J Korean Orthop Assoc.  2020 Feb;55(1):62-70. 10.4055/jkoa.2020.55.1.62.

External Tibial Torsion with Proximal Tibia Vara in Total Knee Arthroplasty of Advanced Osteoarthritis with Severe Varus Deformed Knees

• Sun DH
• Song IS
• Kim JB
• Kim CU
• Jung D
• Jeong U

• KMID: 2470770
• DOI: http://doi.org/10.4055/jkoa.2020.55.1.62

Abstract

PURPOSE
External tibia torsion and proximal tibial vara have been reported in severe varus deformed osteoarthritis, which is a tibio-femoral angle of more than 20°. The radiology measurements were compared with those of control group and the preoperative and follow-up radiology and clinical results were examined.
MATERIALS AND METHODS
From January 2007 to March 2016, 43 knees from 37 persons, who underwent total knee arthroplasty for a severe varus deformity of more than 20° on the tibio-femoral angle on the standing radiographs and had a follow-up period more than two years, were examined. The mean follow-up period was 45.7 months. The control group, who underwent conservative treatments, had Kellgren-Lawrence grade three osteoarthritis and a tibio-femoral angle of less than 3° varus. The external tibial torsion of enrolled patients and control group were estimated using the proximal tibio-fibular overlap length and the tibial torsion values on computed tomography. The proximal tibia vara was measured using the proximal tibial tilt angle. The preoperative and postoperative proximal tibio-fibular overlap length, tibial torsion value, proximal tibial tilt angle, and hospital for special surgery (HSS) score were evaluated.
RESULTS
The mean proximal tibio-fibular overlap length was 18.6 mm preoperatively and 11.2 mm (p=0.031) at the follow-up. The control group had a mean proximal tibio-fibular overlap length of 8.7 mm (p=0.024). The mean tibial torsion value was 13.8° preoperatively and 14.0° (p=0.489) at the follow-up. The control group had a mean tibial torsion value of 21.9° (p=0.012). The mean proximal tibial tilt angle was 12.2° preoperatively and 0° (p<0.01) at the follow-up. The control group had a mean proximal tilt angle of 1.2° (p<0.01). The preoperative tibiofemoral angle and mechanical axis deviation were corrected from preoperative 28.3° and medial 68.4 mm to postoperative 0.7° and medial 3.5 mm (p<0.01, p<0.01), respectively. The HSS scores increased from 34 points of preoperatively to 87 points at the last follow-up (p=0.028).
CONCLUSION
Patients with advanced osteoarthritis with a severe varus deformity of more than 20° had significant increases in the external tibial torsion and varus of the proximal tibia. The tibial torsion value before and after surgery in the enrolled patients was not changed statistically, but good clinical results without complications were obtained.

Keyword

proximal tibia; external tibial torsion; total knee arthroplasty

MeSH Terms

Arthroplasty, Replacement, Knee*
Congenital Abnormalities
Follow-Up Studies
Humans
Knee*
Osteoarthritis*
Tibia*

Figure

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  Figure 1 (A) Preoperative photograph showing a 21° varus deformed knee joint on the non-stressed position. (B) Intraoperative image showing external rotation and varus tilt of the proximal tibia.

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  Figure 2 Proximal tibio-fibular overlap length was measured by assessing the length between the medial cortex of the fibula and the lateral cortex of the tibia in the longest line perpendicular to the anatomical axis of the fibular on long bone frontal view.

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  Figure 3 Tibial torsion was measured by assessing the angle between the transmalleolar axis and the Transcondylar axis of the proximal tibia in the axial cut of computed tomography. A decreased angle means increased tibial torsion of the proximal tibia.

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  Figure 4 Proximal tibial tilt angle was measured by assessing the angle between the anatomical axis of the tibia and the line perpendicular to the articular surface on the long bone frontal view.

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  Figure 5 Autologous structural bone graft was performed at the postero-medial defect area of the proximal tibia.

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  Figure 6 Intraoperative images. (A) The tibial implant position was matched to external rotation of the proximal tibia. (B) Tibial implant facing the intended internal rotational position.

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