Treatment of Severe Valgus Knee Deformity in Patients with Ipsilateral Coxarthrosis：A Report of Five Cases

Case Report

Juntendo Medical Journal 2013. 59(3), 279〜283 Treatment of Severe Valgus Knee Deformity in Patients with Ipsilateral Coxarthrosis：A Report of Five Cases

YUICHIRO MARUYAMA＊1) KATSUO SHITOTO＊1)

TOMONORI BABA＊2) KAZUO KANEKO＊2)

Objective：Adjacent joints including hip joints and knee joints mutually affect each other due to leg length discrepancy and extremity malposition, and severe deformity of these joints may progress. Coxitis knee is the name applied to the particular form of osteoarthritis associated with ankylosis or fixation of the hip joint. Rotational limitations of hip joint and leg length discrepancy cause severe stress to the coxitis knee during walking, resulting in external rotation of the tibia and valgus deformity of the knees, which increase the load on the knee. Materials：In this paper, we describe five cases of total knee arthroplasty performed for severe valgus deformity in patients with ipsilateral coxarthrosis. We investigated the conditions and issues of concern in these patients and report the outcomes. Conclusions：Since the condition of the hip joints is significantly related to valgus knee, it is necessary to carry out comprehensive investigation of the alignment of the legs including not only knee joints but also hip joints. If there is no other option but surgical treatment of the knee joints, then this approach must be prioritized and various efforts must be made. Key words：valgus knee deformity, coxarthrosis, coxitis knee, total knee arthroplasty

part of left tibia and required bed rest in the Introduction hospital for 3 months. Since then, movement of the Relationships are often found between osteoar- left and right hip joints deteriorated and stayed in thritis and rheumatoid arthritis of the hip and almost an ankylosis. Thereafter, valgus deformity of valgus knee deformity 1)〜4). This is due to the fact the left knee advanced and pain was reported. that adjacent joints including hip joints and knee Duration of her walking capacity lasted for about 15 joints mutually affect each other due to leg length min. even with use of a walker. There was no pain in discrepancy and malposition of the extremity, and the left hip joint. Range of motion (ROM) of the left severe deformity of these joints may progress. knee was −10°in extension, 55°in flexion, a In the present study, we describe five cases of femoro-tibial angle (FTA) of left leg was 154°. total knee arthroplasty (TKA) performed for se- Although priority of the treatment for the left hip vere valgus deformity in patients with ipsilateral joint was explained, no consent was obtained. Thus, coxarthrosis. We investigated the conditions and TKA was chosen for the left knee exhibiting the issues of concern in these patients and the outcomes greater pain. In the operation, the adductor muscle are reported in the present study. of the left hip joint was initially separated. Subsequently, TKA was performed for the left Case 1 knee. Since the medial collateral ligament was A 70 year old female. Main complaints included strongly loosened and instability was unable to be pain in the left knee, valgus deformity of the left leg controlled, a semi-constrained type of TKA was and impairment in walking. When she was 12 years needed. After the operation, no pain was reported old, she suffered from osteomyelitis at the proximal and the patient was capable of walking without a

＊1) Department of Orthopaedic Surgery, Juntendo University Urayasu Hospital, Chiba, Japan ＊2) Department of Orthopaedic Surgery, Juntendo University Faculty of Medicine, Tokyo Japan 〔Received Nov. 12, 2012〕〔Accepted Jan. 7, 2013〕

279 Maruyama et al：Treatment of severe valgus knee deformity

（a）（b）

Figure-2 Case 2：Radiographs showed (a) marked valgus deformity of the lower extremity with left （a）（b） coxarthrosis；(b) TKA was performed using semi-constrained type of TKA. Figure-1 Case 1：Radiographs showing (a) severe valgus deformity of the left knee and severe ankylosis of the left hip in excessive adduction；(b) The knee was replaced to improve alignment of the left leg. well as necessity of the stability, left knee TKA was performed. Using a semi-constrained type of TKA, instability could be controlled as much as possible. cane, but mild knee valgus instability remained. In Although up and down movement of the body was the future, treatment for the hip joint seems to be observed due to limitation of the hip joint mobility, necessary (Figure-1a, b). there was no pain in the left knee joint and the patient could walk without use of a cane (Fi- Case 2 gure-2a, b). A 58 year old female. Main complaints included Case 3 left knee pain, valgus deformity and abnormal valgus instability of the left knee. Congenital A 74-year-old female suffering from osteoarthri- dislocation of the left hip joint was surgically tis received total hip arthroplasty in another treated when she was young, but the details were hospital in 1987 for the left hip joint and in 2001 for unknown. Recently, left knee pain slowly worsened right hip joint. After the right THA, valgus and after the left knee was sprained when she fell deformity of the right knee and pain were down two months ago, an abnormal instability was intensified and gradually walking became difficult. detected at the left knee. There was no pain in the The ROM at the right knee joint was 0°in left hip joint. The ROM of left knee joint had 0°in extension, 80°in flexion. There was no pain in either extension, 100°in flexion. FTA of left leg was 155°, hip joint. FTA of the right leg was 155°exhibiting exhibited a marked valgus deformity of the left leg. serious valgus deformity. A leg length discrepancy Since no pain was reported despite advanced was detected showing that the right leg was longer deformation of the left hip joint, the patient herself by 3 cm. In surgery, a posterior stabilizer type of did not wish surgical treatment for the hip joint. TKA was applied. Due to strong tension of lateral Because of marked instability of the left knee as side of the knee, the iliotibial tract was partially

280 Juntendo Medical Journal 59(3), 2013

（a）（b）

Figure-4 Case 4 ： Radiographs showed (a) Revision surgery of the hip was performed but intensive valgus deformity of the lower limb persisted. (b) Two months later, posterior stabilizer type of （a）（b） TKA was performed.

Figure-3 Figure-3 Case 3：Radiographs showing (a) serious valgus deformity of the right leg and right hip treated with joint replacement；(b) Post- used while walking (Figure-4a, b). erior stabilizer type of TKA was applied. Case 5

The patient was an 82-year-old female with left separated and finally alignment was obtained knee pain and valgus deformity of the left lower (Figure-3a, b). limb. In 2005, she underwent left THA. After the operation, the left hip joint was painless and Case 4 presented no problems. However, deformation and A 75 year old female. The present medical history high dislocation of the right hip joint gradually indicated the onset of rheumatoid arthritis at the progressed. The left lower limb became functionally age of 14. Right THA was performed 15 years ago long due to marked pelvic inclination, and severe and left THA was also performed 12 years ago. claudication was observed. There was no pain in the Subsequently, loosening appeared at the acetabu- right hip joint. The ROM of the left knee was −35° lum side of the right hip joint recently and valgus in extension and 90°in flexion. The FTA was 165°. deformity of the right knee and pain were also Although there was no pain in the right hip joint, reported. The ROM of the right knee had −30°in we recommended surgery for leg length correction extension, 45°in flexion, The FTA was revealed to achieve balance, but she refused it and eagerly 152°, exhibited marked valgus deformity. As for desired surgery for the painful left knee. For treatments, initially revision surgery of hip joints surgery, TKA using the posterior stabilizer type was performed using a Kerboull cross and was performed. Considering the strong varus/val- polyethylene cup. Two months later, a right TKA gus force imposed on the implant, stems were used was performed. Knee pain disappeared postoper- for both the femoral and tibial implants. At present, atively and ROM became 0-80°, but due to the ROM of the left knee is slightly restricted (−10 instability of the knee, a knee supporting device is to 95°), but she can walk using a T cane without

281 Maruyama et al：Treatment of severe valgus knee deformity

Figure-5 Case 5：Radiographs showed (a) deformation and high dislocation of the right hip joint. (b) The left lower limb became functionally long due to marked pelvic inclination and showed valgus deformity.

pain (Figure-5a, b). and 2 in the present study. Also, as long leg arthropathy 6), shortening of legs in advanced Discussion dislocation of the hip joints is compensated by genu Subjects selected were five patients including 2 valgum and knee flexion at the long leg side, but in cases of treatment performed for knees due to the this case, arthrosis of hip joint may be associated. In presence of severe deformity in the ipsilateral hip addition, inclination of the pelvis may occur due to joints exhibiting no pain and 3 other cases of the pain and muscle impairment in the coxarthritis presence of severe valgus knee deformity of the which may functionally result in adduction of the ipsilateral knees after the total hip arthroplasty of hip joint and relative long leg arthropathy. As in the hip joints. All cases exhibited severe valgus Case 3 of the present study, leg length discrepancy deformity and pain and claudication while walking may occur iatrogenically to induce valgus deformity were present so that this activity of daily life was of the legs. Further, as in the Case 4 of the present severely impaired. Since various kinds of conserva- study, knee valgus deformity was found in RA and tion treatments were invalid, TKA was performed. the deformity may be complicated with deformity Complications of hip joint deformity with valgus of the hip joints. As therapeutic measures, accord- deformity of the coxitis knee are characteristic. The ing to Romness et al. 7), the group with TKA after coxitis knee 5) is a deformity found when the release of ankylosis in THA and the group with screw-home movement is limited while walking TKA alone were compared in 16 cases of ankylosis due to fixation of the hip joints and adduction of hip joints. Although there were no differences in contracture so that a stress is applied to the coxitis the results, it was reported that if the position of the knee to cause abduction of the tibia and valgus ankylosis is bad, THA of the hip joints should deformity of the knees. This corresponds to Cases 1 proceed. According to Rittermeisteret al. 8), THA

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was performed in 18 patients with hip joint TKA for the severe coxitis valgus knee in contracture and the group with TKA and the TKA association with hip joint arthritis with respect without THA group were compared. It was to the mechanisms of onset, therapeutic methods reported that the TKA group after THA indicated and the points of concern. better knee scores. Thus, it was concluded that the 2. Since the conditions of the hip joints are treatment of hip joints should be prioritized. significantly related to the valgus knee, it is However, in the case when it is difficult to obtain necessary to carry out comprehensive investiga- patient agreement for an operation of the hip joints tion of the alignment of the legs including not without pain and in the case when it is necessary to only knee joints but also hip joints. acquire walking ability earlier due to strong 3. If there is no other way but that the surgical instability of the knees, there are cases when the treatment of knee joints must be prioritized, treatment of the knee joints must proceed. In the various efforts must be made. surgery prioritizing knees, some effort must be References made. If flexion of the knees cannot be obtained sufficiently due to the limitation of the ROM of the 1）Shakoor N, Hurwitz DE, Block JA, et al：Asymmetric hip joints, a method using an femoral intramedul- knee loading in advanced unilateral hip osteoarthritis. Arthritis Rheum, 2003；48：1556〜1561. lary rod by simultaneously lifting both thighs and 2）GolightlyYM, Allen KD, Renner JB, et al：Relationship of pelvis while making flexibility of the hip joints at limb length inequality with radiographic knee and hip the opposite side possible and an operation table osteoarthritis. Osteoarthritis Cartilage, 2007；15： 824〜829. where the lower thigh can be descended must be 3）Wedge JH, Wasylenko MJ：The natural history of provided. In addition, use of navigation is also congenital disease of the hip. J Bone Joint Surg Br, 1979； another choice. Further, if functional failure of the 61：334〜338. 4）Chitnavis J, Sinsheimer JS, Suchard MA, et al： ligament is prominent, it is difficult to adjust the End-stage coxarthrosis and gonarthrosis. Aetiology, amount of the bone cutting and ligament balance, clinical patterns and radiological features of idiopathic and selection of a constricted type device becomes osteoarthritis. Rheumatology, 2000；39：612〜619. 5）SmillieIS：Angular deformity. Diseases of the knee joint. necessary. In addition, a method for regaining Churchill Livingstone Edinburgh and London, 1974： tension of the loosened ligament and ligament 311〜312. reconstruction may be needed. Since early training 6）BrattströmHM：Long-term results in knee arthrodesis in rheumatoid arthritis. Acta Rheumatica Scandinavia, of the mobile area is necessary in the case of elderly 1971；17：86〜93. patients, application of soft tissue reconstruction 7）Romness DW, Morrey BF：Total knee arthroplasty in must be done carefully. patients with prior ipsilateral hip fusion. J Arthroplasty, 1992；7：63〜70. Conclusions 8）RittermeisterM, Zichner L：Hip and knee replacement after longstanding hip Arthrodesis. Clin Orthop Relat 1. We investigated five cases of performance of Res, 2000；37：136〜145.

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