Varus scenarios in indian knee

Varus Scenarios, inVarus Scenarios, in
Indian KneesIndian Knees
Dr L.Prakash M.S., M.Ch.Dr L.Prakash M.S., M.Ch.
Institute for Special Orthopaedics Chennai.Institute for Special Orthopaedics Chennai.

A varus knee can vary in degreesA varus knee can vary in degrees

A varus knee may be somewhat likeA varus knee may be somewhat like
thisthis

Or even like thisOr even like this

But before thatBut before that
But why Varus scenario inBut why Varus scenario in IndianIndian knees?knees?
AreAre ourour knees different?knees different?
Is there aIs there a racial variationracial variation in coronalin coronal
deviation of the knee joint?deviation of the knee joint?

Apparently yes. Apart from my studies I haveApparently yes. Apart from my studies I have
found two references. One for adults and one forfound two references. One for adults and one for
children.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 Pope5
Significantly 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, inI could locate one study, in
childrenchildren
Normal development of theNormal development of the
knee angle in healthy Indianknee angle in healthy Indian
children: a clinical study ofchildren: a clinical study of
215 children215 children
Uttam Chand SainiUttam Chand Saini,,
Kamal BaliKamal Bali,, Binoti ShethBinoti Sheth,,
Nitesh GahlotNitesh Gahlot, and, and
Arushi GahlotArushi Gahlot

Normal development of the knee angle in healthyNormal development of the knee angle in healthy
Indian children: a clinical study of 215 childreIndian children: a clinical study of 215 childrenn
The overall pattern of development might be slightlyThe overall pattern of development might be slightly
different in Indian children, especially in Indian girls,different in Indian children, especially in Indian girls,
with early reversal of physiological varus (<2 years ofwith early reversal of physiological varus (<2 years of
age) and a late peak of maximal valgus at the kneeage) and a late peak of maximal valgus at the knee
(6 years of age).(6 years of age).
Varus after 3 years seems atypical for IndianVarus after 3 years seems atypical for Indian
children.children. We provide an elaborate set of data for theWe provide an elaborate set of data for the
mean TFA of different age groups and believe thatmean TFA of different age groups and believe that
this data could be of potential benefit to thethis data could be of potential benefit to the
physicians while evaluating lower limb alignment inphysicians while evaluating lower limb alignment in
Indian children aged 2–15 years.Indian children aged 2–15 years.

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

My anthropological study of IndianMy anthropological study of Indian
knee saggital and coronal positionsknee saggital and coronal positions
Study conducted in prisonStudy conducted in prison
Conducted over 12 yearsConducted over 12 years
Fourteen thousand IndianFourteen thousand Indian
Males were studiedMales were studied

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

MethodsMethods
Patient stood with back to thePatient stood with back to the
wall.wall.
Second toe faced straightSecond toe faced straight
towards the observertowards the observer
Line drawn from hip centre toLine drawn from hip centre to
knee centre was allowed toknee centre was allowed to
bisect the line from centre ofbisect the line from centre of
ankle to centre of knee.ankle to centre of knee.

MaterialMaterial
All subjects were maleAll subjects were male
Convict and under-trial prisoners.Convict and under-trial prisoners.
Age from 18 to 91Age from 18 to 91
Only 9% complained of anyOnly 9% complained of any
problemsproblems
Except for Sex, they representedExcept for Sex, they represented
the average Indian populationthe average Indian population

Results Saggital planeResults Saggital plane
Total Knees
studied
14,321
Varus
alignment
7642
Valgus
alignment
1387
Neutral
alignment
5292

Varus kneesVarus knees
Total kneesTotal knees
Neutral kneesNeutral knees
Valgus kneesValgus knees

Relationship between age andRelationship between age and
VarusVarus

Correlation between symptoms ofCorrelation between symptoms of
medial compartment OA and kneemedial compartment OA and knee
varusvarus

Progression of varus withProgression of varus with
ageage
1640 subjects over 40 years1640 subjects over 40 years
of age were progressivelyof age were progressively
followed up for ten yearsfollowed up for ten years
or longer.or longer.
Average rate of progressionAverage rate of progression
of varus was two degreesof varus was two degrees
per year and increasedper year and increased
exponentially with age.exponentially with age.

Varus progresses with age and theVarus progresses with age and the
progress is more rapid in obeseprogress is more rapid in obese
individualsindividuals
While less than 15% of those in twenties hadWhile less than 15% of those in twenties had
varus knees, over 60% of those above 70 had varusvarus knees, over 60% of those above 70 had varus
knees.knees.
Varus progressed most rapidly between the ages ofVarus progressed most rapidly between the ages of
60 to 80.60 to 80.
Once a knee gets into varus disposition, it continuesOnce a knee gets into varus disposition, it continues
to progress till the patient’s death.to progress till the patient’s death.

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

Limitations of the studyLimitations of the study
No facilities for radiographic co-relationNo facilities for radiographic co-relation
It was only a clinico-anthropometric study.It was only a clinico-anthropometric study.
Large numbers give the findings credibilityLarge numbers give the findings credibility
Study will be published soon.Study will be published soon.

We must rememberWe must remember
TKR is not always the only choiceTKR is not always the only choice
If you do embark on replacement, correcting VARUSIf you do embark on replacement, correcting VARUS
(or every other deformity) is of paramount importance.(or every other deformity) is of paramount importance.

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

Prakash’s classification of VarusPrakash’s classification of Varus
deformitiesdeformities
Type 1 : Primarily medialType 1 : Primarily medial
compartment OA. Lateral andcompartment OA. Lateral and
PF joints near normal.PF joints near normal.
Type 2: Bi or tri compartmentalType 2: Bi or tri compartmental
OA without subluxation.OA without subluxation.
Type 3: Wobbly, lax, orType 3: Wobbly, lax, or
destroyed knee with primarydestroyed knee with primary
varusvarus

Type 1: Primarily medialType 1: Primarily medial
Type 2: Wobbly, lax or destroyedType 2: Wobbly, lax or destroyed
knee with primary varusknee with primary varus

Type 1:Primarily medialType 1:Primarily medial

This classification is superior toThis classification is superior to Thienpont EThienpont E11 ,, ParviziParvizi
JJ22 .’s classification of 2016.’s classification of 2016

What would you do in thisWhat would you do in this
case?case?
56 year old gyaenacologist56 year old gyaenacologist
Advised TKR by sixAdvised TKR by six
surgeons.surgeons.
Severe pain on walking, noSevere pain on walking, no
rest pain.rest pain.

Pre and post surgeryPre and post surgery

PFO, something newPFO, something new
Accidental discovery in 2004Accidental discovery in 2004
Based on my experiences in prisonBased on my experiences in prison
An out of the box method which produces remarkableAn out of the box method which produces remarkable
and startling results both functionally andand startling results both functionally and
radiologically.radiologically.

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

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

candidatescandidates for TKR, due to thefor TKR, due to the
bad state of their knees.bad state of their knees.
Its natural that a prison too wouldIts natural that a prison too would
have its share of ideal TKRhave its share of ideal TKR
candidates on their waiting list.candidates on their waiting list.
Its natural that a prison too would haveIts natural that a prison too would have
its share of ideal TKR candidatesits share of ideal TKR candidates
on their waiting list.on their waiting list.
Its natural that a prison too would haveIts natural that a prison too would have
its share of ideal TKR candidatesits share of ideal TKR candidates
on their waiting list.on their waiting list.
Unfortunately a convict prisoner seldom gets any surgery exceptUnfortunately a convict prisoner seldom gets any surgery except
for life threatening conditionsfor life threatening conditions

It is only natural that a few of theseIt is only natural that a few of these
ripe candidates for TKR wouldripe candidates for TKR would
indulge in riots and break theirindulge in riots and break their
fibula.fibula.
Miraculously, in all these patients, the symptoms ofMiraculously, in all these patients, the symptoms of
OA disappeared immediately after fractured fibula.OA disappeared immediately after fractured fibula.
Those waiting for surgery refused a kneeThose waiting for surgery refused a knee
replacement as their symptoms had disappeared!replacement as their symptoms had disappeared!

Fractures below fibular neck curedFractures below fibular neck cured
pain from severe medial compartmentpain from severe medial compartment
OAOA
How does it work?How does it work?
The single versus triple cortexThe single versus triple cortex
theory.theory.
Whatever be the theory, itWhatever be the theory, it
really works well in mostreally works well in most
patients.patients.

Anatomical studiesAnatomical studies

The first patientThe first patient

PFO, indicationsPFO, indications

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

PFO, a day carePFO, a day care
procedureprocedure

PFO, observations so farPFO, observations so far
Effective in all patients, even those withEffective in all patients, even those with
patellofemoral OApatellofemoral OA
Patient remains pain free for three years or longer.Patient remains pain free for three years or longer.
My first patient operated in 2004, is still happyMy first patient operated in 2004, is still happy
and refuses knee replacement.and refuses knee replacement.
A multi-centre trial is being conducted presentlyA multi-centre trial is being conducted presently
and about 1800 surgeries have been done in the lastand about 1800 surgeries have been done in the last
one year.one year.

PFO, the first case, nine yearsPFO, the first case, nine years
follow upfollow up

PFO, other referencesPFO, other references

PFO, other referencesPFO, other references
Zong-You Yang, MD; Wei Chen, MD; Cun-Xiang Li, MD; Juan Wang, MD; De-Cheng Shao, MD; Zhi-Zong-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,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, MDMD; Ying-Ze Zhang, MD
It is a safe, simple, and effective procedure that is an alternative to total kneeIt 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 toarthroplasty for medial compartment OA of the knee joint. Care must be taken to
avoid potential nerve injuries.avoid potential nerve injuries.
Proximal fibular osteotomy may reduce knee pain significantly in the varusProximal fibular osteotomy may reduce knee pain significantly in the varus
osteoarthritic knee and improve the radiographic appearance and functionalosteoarthritic knee and improve the radiographic appearance and functional
recovery of the knee joint.recovery of the knee joint.

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

Choice of implants andChoice of implants and
techniquetechnique
CR vs CSCR vs CS
Cemented versus cementlessCemented versus cementless
Fixed versus modular bearings.Fixed versus modular bearings.
Snap on versus rotating bearings.Snap on versus rotating bearings.
Gap balance versus bone resection methodsGap balance versus bone resection methods
Navigation versus open surgeryNavigation versus open surgery
Makes absolutely no difference at 10 to 15 yearsMakes absolutely no difference at 10 to 15 years

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

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

The freeman technique for softThe freeman technique for soft
tissue balancing in varus kneestissue balancing in varus knees
Medial structures are released as one single sub periostealMedial structures are released as one single sub periosteal
sleevesleeve

Complete resection and nibbling of all osteophytes, and sequentialComplete resection and nibbling of all osteophytes, and sequential
release as the limb is externally rotated.release as the limb is externally rotated.

External rotation and anterior translation of tibia will expose posteriorExternal rotation and anterior translation of tibia will expose posterior
osteophytes which have to be removed.osteophytes which have to be removed.

The limb can be straightened to a 6 degree values at this stage.The limb can be straightened to a 6 degree values at this stage.

Distal femur and proximal tibia are cut with instruments of your choice.Distal femur and proximal tibia are cut with instruments of your choice.

Prakash instruments for thesePrakash instruments for these
cutscuts
Distal femur and proximal tibia are cut with instruments of your choice.Distal femur and proximal tibia are cut with instruments of your choice.

Freeman gap balancer and tissue tensionerFreeman gap balancer and tissue tensioner

The gap balance methodThe gap balance method
Flexion and extension gaps should be equalFlexion and extension gaps should be equal

Knee is stable through the entire range of motionKnee is stable through the entire range of motion

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
arthritis
Wind swept/ Varus - Valgus knees.

Questions
Do 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?
Any tricks to equalise the flexion and extension
gaps?
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

Two approaches Biological andTwo approaches Biological and
Mechanical.Mechanical.
I follow the biological approachI follow the biological approach

Biological Versus MechanicalBiological Versus Mechanical
Methods.Methods.
Biological methodsBiological methods
•
Good soft tissue releasesGood soft tissue releases
•
Minimal tibial cut, to the level ofMinimal tibial cut, to the level of
defect on Lateral tibial plates.defect on Lateral tibial plates.
•
Defect is augmented by grafts fromDefect is augmented by grafts from
femoral cut.femoral cut.
•
Screw, graft and cement make theScrew, graft and cement make the
biological wedge augment.biological wedge augment.
•
Tibial bearing is usually 8 mm and noTibial bearing is usually 8 mm and no
stem is used.stem is used.
Mechanical methodsMechanical methods
• Cut is a little lower.Cut is a little lower.
• Defect is augmented by metal wedgesDefect is augmented by metal wedges
attached to the stem.attached to the stem.
• A thick insert is used usually 12A thick insert is used usually 12
mm or thicker.mm or thicker.
• PCL is usually sacrificed.PCL is usually sacrificed.
• Tibial stems are often used.Tibial stems are often used.

Biological Versus MechanicalBiological Versus Mechanical
Methods.Methods.

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

Biological methodBiological method

Take home messagesTake home messages
Over 50% of Indian knees present with VarusOver 50% of Indian knees present with Varus
deformities.deformities.
Children who have valgus knees gradually developChildren who have valgus knees gradually develop
varus as they grow old.varus as they grow old.
Not all Varus knees have symptomatic medialNot all Varus knees have symptomatic medial
joint OAjoint OA

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

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

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

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

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

It is not important to just knowIt is not important to just know howhow to do a kneeto do a knee
replacement.replacement.
More important is to knowMore important is to know when not towhen not to do it.do it.
More than the implant design or instrumentation,More than the implant design or instrumentation,
ssoft tissue handlingoft tissue handling is important.is important.
AA gardener’s approachgardener’s approach is preferable to ais preferable to a
carpenters’s approach.carpenters’s approach.

Basic Total Knee ArthroplastyBasic Total Knee Arthroplasty
Conference and Workshop.Conference and Workshop.
Location: Chennai Tamil Nadu IndiaLocation: Chennai Tamil Nadu India
Dates:Dates: Saturday and Sunday 18th andSaturday and Sunday 18th and
19th February 2017.19th February 2017.
Venue - Hotel Shan Royal
85, Poonamalle High Road, Koyambedu, Chennai - 600107
Expected participation: 100 delegates from all over India and a
few from abroad.

Varus scenarios in indian knee

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