Evaluation of soft tissue balancing and component alignment in computer-navigated TKA for valgus knee

Takuya Naraoka; Hikaru Soneda; Runa Hori; So Morioka; Yukihiro Matsuyama

doi:10.1016/j.jor.2025.03.054

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doi:

10.1016/j.jor.2025.03.054

Evaluation of soft tissue balancing and component alignment in computer-navigated TKA for valgus knee

Takuya Naraoka^a,b,, Hikaru Soneda^a,b, Runa Hori^a,b, So Morioka^a,b, Yukihiro Matsuyama^b

a Department of Orthopaedic Surgery, Fujinomiya City General Hospital, 3-1 Nishiki-cho, Fujinomiya, Shizuoka, 418-0076, Japan

b Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1, Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan

⁎Corresponding author: Takuya Naraoka. takuya5mtmd@yahoo.co.jp

Received: 2025-3-20, Accepted: 2025-3-25, Published: 2025-3-25

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Computer-navigated total knee arthroplasty (CN-TKA) is useful for improving the accuracy of osseous cuts, soft tissue balance, and component placement. However, the usefulness of CN-TKA for valgus deformity remains unclear. This study aimed to assess the availability of CN-TKA for valgus deformities and compare it with CN-TKA for varus knees.

A total of 74 cruciate-retaining CN-TKAs (20 valgus, 54 varus) were included in this study. After implantation, the intraoperative hip-knee-ankle (HKA) angle was recorded during full extension and at 30° and 90° of flexion under three conditions (no stress, valgus stress, and varus stress), and the medial and lateral laxities were calculated. The femorotibial angle (FTA), HKA angle, patellar tilt, mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) were measured on postoperative radiographs. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Lysholm score were determined at 1 year postoperatively.

The lateral laxity of varus knee in full extension was significantly larger than that of valgus knee (valgus: 0.5 ± 0.7°, varus: 1.2 ± 1.0°, p = 0.011). The medial laxity of valgus knee at 90° of flexion was significantly larger than that of varus knee (valgus: 0.4 ± 0.6°, varus: 0.1 ± 0.3°, p = 0.004). There were no significant differences in the FTA, HKA angle, patellar tilt, mLDFA, mMPTA, KOOS scores, or Lysholme score between the two groups postoperatively.

CN-TKA for valgus knee demonstrated acceptable soft tissue balancing and component alignment and good early clinical results comparable to those of CN-TKA for varus knees.

Abstract

Highlights

•Computer-navigated TKA for valgus deformity produces accurate soft tissue balancing.•Computer-navigated TKA for valgus deformity produces accurate component alignment.•Computer-navigated TKA for valgus deformity produces good early clinical results.

Keywords

Valgus knee

Total knee arthroplasty

Navigation

Laxity

Alignment

Clinical outcome

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1 Introduction

The number of patients presenting with valgus deformities represents approximately 10 % of patients undergoing total knee arthroplasty (TKA).¹ Valgus deformities are sustained by anatomical variations divided into bone tissue remodeling and soft tissue contraction/elongation.² Bone tissue variations include lateral cartilage erosion, lateral condylar hypoplasia, and metaphyseal femur and tibial plateau remodeling.² Soft tissue variations are represented by the tightening of lateral structures, including the lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendon, lateral head of the gastrocnemius, and iliotibial band.² The presence of this type of deformity can lead to tibial external rotation and patellar lateral subluxation³^,⁴ and requires surgery to achieve proper alignment, stability, and balance to obtain successful clinical outcomes. In a registry-based population, valgus deformity had a 2.1-fold higher risk of revision than varus deformity, and aseptic loosening, dislocation, and instability were the major causes of implant failure in TKAs for valgus deformity.⁵

Computer-navigated TKA (CN-TKA) is a dedicated technique that is beneficial for improving accuracy in osseous cuts, soft tissue balance, and component placement.^6–9 Previous studies have shown that CN-TKA is more useful than conventional TKA for restoring the joint line, properly aligning the limb, and accurately positioning the components in patients with valgus deformity.^10–12 However, few reports have described the clinical comparison of valgus and varus deformities in CN-TKA.

This study aimed to assess the availability of CN-TKA for valgus deformities and compare it with CN-TKA for varus knees. We hypothesized that CN-TKA for valgus knees would produce acceptable soft tissue balancing and component alignment and good early clinical results comparable to those of CN-TKA for varus knees.

2 Materials and methods

2.1

2.1 Subjects

Between 2019 and 2022, TKA was performed on 74 knees of 57 consecutive patients, 20 of which had a valgus deformity with an anatomic axis >5° on the preoperative anteroposterior radiographs. The incidence of valgus knees in this patient population was 27 %. This was a retrospective analysis of 74 consecutive TKA procedures performed under the care of a single surgeon. The detailed demographic characteristics of the patients in the valgus and varus groups are listed in Table 1. The primary diagnosis was primary osteoarthritis in all knees. According to Ranawat's classification,¹ the 20 valgus knees included 10 type I and 10 type II knees. The study protocol was approved by our institutional review board (approval no. 179), and informed consent was obtained from all participants.

Table 1 Demographic data of the participants.

	Valgus knee	Varus knee	p value
Age (y)	72.2 ± 8.3	75.7 ± 6.4	0.165
Gender, male/female (n)	5/15	20/34	0.330
BMI (kg/m²)	24.5 ± 2.9	26.3 ± 3.5	0.047
Side, rt/lt (n)	10/10	34/20	0.313
Operative time (min)	132.5 ± 24.2	127.8 ± 23.2	0.449

2.2

2.2 Surgical techniques

All TKAs were performed with the medial stabilizing technique¹³ and aiming to restore neutral mechanical coronal alignment using the navigation-assisted gap balancing technique (OrthoPilot™, version 4.0; B. Braun Aesculap, Tuttlingen, Germany). All patients received cruciate-retaining total knee components (E-motion™; B. Braun Aesculap). In all patients, a fully cemented implant was placed, and none of the patients underwent patellar resurfacing. The lateral parapatellar approach was used for all valgus knees.³ The conventional medial parapatellar approach was used in all knees with varus.

All patients underwent surgery in the supine position using a tourniquet. An anterior midline longitudinal incision was made across the knee from the proximal side of the patella to the medial side of the tibial tubercle. The subcutaneous tissue and aponeurotic fascia were cut in turn and sharply separated outward. After the knees were exposed with each arthrotomy and the patella was everted, the anterior cruciate ligament was resected. A tibial cut was made perpendicular to the mechanical axis using a cutting block positioned under navigational guidance. Using a measuring device, the extension and flexion gaps were measured on the medial and lateral sides with a distraction force of 150N before femoral cutting, according to a previous study.¹⁴ Using the navigation system, the surgeon simulated distal femoral cutting and component sizing and rotation to obtain a balanced gap. If an extreme gap difference was encountered, an additional soft tissue release was performed. Femoral cutting was performed after positioning the femoral cutting block.

2.3

2.3 Evaluation of intraoperative laxity using navigation system

After implantation, the intraoperative hip-knee-ankle (HKA) angle, which was displayed by the navigation system, was recorded during full extension and at 30° and 90° of flexion under three conditions (no stress, valgus stress, and varus stress).¹⁵ In the measurement of the HKA angle, the valgus and varus angles were represented by positive and negative values, respectively. Valgus and varus stresses were applied using the surgeon's manual maximum force and kept as consistent as possible throughout the evaluation stages. Post-implantation medial and lateral laxity were defined as the differences in the intraoperative HKA angle between the valgus stress and the no stress conditions, and between the no stress and varus stress conditions, respectively.

2.4

2.4 Radiographic evaluation

Radiographic assessment consisted of radiographs of the knee (anteroposterior, lateral, and patellar axial views), and a standing long-leg radiograph was obtained pre- and postoperatively. Postoperative radiographs were obtained 1 month after surgery.

The femorotibial angle (FTA), HKA angle, and patellar tilt were measured on preoperative and postoperative radiographs. The patellar tilt on axial radiography was examined using a previously described technique.¹⁶ To investigate the component alignment, the mechanical lateral distal femoral angle (mLDFA) and mechanical medial proximal tibial angle (mMPTA) were measured on postoperative radiographs. A neutral postoperative mechanical alignment was defined within ±3°. An outlier was defined as a mechanical axis of >3° varus or valgus.

2.5

2.5 Clinical evaluation

The knee range of motion (ROM) was evaluated preoperatively and 1 year postoperatively. Outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Lysholm knee score preoperatively and 1 year postoperatively.

2.6

2.6 Statistical analysis

Statistical analyses were performed using SPSS version 22.0 (IBM, Armonk, NY). A two-sample t-test was used to compare patient age, body mass index, and operative time between the groups. The chi-square test was used to compare other demographic data. Comparison of post-implantation medial laxity with lateral laxity in full extension and at 30° and 90° of flexion in each group was performed using the Wilcoxon signed-rank test. Comparison of post-implantation medial and lateral laxity between the valgus and varus knee groups was performed using the Mann–Whitney U test. The Wilcoxon signed-rank test was used to compare the preoperative and postoperative Lysholm scores. The Mann–Whitney U test was used to compare preoperative and postoperative values, including ROM, Lysholm score, and the results of radiographic measurements, including patellar tilt, mLDFA, and mMPTA, between the two groups. The chi-square test was used to compare Kellgren and Lawrence (K-L) grade. A paired t-test was used to compare preoperative and postoperative KOOS scores in each group, and a two-sample t-test was used to compare preoperative and postoperative values, including KOOS and the results of radiographic measurements, including FTA and HKA, between the two groups. The distribution of outliers between groups was analyzed using the chi-square test. For all analyses, statistical significance was set at p < 0.05. All data were reported as mean ± SD.

3 Results

3.1

3.1 Intraoperative laxity under valgus and varus stress after implantation

There were no significant differences between medial and lateral laxity after implantation at all knee angles in the valgus knee group (Table 2). In the varus knee group, the medial and lateral laxity in full extension was 0.5 ± 0.6° and 1.2 ± 1.0°, respectively, and the difference was significant (p < 0.001). Furthermore, the medial and lateral laxity at 90° of flexion was 0.1 ± 0.3° and 0.4 ± 0.6°, respectively, and the difference was significant (p = 0.004). Regarding a comparison between the valgus knee and varus knee groups, the lateral laxity in full extension was 0.5 ± 0.7° and 1.2 ± 1.0°, respectively, and there was a significant difference (p = 0.011) (Table 3). Furthermore, the medial laxity at 90° of flexion was 0.4 ± 0.6° and 0.1 ± 0.3°, respectively, and there was a significant difference (p = 0.004).

Table 2 Intraoperative medial and lateral laxity after implantation.

		Medial laxity	Lateral laxity	p value
Valgus knee	Full ext. (°)	0.5 ± 0.7	0.5 ± 0.7	1.000
	30° flex. (°)	1.0 ± 1.1	0.7 ± 0.7	0.635
	90° flex. (°)	0.4 ± 0.6	0.5 ± 1.0	0.763
Varus knee	Full ext. (°)	0.5 ± 0.6	1.2 ± 1.0	<0.001
	30° flex. (°)	0.8 ± 1.2	0.7 ± 0.8	0.451
	90° flex. (°)	1.1 ± 0.3	0.4 ± 0.6	0.004

Table 3 Comparison of medial and lateral laxity between valgus knee and varus knee.

		Valgus knee	Varus knee	p value
Full ext.	Medial laxity (°)	0.5 ± 0.7	0.5 ± 0.6	0.663
Full ext.	Lateral laxity (°)	0.5 ± 0.7	1.2 ± 1.0	0.011
30° flex.	Medial laxity (°)	1.0 ± 1.1	0.8 ± 1.2	0.712
30° flex.	Lateral laxity (°)	0.7 ± 0.7	0.7 ± 0.8	0.586
90° flex.	Medial laxity (°)	0.4 ± 0.6	0.1 ± 0.3	0.004
90° flex.	Lateral laxity (°)	0.5 ± 1.0	0.4 ± 0.6	0.585

3.2

3.2 Radiological evaluation of lower extremity and component alignment

There were no significant differences in the patellar tilt or K-L grade between the valgus and varus groups (p = 0.892 and 0.347, respectively), even though there were significant differences in the FTA and HKA angle (p < 0.001 and < 0.001, respectively), preoperatively (Table 4). However, there were no significant differences in the FTA, HKA angle, or patellar tilt between the groups (p = 0.511, 0.498, and 0.952, respectively), postoperatively. In terms of postoperative component alignment, mLDFA and mMPTA in the valgus and varus knee groups were 90.2 ± 2.1° and 89.0 ± 1.5°, and 90.4 ± 1.9° and 89.7 ± 1.5°, respectively, and there were no significant differences between the groups (p = 0.978 and 0.090, respectively). The mLDFA outliers in the valgus and varus knee groups were 5.0 % (1/20) and 3.7 % (2/54), respectively, with no significant difference between the groups (p = 0.619). None of the groups exhibited any mMPTA outliers.

Table 4 Radiographic evaluation.

	Valgus knee	Varus knee	p value
Preoperative
FTA (°)	168.9 ± 4.2	182.8 ± 3.6	<0.001
HKA angle (°)	8.2 ± 6.3	−12.5 ± 5.0	<0.001
Patellar tilt (°)	5.7 ± 5.5	4.8 ± 3.8	0.892
KL grade 3 (n)	7	13	0.347
4 (n)	13	41	0.347
Postoperative
FTA (°)	175.2 ± 2.8	174.7 ± 3.2	0.511
HKA angle (°)	−0.5 ± 3.1	−1.1 ± 3.4	0.498
mLDFA (°)	90.2 ± 2.1	90.4 ± 1.9	0.978
mMPTA (°)	89.0 ± 1.5	89.7 ± 1.5	0.090
Patellar tilt (°)	6.7 ± 3.9	7.2 ± 4.1	0.952
Outlier (>3°)
mLDFA (n)	1	2	0.619
mMPTA (n)	0	0	1.000

3.3

3.3 Clinical outcomes

No complications including aseptic loosening, dislocation, instability, or patellar maltracking were observed in either group during the study period. There were no significant differences in the knee ROM between the valgus and varus groups preoperatively (extension, p = 0.486; flexion, p = 0.493) or postoperatively (extension, p = 0.969; flexion, p = 0.990) (Table 5). The Lysholm score significantly increased from 54.1 ± 11.7 to 86.4 ± 16.7 points in the valgus knee group (p < 0.001) and from 53.8 ± 9.7 to 93.1 ± 7.3 points in the varus knee group (p < 0.001), and there were no significant differences in the mean Lysholm score between the two groups preoperatively (p = 0.600) and postoperatively (p = 0.390). KOOS scores in the valgus and varus groups significantly increased from 43.9 ± 25.5 to 85.3 ± 14.7 points and 54.0 ± 19.1 to 85.0 ± 16.3 points in KOOS-Symptom (p < 0.001 and p < 0.001), from 41.8 ± 20.5 to 88.6 ± 14.9 points and 41.3 ± 19.1 to 83.6 ± 20.9 points in KOOS-Pain (p < 0.001 and p < 0.001), 53.8 ± 20.5 to 79.7 ± 21.2 points and 52.2 ± 17.2 to 83.0 ± 17.4 points in KOOS-function in activities of daily living (p < 0.001 and p < 0.001), from 22.1 ± 23.9 to 52.0 ± 32.6 points and 18.8 ± 19.9 to 50.9 ± 31.3 points in KOOS-sports and recreation (p < 0.001 and p < 0.001), and from 25.0 ± 22.0 to 68.1 ± 18.7 points and from 23.5 ± 19.0 to 71.6 ± 22.9 points in KOOS-quality of life (p < 0.001 and p < 0.001), respectively. There were no significant differences in the KOOS scores between the two groups preoperatively (p = 0.106, 0.934, 0.763, 0.589, and 0.803, respectively) or postoperatively (p = 0.954, 0.499, 0.632, 0.930, and 0.670, respectively).

Table 5 Comparison of clinical scores 1 year postoperatively between valgus and varus knee.

	Valgus knee	Varus knee	p value
Knee extension angle (°)	−2.1 ± 5.0	−2.1 ± 3.9	0.969
Knee flexion angle (°)	117.5 ± 10.5	116.8 ± 13.7	0.990
Lysholm score (points)	86.4 ± 16.7	93.1 ± 7.3	0.390
KOOS (points)
Symptom	85.3 ± 14.7	85.0 ± 16.3	0.954
Pain	88.6 ± 14.9	83.6 ± 20.9	0.499
ADL	79.7 ± 21.2	83.0 ± 17.4	0.632
Sport/Rec	52.0 ± 32.6	50.9 ± 31.3	0.930
QOL	68.1 ± 18.7	71.6 ± 22.9	0.670

4 Discussion

We performed a retrospective analysis of primary CN-TKA for mild to moderate valgus deformities. We used the lateral approach for valgus deformities to reach and release tense lateral soft tissues directly with little damage to the medial soft tissues.¹⁷ The most important findings of the present study were that CN-TKA for valgus knees demonstrated acceptable soft tissue balancing and component alignment, and good early clinical results comparable to those of CN-TKA for varus knees. A previous registry-based study showed that valgus deformity had a 2.1-fold higher risk of revision than varus deformity.⁵ Among the causes of revision, aseptic loosening, dislocation, and instability have been recorded in cases of valgus deformity; hence, it is important to obtain accurate soft tissue balancing and component positioning for successful clinical outcomes.

This study noted that the medial laxity in the valgus knee group at 90° of flexion was significantly higher than that in the varus group. In valgus knees, the lateral gaps in flexion are relatively tight compared with the medial gaps in flexion, and as the valgus deformity becomes more severe, the flexion gap differences increase, with the lateral gaps being considerably narrower than the medial gaps.¹⁸ A previous study demonstrated that excessive intraoperative medial joint laxity at 90° of flexion resulted in poor clinical results.¹⁹ Another study showed that lateral laxity at 90° of flexion was one of the most important factors affecting the postoperative knee flexion angle in CR-TKA.²⁰ Hence, it is crucial to maintain lateral flexion laxity equal to or greater than medial flexion laxity to achieve good clinical results. The present study showed that medial flexion laxity in valgus knees was significantly greater than that in varus knees. However, the medial flexion laxity was almost equal to the lateral flexion laxity in valgus knees, and it was comparable to the previous study.¹⁵ CN-TKA for valgus knees was considered to produce acceptable soft tissue balancing.

Anatomical variations in valgus deformities can lead to tibial external rotation and patellar lateral subluxation tendency.⁴ The complication rate of TKA for valgus deformities, especially in patellar maltracking, has been described as 2–10 %.²¹ Our radiographic evaluation results showed no significant differences in patellar tilt between the valgus and varus knee groups, and patellar maltracking was not observed in either group. Since a previous study showed that the lateral approach provided better patellar tilt after TKA for valgus deformities,²² we used a lateral approach for valgus deformities. A lateral approach also has an advantage of the blood supply of the patella if the lateral patellar retinaculum is needed to release for good patellar tracking.²³^,²⁴ Furthermore, computer-assisted TKA is beneficial for obtaining proper femoral rotational alignment in patients with advanced valgus deformity.¹² It is possible that CN-TKA produced proper femoral rotational alignment, and as such, good patellar tracking was obtained in our study, although we did not evaluate it. CN-TKA is also beneficial for the alignment of other components. Lee et al.¹¹ reported that CN-TKA correlated with lower outliers of the postoperative lower limb mechanical axis and femoral component position (mLDFA) in TKA for valgus knees. In this study, there were no significant differences in mechanical alignment or component position, in addition to the incidence of outliers after surgery, between the two groups. CN-TKA is a useful treatment strategy for mild to moderate valgus deformities to obtain an acceptable component alignment comparable to medial deformities.

TKA for valgus deformities is a uniquely challenging issue that is less routinely encountered than that for varus deformities.⁴^,²¹ Nevertheless, a previous study showed that the Knee Society Score (KSS) and KSS-function were similar in primary TKA between valgus and varus deformities at a mean follow-up of 72 months.²⁵ Another study showed no significant differences in postoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores at 1 year between valgus and varus deformities.²⁶ We also found no clinically significant differences in any of the KOOS subscales or Lysholm scores in patients with preoperative valgus deformity versus those with varus deformity within the first year after CN-TKA. Regarding the effectiveness of CN-TKA, van der List et al.²⁷ performed a meta-analysis of CN versus conventional TKA outcomes and reported that KSS total scores were better in patients who underwent CN-TKA than in those who underwent conventional TKA [mean difference (MD) 2.86 (0.96, 4.76), p = 0.003]. In valgus knees alone, Lee et al.¹¹ reported that the clinical outcomes, including WOMAC and KSS, of CN-TKA were not superior to those of conventional TKA. Huang et al.¹⁰ also found no significant differences in the postoperative International Knee Society and patellar scores between CN-TKA and conventional TKA. In a meta-analysis, using a navigation system for controlling soft tissue balance, in addition to lower leg alignment and component positioning, yielded better functional outcomes in CN-TKA than in conventional TKA [MD 4.84 (1.61, 8.07), p = 0.003].²⁷ Our results showed that acceptable soft tissue balancing and component alignment were achieved in TKA for valgus deformity by CN; thus, we obtained good early clinical results comparable to those of CN-TKA for varus knees.

This study has several limitations. First, this was a retrospective study with inherent limitations and bias. Second, the duration of follow-up in this study was relatively short and the number of patients enrolled was small. It is unclear whether the postoperative clinical outcomes of this study will be maintained in the long term. Third, it is possible that valgus and varus stresses during laxity assessment were not constant at each evaluation point. In addition, a potential confirmation bias may have affected the measurement of laxity. Fourth, we were unable to provide data on the rotational alignment of the femoral components. Further studies using computed tomography to evaluate rotational alignment are necessary to elucidate the effects of CN-TKA for valgus deformities on joint laxity at 90° of flexion and patellar tracking. Fifth, patients in the valgus group in this study had mild to moderate deformities. It is unclear whether patients with severe valgus deformities show results similar to those in this study.

5 Conclusion

CN-TKA using a lateral approach for valgus knees demonstrated acceptable soft tissue balancing and component alignment and good early clinical results comparable to those of CN-TKA for varus knees. Our short-term results of CN-TKA for mild to moderate valgus deformity are encouraging, but the long-term results and those for severe valgus deformity remain unknown. These findings warrant further investigation.

CRediT authorship contribution statement

Takuya Naraoka: was responsible for the organization and coordination of this study, All authors contributed to the management of this study, acquisition, analysis, and interpretation of data. Hikaru Soneda: All authors contributed to the management of this study, acquisition, analysis, and interpretation of data. Runa Hori: All authors contributed to the management of this study, acquisition, analysis, and interpretation of data. So Morioka: All authors contributed to the management of this study, acquisition, analysis, and interpretation of data. Yukihiro Matsuyama: All authors contributed to the management of this study, acquisition, analysis, and interpretation of data, All authors approved the manuscript to be published.

Ethics approval

This study was approved by the ethical committee of our institution.

Funding

The authors did not receive support from any organization for the submitted work.

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Evaluation of soft tissue balancing and component alignment in computer-navigated TKA for valgus knee

Abstract

Abstract

Abstract