Гений oртопедии (Mar 2020)
Total knee arthroplasty in patients with extra-articular deformity: which strategy to choose? (case report and literature review)
Abstract
Background Extraarticular deformity of the femur or tibia may be critical for the success of primary total knee arthroplasty (TKA). Recognizing an extraarticular deformity preoperatively allows a surgeon to choose between various management strategies. The surgical treatment options for correction of an extraarticular deformity include (1) primary TKA, (2) simultaneous corrective osteotomy and TKA and (3) staged corrective osteotomy and delayed TKA. Objective To substantiate differentiated approach to treatment strategies for osteoarthritic knee with extraarticular deformity based on international and our own experience. Material and methods Comparative analysis of current literature on surgical treatment of extraarticular deformities in arthritic knees was produced. The differentiated approach was illustrated by a clinical instance of a 35-year-old patient with bilateral end-stage gonarthrosis associated with extraarticular deformity of both lower limbs. Staged treatment was considered for the congenital multiplanar multilevel deformity in the shaft of the left femur with 26º valgus alignment, procurvatum, external rotation to be corrected with bifocal osteotomy addressing all components of the deformity and stabilized with interlocking intramedullary nail. Standard TKA on the left side was produced a year later with posterior cruciate ligament (PCL) retention. Acquired uniplanar varus deformity of the right femur was corrected using computer-assisted navigation TKA and the PCL substitution at 5 months after the first procedure. Results Knee score improved from 28 to 85 and from 52 to 86 in the left and right sides while functional activity score increased from 42 to 90 and from 52 to 92, respectively, as measured with American Knee Society scoring system (KSS). There is plenty of evidence in the literature that computer-assisted navigation TKA facilitates accurate limb alignment, better flexion angle and improved functional score whereas osteotomies are associated with a higher risk of complications that can result in delayed consolidation or nonunion. Conclusion Differentiated approach can be advocated for correction of an extraarticular deformity of lower limb to be addressed with TKA depending on the magnitude (in degrees), the location of the deformity in relation to the knee joint and relevant patient specific charactreristics, such as age, gender, clinical history. Computer-assisted navigation TKA is practical for mild diaphyseal deformity associated with gonarthritis. Corrective osteotomy can be useful for severe diaphyseal deformity or with the apex localized close to the joint for realignment at the first stage.
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