenters approach.Correct soft tissue balance, precise bone cuts, and an exactly equal flexion, mid flexion, and extension gaps is the key to a successful long term outcome.

Take home messages

In grade one varus, with decent lateral joint space, a proximal fibular osteotomy gives excellent results and probably postpones TKR by a few years and in some cases indefinitely.

Take home messages

In grade two varus, after releases and bone cuts, soft tissue balance is very important

Take home messages

Grade three varus can be managed by either biological or mechanical methods.As far as possible, Biological methods are used, so that mechanical methods like wedges and stems are used during revision.

Take home messages

It is not important to just know how to do a knee replacement.More important is to know when not to do it.More than the implant design or instrumentation, soft tissue handling is important.A gardeners approach is preferable to a carpenterss approach.

Basic Total Knee Arthroplasty Conference and Workshop.

Location: Chennai Tamil Nadu India

Dates: Saturday and Sunday 18th and 19th February 2017.

Venue - Hotel Shan Royal85, Poonamalle High Road, Koyambedu, Chennai - 600107

Expected participation: 100 delegates from all over India and a few from abroad.

Thank You

varus scenarios in indian knee

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