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Medial Release for Fixed-Varus Deformity

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Medial Release for Fixed-Varus Deformity Chapter 3 Medial Release for Fixed-Varus Deformity David J.Yasgur, Giles R. Scuderi, and John N. Insall INTRODUCTION Varus deformity of the knee is one of the most common deformi- ties seen at the time of total knee arthroplasty. When a fixed defor- mity is present, the pathoanatomy usually involves erosion of medial tibial bone stock with medial tibial osteophyte formation, and contractures of the medial collateral ligament (MCL), pos- teromedial capsule, pes anserinus, and semimembranosus muscle (Fig. 3.1). Elongation of the lateral collateral ligament is a late event. A flexion contracture may coexist, which is manifested by contractures of both posterior capsule and posterior cruciate ligament. Success and longevity of total knee arthroplasty is predicated in part on achieving proper limb alignment of 5 to 10 degrees of valgus.1 The limb should be corrected to this ideal alignment without regard to the contralateral alignment, because a varus deformity often exists bilaterally. Furthermore, the ideal alignment of the femoral component is 7 ± 2 degrees of valgus angulation, whereas that of the tibial component is 90 ± 2 degrees relative to the longitudinal axis of the tibia.1 The ideal alignment is achieved through soft tissue releases aimed at balancing the collateral ligaments, and by placing the components in the correct orientation. If the proper alignment is not achieved, or if the ligaments are inadequately balanced, the components will be overloaded medially and subjected to excessive stresses, which may result in the eventual failure of the arthro- plasty via either component loosening or accelerated wear. Intra- operatively, it is imperative to reassess each step of the soft tissue release so as not to overcorrect the deformity and create valgus instability. 26 D.J.YASGUR ET AL. (A) LAX (B) TENSED MCL contracture Bone loss [Varus deformity] FIGURE 3.1. Genu varum usually caused by medial tibial bone loss and con- tractures of the medial soft tissue structures. PREOPERATIVE PLANNING A careful physical examination of the knee should assess the range of motion, flexion contracture, degree of deformity, ligamentous stability, and muscle strength. Anterior cruciate ligament defi- ciency is a common finding in a degenerative knee, but it is not a surgical dilemma in total knee arthroplasty. In contrast, deficiency of the posterior cruciate ligament (PCL) is much less common. A more likely scenario is the situation of a fixed-varus deformity with a flexion contracture, which requires resection of the PCL for com- plete correction of the limb alignment and flexion contracture. For these cases, a PCL-substituting design should be utilized. In those cases with severe contracture requiring extensive soft tissue release, a constrained condylar implant should be available. This is more often the case for severe genu valgum and not for fixed- varus deformities. A detailed assessment of preoperative radiographs should be made for accurate preoperative assessment. This includes weight- bearing anteroposterior (AP), lateral, and tangential patella radi- 3. MEDIAL RELEASE FOR FIXED-VARUS DEFORMITY 27 ographs, as well as a full length standing AP radiograph. Patella tracking should be noted on the tangential patella view, because this may suggest preoperatively the need for lateral retinacular release. Bony defects should also be noted, because prosthetic augmentation or bone grafting may be required. The mechanical axis, degree of deformity, and femoral valgus should also be noted. If an intramedullary instrumentation system is utilized in which the valgus orientation of the distal femoral cut can be adjusted, then knowledge of the deformity and anatomic femoral valgus can allow one to slightly increase the valgus orientation of the distal femoral cut. This would then facilitate ligamentous balancing in severe fixed deformities. TECHNIQUE Approach The anterior midline approach, with a medial parapatellar arthro- tomy, is preferred because this allows for adequate exposure in most knees. It is also extensile in nature and can easily be con- verted into a quadriceps snip2,3 or V-Y turndown4 when warranted by knees that are difficult to expose, such as post-osteotomy or in patella infera. An anterior incision also allows for exposure of both medial and lateral supporting structures, and obviates the need for additional incisions. The anterior longitudinal skin incision is carefully placed medial to the tibial tubercle to avoid a tender scar postoperatively. Following this, a medial parapatellar arthrotomy is carried out through a straight incision extending over the medial one-third of the patella and is continued onto the tibia 1cm medial to the tibial tubercle. The quadriceps expansion is peeled off of the anterior patella via sharp dissection. The synovium is divided in line with the arthrotomy, and the anterior horn of the medial meniscus is divided. Patellofemoral ligaments are released, and the patella is everted and dislocated laterally, while the knee is flexed up. The anterior cruciate ligament, if present, should then be divided, as should the anterior horn of the lateral meniscus, which will facilitate eversion of the extensor mechanism. To avoid avul- sion of the tibial tubercle, the patellar tendon should be dissected subperiosteally with a cuff of periosteum to the crest of the tibial tubercle. As much as one-third of the tubercle may be exposed, but this is rarely necessary. Lastly, the fat pad and synovium can be resected to help expose the lateral tibial plateau. This exposure is the most versatile and utilitarian of all the exposures for total knee arthroplasty. 28 D.J.YASGUR ET AL. Medial Release To correct a fixed-varus deformity, progressive release of the tight medial structures is performed until they reach the length of the lateral supporting structures.3 The release is begun with the knee in extension using sharp dissection of a subperiosteal sleeve from the proximal anteromedial tibia (Fig. 3.2). A periosteal elevator is useful in continuing this dissection to the midline. Care should be taken to pass the elevator deep to the superficial MCL. The eleva- tor should be used at a level approximately 3 to 4cm from the medial tibial plateau, where the medial metaphysis is curving to join the tibial diaphysis. It is at this location where the inferome- dial geniculate artery may be seen (Fig. 3.3). A bent Hohmann retractor may then be placed, being sure that the tip is deep to the Vastus medialis muscle Medial collateral ligament Pes anserinus Periosteum sharply dissected FIGURE 3.2. Subperiosteal sleeve sharply dissected from proximal antero- medial tibia, including superficial and deep MCL, along with the pes anser- inus tendons, if needed. 3. MEDIAL RELEASE FOR FIXED-VARUS DEFORMITY 29 FIGURE 3.3. Subperiosteal sleeve continued posteriorly, using a periosteal elevator. MCL (Fig. 3.4). Placement of this retractor allows for traction to be placed on the medial structures, thereby facilitating subpe- riosteal dissection. With the knee in extension, a flat three-fourths inch osteotome is passed distally and deep to the superficical MCL (Fig. 3.5). A complete release requires that the osteotome be passed as much as 6 inches distal to the medial tibial plateau. Depending on the degree of release required, the pes anserinus can also be completely detached, or left partially attached as the osteotome elevates the MCL immediately posterior to the most anterior attachment of the pes tendons. Similarly, the osteotome can be used to release the deep attachment of the soleus muscle from the posteromedial tibial metadiaphysis. Sharp dissection can then proceed superiorly to the level of the joint, which will elevate the deep MCL off of the tibia. Proceeding posteromedially with the lower leg externally rotated and the knee flexed, one can sharply elevate the semimembranosus off of the tibia, which often liberates fluid from the semimembranosus bursa FIGURE 3.4. Hohmann retractor placed deep to subperiosteal sleeve places tension on structures, permitting further dissection. Superficial medial collateral ligament Deep medial collateral ligament released off tibia Osteophyte Pes anserinus removed Inferomedial geniculate artery Subperiosteal dissection carried posteriorly and 6" distally Subperiosteal dissection FIGURE 3.5. Osteotome inserted deep to periosteal flap or MCL, used to sub- periosteally strip medial supporting structures from proximal tibia, while maintaining a continuous soft tissue sleeve. 3. MEDIAL RELEASE FOR FIXED-VARUS DEFORMITY 31 (Fig. 3.6). In this way, the posteromedial tibia can be safely exposed to the midline. At this point, the tibia appears skeletonized (Fig. 3.7). Medial tibial osteophytes may serve to tighten the medial side, because the MCL is draped over the osteophytes. Thus, resection of the medial tibial osteophytes is the final step in releasing a fixed- varus knee. It is often useful to wait until a trial tibial component has been inserted before resecting the medial tibial osteophyte. In that way, one can use the trial component as a template and ensure that excessive bone is not excised. Over release of the medial structures in a knee with even a mild deformity is usually not encountered, because this technique ensures that the MCL is not transected, but rather is maintained as a continuous sheet of tissue confluent with the periosteum. The extent of release can be monitored by placing the knee into full extension and exerting a valgus force. Alternatively, lamina spread- ers can be gently inserted into the
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