Orthopaedics & Traumatology: Surgery & Research (2009) 95, 260266

ORIGINAL ARTICLE

Total knee arthroplasty in valgus knees: Predictive

preoperative parameters inuencing a constrained
design selection
J. Girard a,, M. Amzallag b, G. Pasquier a, A. Mulliez a, T. Brosset a,
F. Gougeon c, A. Duhamel d, H. Migaud a

a
C and D Orthopaedic Units, University Department of Orthopaedics and Traumatology, Lille 2 University Faculty of Medicine,
Roger-Salengro Hospital, Lille Regional University Hospital Center, 59037 Lille cedex, France
b
Orthopaedics and Traumatology Department, Dron Hospital, Tourcoing, France
c
Louvire Private Hospital, Lille, France
d
Biostatistics Laboratory, Medical Computer Science Research Center, Faculty of Medicine, Lille, France

Accepted: 21 April 2009

KEYWORDS Summary
Total knee Introduction: In valgus knees, ligament balance might remain a challenge at total knee pros-
arthroplasty; theses implantation; this leads some authors to systematically propose the use of constrained
Valgus knee; devices (constrained condylar knee or hinge types. . .). It is possible to adapt the selected level
Laxity; of constraints, by reserving higher constraints to cases where it is not possible to obtain nal
Instability; satisfactory balance: less than 5 of residual frontal laxity in extension in each compartment,
Constrained and a tibiofemoral gap difference not in excess to 3 mm between exion and extension.
prosthesis Hypothesis: It is possible to establish preoperative criteria that can predict a constrained design
prosthetic implantation at surgery.
Materials and methods: A consecutive series of 93 total knee prostheses, implanted to treat
a valgus deformity of more than 5 was retrospectively analysed. Preoperatively, full weight
bearing long axis AP views A-P were performed: hip knee angle (HKA) averaged 195 (186 to
226 ), 36 knees had more than 15 of valgus, and 19 others more than 20 of valgus. Laxity was
measured by stress radiographies with a TelosTM system at 100 N. Fifty-two knees had preop-
erative laxity in the coronal plane of more than 10 . Fourteen knees had more than 5 laxity
on the convex (medial) side, 21 knees had more than 10 laxity on the concave (lateral) side.
Statistical assessment, using univariate analysis, identied the factors that led, at surgery, to
an elevated constraint selection level; these factors of independence were tested by multivari-
ate analysis. Logistical regression permitted the classication of the said factors by their odds
ratios (OR).

Corresponding author.
E-mail address: j girard lille@yahoo.fr (J. Girard).

1877-0568/$ see front matter 2009 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2009.04.005
Total knee arthroplasty in valgus knees 261

Results: High-constraints prostheses (CCK type) numbered 26 out of 93 implantations; the

other total knee prostheses were regular posterostabilized (PS) prostheses. Statistically, the
preoperative factors that led to the choice of a constrained prosthesis were: (1) valgus sever-
ity as measured by HKA (PS = 193 , CCK = 198 ), (2) increased posterior tibial slope (PS = 4.8 ,
CCK = 6.5 ), (3) low patellar height (using Blackburne and Peel index PS = 0.89, CCK = 0.77), (4)
severity of laxity in valgus (PS = 2.3 , CCK = 4.3 ). Among all these factors, the only indepen-
dent one was laxity in valgus (convex side laxity) (p = 0.0008). OR analysis showed a two-fold
increased probability of implanting an elevated constraints prosthesis for each one degree
increment of laxity in valgus.
Discussion: This study demonstrated that it was not the valgus angle severity but rather the
convex medial side laxity that increased the frequency of constrained prostheses implantation.
Other factors, as a low patellar height or an elevated posterior tibial slope, when associated,
potentiate this possible prosthetic switch (to higher constraints) and should make surgeons
aware, in these situations, of encountering difculties when establishing ligament balance.
Level of Evidence IV: Therapeutic retrospective study.
2009 Elsevier Masson SAS. All rights reserved.

Introduction presumes the availability, in operating room, of different

The correction of deformities and establishing ligament bal-
ance are priority mechanical objectives in the implantation
of total knee prostheses (TKPs) to ensure a good, durable
and functional result [14]. In cases of frontal deformity
in valgus, achieving these two objectives may be difcult
[5,6], notably in patients with convex laxity and/or defor-
mity surpassing 20 [7]. Specic management techniques for
the soft tissue release have been developed to treat this
type of deformity:
the lateral approach with elevation of Maissiats band of
Gerdys tubercule [810];
the medial articular approach and the release of lateral
structures by the trans-articular approach with partial
section of the iliotibial band by pie-crusting [11,12];
lateral condyle osteotomy allowing the displacement of
femoral insertions of the lateral collateral ligament and
of the popliteal muscle for adjustment of laxity and space
in exion as in extension [13].
Other methods were proposed when the previous tech-
niques reached their limits:
osteotomy combined with prosthesis implantation when
the deformity is extra-articular [14];
constrained prosthesis (with constrained condylar knee
[CCK] type), notably for elderly patients to simplify and
shorten the operative procedure [1517];
hinge prosthesis to simplify the intervention to the maxi-
mum when signicant laxity exists [18,19].
Several authors have raised concerns that these high-
constraint prosthesis (CCK type) and hinge prostheses
represent a higher risk of loosening and exposure to tech-
nical difculties in case of revision [2022]. Systematic
recourse to prostheses implanted with high-level constraint
is questionable, and several authors have proposed adjust-
ment of this indication to the ligament balancing problems
[19,2325]. This attitude appears to be reasonable, but it
implant types and corresponding ancillary components (or
evolutive ancillary items), to adapt to operative difcul-
ties during intervention. Among these operative problems
encountered, the adjustment of ligament tension is the most
unpredictable, notably, to obtain evenness of spaces in ex-
ion and in extension [26].
To facilitate the management of operating rooms (inter-
vention duration, ancillaries, implants), it seems justied to
identify cases where recourse to high-constraint prostheses
is the most probable. Our hypothesis is that preoperative
data are predictive of the use of constrained prostheses in
cases of valgus deformity greater than 5 .
Materials and methods
Patients
This continuous, monocentric, retrospective series com-
prised 93 TKPs implanted between 1996 and 2004 for the
treatment of valgus knees with deformity of more than
5 . During the study period, only two hinge prostheses
(excluded from the study) were implanted in rst inten-
tion for genu valgum. There were 89 patients (four bilateral
cases, 80 women and nine men) with an average age of
70.1 years 11.5 (32 to 90 years). Indications for arthro-
plasty were gonarthrosis in 63 knees (62.4%), rhumatoid
arthritis in 14 knees (15.1%), post-traumatic arthrosis in 12
knees (13%), lateral condyle necrosis in two cases (2.1%),
one haemophilic arthropathy and one sequella of septic
arthritis. Body mass index (BMI) was, on average, 28 5 (17
to 41), and 27 patients were signicantly overweight with
BMI greater than 30.
In the 93 knees, 22 already had at least one inter-
vention (12 knees with one intervention, nine knees with
two interventions, and another one which underwent three
interventions). The preliminary interventions consisted of
eight internal xations, seven osteotomies (four tibial valgus
and three femoral varus osteotomies), 10 hardware removal,
two debridement arthroscopies for arthrosis, two sections of
the lateral patellar retinaculum, one transfer of the anterior
262 J. Girard et al.

according to the method of Blackburne and Peel [30]

Table 1 Laxity values measured manually and radiographi-
(ratio between the distance from the tangent of the tibial
cally by a TelosTM system with an applied force of 100 N. With
plateau to the lower point of the patella articular surface
manual measurements, 21 laxities of 10 or more would not
and the length of the patellar surface [normal between
have been known.
0.56 and 1.04]);
Manual measurements Radiographic a patellofemoral view at 30 to evaluate patellar center-
[number (%)] measurements ing and classifying three states (centered, subluxation,
[number (%)] luxation);
anterior stress radiographs in valgus and varus by a TelosTM
Frontal laxity system with an applied force of 100 N to measure concave
< 5 27 (29) 1 (1.3) laxity (in varus) or convex laxity (valgus).
5 to 9 35 (37.6) 25 (32.1)
10 to 14 17 (18.4) 42 (53.8)
15 14 (15.1) 10 (12.8) The radiographic data appear in Table 2. Valgus was pre-
dominantly of femoral origin, but tibial deformity in valgus
Saggital laxity was associated with more than 5 in 1/3 of these cases.
< 5 mm 77 (82.9) Convex laxity of 5 or more occurred 14 times. Compar-
5 to 9 mm 12 (12.9) ing Tables 1 and 2, it can be seen that clinical examination
10 mm 4 (4.3) underestimated frontal laxity of 10 or more.

tibial tubercle and a reconstruction of the anterior cruci- Operative technique

ate ligament. The average index of arthroplasty was 1.35
(1 to 4).
According to the International Knee Society (IKS) scor-
ing system [27], 48 knees were class A, 34 class B, and
11 class C, indicating multiarticular involvement. The IKS
knee score averaged 30 15.5/100 points (0 to 70) and
the IKS function score was 36.8 21.6/100 points (0
to 80), giving a global score of 66.8 28.8/200 points (4
to 127). Preoperative mobility in exion was, on average,
113 12 (75 to 135 ). Before the procedure, 53 knees had
essum greater than 5 , and 22 knees had essum above
15 . The clinically measured laxity values are reported in
Table 1.
Preoperative radiographs were taken in all patients:
an anterior, standing pangonogram with bipodal support
to measure the deformity according to IKS criteria [28];
a precise prole of the knee to assess tibial slope, start-
ing from the posterior cortical [29], and patellar height
All surgeries were performed under vertical laminar ow, 53
times under general anaesthesia and 40 times under epidu-
ral anaesthesia. The pneumatic tourniquet, which was used
86 times, was not inated until the time of sealing, that
is to say, after all cuts were made and ligament balance
adjusted. The chosen approach was left to the discretion of
the surgeon (four seniors undertook or supervised the oper-
ations): 54 lateral approaches and 39 medial approaches
were taken; elevation of the anterior tibial tubercle was per-
formed [31] 25 times, always during the lateral approach.
No preoperative factor had any signicant inuence on
the choice of approach: deformity severity, frontal lax-
ity, patellar height, etiology, mobility and essum, obesity
(non-signicant). The same surgical sequence was followed
by all surgeons, with the tibial cut rst (under cen-
tromedullary guidance coupled with extramedullary vision)
and then the femoral cut, both undertaken orthogonally
to the mechanical axis to correct the frontal axis defect.

Table 2 Average values, standard deviation and ranges of radiographic variables.

Variable Average S.D. Range Remarks

Blackburne & Peel 0.86 0.16 0.5 to 1.52 3 patella baja and 8 alta
Tibial slope 5 3.1 0 to 17 17 knees with more than 7
Patellar position 28 subluxations, no
dislocation
HKA 195 6.8 186 to 226 36 knees > 15 of valgus and
19 knees > 20 of valgus
HKS angle 6.8 1.4 4 to 11 27 knees with divergence
> 7
Alpha angle (anatomical femoral valgus) 101.5 4 89 to 115 56 knees with > 100 and 18
knees with 105
Beta-angle 93.7 4.8 85 to 118 Only 9 tibia in varus (< 90 )
but 35 tibia in valgus > 5
(beta > 95 )
Laxity in varus (concavity) 7.9 3.1 1 to 17 21 knees with 10 or more
Laxity in valgus (convexity) 3 2 1 to 10 14 knees with 5 or more
HKA: hip-knee angle; HKS: angle between the mechanical axis and femoral shaft axis.
Total knee arthroplasty in valgus knees
Ligament balancing was guided and evaluated by tension
(V-StatTM or HLSTM tensioning device) and/or wedges of
increasing thickness reproducing gaps in exion and exten-
sion. Ligament tension was regulated with instruments by
progressive release and, as needed, by lateral (54 cases)
and/or medial structures (six cases) according to the method
proposed by Insall et al. [4,6]. In principle, for all the sur-
geons, a posterostabilised (PS) prosthesis was implanted
(Nexgen-LegacyTM , HLSTM ) if the tensioning device and/or
the wedges indicated that there was less than 5 of resid-
ual frontal laxity in extension in each compartment and
a difference of less than 3 mm between the spaces in
exion and extension. In opposite cases, the cuts were
revised for the implantation of a constrained prosthesis
(Nexgen-Legacy CCKTM ). The lateral patellar retinaculum
was sectioned in 54 surgeries by the lateral approach and
in 19 of 39 surgeries by the medial approach (with no statis-
tical correlation to preoperative subluxation). One lateral
condyle osteotomy, according to Burdin & Brilhault [13] was
done to rene ligament balance to allow the use of a PS
prosthesis.
Evaluation and statistical methods
The judging point was the recourse to a constrained pros-
theses implanted because of defective balance according
to the modalities mentioned above. Statistical analysis was
performed with SAS software (SAS, Cary, CA, USA) to identify
the factors that could predict variations of the judging point.
Univariate analysis was conducted by the Chi2 test for cate-
gorical variables, analysis of variance for the comparison
of averages, and logistic regression for quantitative vari-
ables. Univariate analyses identied the factors that had an
inuence on the choice of constrained prostheses. The inde-
pendence of these factors was evaluated by multivariate
analysis, and logistical regression analysis then permitted
the classication of factors by odds ratios (OR) (with 95%
condence intervals). The alpha risk was 5%.
Results
PS prostheses (36 HLSTM and 31 Nexgen-LegacyTM prostheses)
were implanted in 67 of the 93 knees (72%). In 26 cases (28%),
the surgeon estimated that the balancing criteria were not
met, and a constrained prosthesis (Nexgen-Legacy LCCKTM )
was inserted.
Five preoperative factors were identied by univariate
analysis to be associated more frequently with the implan-
tation of sliding, constrained prostheses:
preoperative valgus severity measured by HipKnee
Ankle angle (HKA), 193 in the group with PS prosthe-
ses versus 198 in the group with constrained prostheses
(p = 0.009). On the other hand, other angles evaluating
femoral deformity (alpha, HKS) were not correlated with
the use of a high-constraint device;
elevated tibial slope (4.8 in the group with a PS prosthesis
versus 6.5 in the TKP-constrained group [p = 0.02]);
tibial valgus identied by beta angle of 93 in the PS group
versus 96 in the TKP-constrained group (p = 0.01);
263
a low patella identied by the index of Blackburne and
Peel of 0.89 in the group with PS prostheses versus 0.77
in the TKP-constrained group (p = 0.001);
radiological laxity in valgus was higher than 4.3 in the
TKP-constrained prostheses group versus 2.3 in the PS
prostheses group (p = 0.0001).
On the other hand, other factors were not correlated with
the use of constrained prostheses: (1) signicant laxity in
varus, (2) osteotomy history, (3) correction of the deformity
on stress radiographs, and (4) ligament loosening.
No other preoperative clinical factor (age, aetiology,
obesity, mobility, essum, function and IKS score), oper-
ative (approach, type of anaesthesia, tubercle elevation)
or radiographic procedure (patella position on the dele)
was correlated with the greater frequency of constrained
prostheses.
Multivariate analysis showed that the sole independent
factor associated with the more frequent implantation of
constrained prostheses was laxity in valgus with an OR of
1.9 (1.22.7) (p = 0.0008). Each increase of 1 in laxity in
valgus augmented the risk of inserting a constrained pros-
thesis by 1.9-fold (p = 0.0003). The existence of a low patella
was at the limit of signicance as an independent risk factor
(p = 0.08).
The frequency of per- or postoperative complications was
comparable for PS and constrained prostheses with, how-
ever, three conversions of PS to constrained prostheses: one
lateral tibial plateau fracture, initially unseen, revised at
day 10, and two revisions for frontal instability at 15 and
18 months by CCK type constraint prostheses (one being a
Burdin and Brilhault type osteotomy (Fig. 1)). Fibular nerve
palsy occured once, with partial recovery after a PS prosthe-
sis. On the other hand, surgical duration was much greater
in the case of constrained prosthesis (171 minutes versus
141 minutes [p = 0.0006]), and while intraoperative bleed-
ing was comparable between the two groups, postoperative
bleeding was more signicant in the constrained prostheses
group (1233 ml versus 1081 ml [p = 0.02]).
Discussion
This study conrmed the seriousness of convex laxity during
TKP implantation in valgus. The idea has already been pro-
posed by Stern et al. [6] and Miyasaka et al. [7], but it has
not been conrmed statistically by multivariate analysis of
a large series. In fact, Stern et al. [6], Miyasaka et al. [7],
and Anderson et al. [17] also emphasized the role of defor-
mity severity in valgus that our study refuted, demonstrating
that the only independent factor predictive of constrained
prostheses is laxity in valgus (that is to say, of convexity).
Our study has limits due to its high number of operators,
but all respected the same criteria of indications for a con-
strained prosthesis. A principle position on the indication
of CCK prostheses was followed by all operators, guided by
instruments (tensioning devices and/or wedges). No authors
have cited this type of reference, but it seems reason-
able to report these numbers which correspond to a laxity
threshold classied as abnormal on the IKS score [27,28].
Our principal objectives were to obtain comprehensive,
preoperative radiographic measurements, notably radio-
264 J. Girard et al.

Figure 1 A 64-year-old patient suffering from lateral arthrosis of the left knee (sequellae of hip dysplasia with varus tibial
osteotomy history and hip prosthesis). A and B. Valgus knee of 19 , normal patellar height and tibial slope at 9 . C: Valgus stress
radiograph on TelosTM : convex laxity of 6 . D and E. Lateral approach with elevation of the tibial tubercle and condylar osteotomy:
correction of the deformity and proper ligament balance with a PS prosthesis (radiographs at 4 months). F, G and H. Reappearance
of convex laxity 14 months later necessitating revision with a CCK type prosthesis.

graphic quantication of frontal laxity by means of a TelosTM
type dynamometer [32,33] which improved the reproducibil-
ity of measurements in relation to manual assessments
[34,35]. Our study stresses the point that 21 frontal laxi-
ties surpassing 10 would have remained unknown by manual
measurements, hampering the prediction of recourse to con-
strained prostheses. The Socit orthopdique de lOuest
symposium on TKP for valgus deformities of more than 10
reported four situations of reducibility and of convex lax-
ity: reducible deformity without convex laxity, irreducible
deformity without convex laxity, reducible deformity with
convex laxity, and irreducible deformity with convex lax-
ity [36]. Our investigation did not conrm the statistical
inuence of deformity correction as a factor predictive of
recourse to constrained prostheses. On the contrary, con-
vex laxity, a criterion proposed by Hulet et al. [36], is seen
as an essential and independent predictive factor in our
study.
Some authors have suggested that it is possible to treat all
knee arthropathies with deformity in valgus by sliding, non-
constrained prostheses: Ranawat et al. [5] did not implant
any constrained prostheses in 85 TKPs in valgus of more
than 10 , and Whiteside [37] inserted no constrained pros-
theses among 231 TKPs in valgus of 12 to 45 . However,
the tolerance level of residual instability was not speci-
ed, and these series both came from a single operator
Total knee arthroplasty in valgus knees
[5,37]. On the contrary, as we have observed three times
in our study, the use of limit conditions of a PS prosthe-
sis exposed patients to secondary instability, seen in 24%
of cases by Miyasaka et al. [7], while CCK type prosthe-
ses avoided secondary instability in this indication [17]. The
solution proposed by Brilhault et al. [13] is the most effec-
tive in limiting the implantation of constrained prostheses.
This technique is the only one that allows imbalance to be
controlled between the medial and lateral compartments
in exion and extension. The only case where we applied
it was initially successful, but secondary loosening of the
medial collateral ligament at 12-month follow-up (Fig. 1)
was probably associated with varus tibial osteotomy his-
tory and led to failure. This observation suggests difculties
in establishing durable balance of multisurgery knees on
the medial side as they are exposed to secondary loosen-
ing of the medial collateral ligament. To treat ligament
imbalance with convex laxity, the Brilhault et al. [13] proce-
dure appears to be more reliable than ligament retensioning
abandoned by their promoter [38], and it is the only one
able of avoiding increased constraint for frontal instabil-
ity combined with imbalance of the space in exion and
extension [39].
We chose the valgus threshold of minimum 5 to include
patients in this study, whereas other authors retained defor-
mities in valgus of more than 10 [57], sometimes even
more than 15 [17]. It appears to us that valgus of more
than 5 indicates a deformity which could not be explained
by simple wear of the lateral compartment, suggesting bone
deformity. The deformities that we observed were pro-
portionately comparable to those reported by Desm et
al. [40], who indicated that the majority of arthrosic val-
gus deformities comes from the femur, emphasizing tibial
involvement in 21% (6/28 cases), a little lower than in our
study (33%).
In the literature, the results with CCK type constrained
prostheses [17,20,23] are generally favourable up to follow-
up of 10 years. However, we emphasize that these models
have preferentially been used in elderly and less active
patients [16], and some series have reported loosening and
pains at the extremities of diaphyseal extensions [41,42].
Similarly, hinge prostheses for such indications are discussed
[19], as their survival at ve years is less than 70%, despite
the introduction of newly-conceived, modern implants [22].
Also, the attitude of choosing the constraint level accord-
ing to balancing difculties appears to be more prudent
[23,24]. However, this attitude supposes the use of a TKP
model with constraint level and ancillaries which can evolve
during the intervention, for fear of having to change the
implant type during surgery, exposing patients to excessively
prolonged operating time. Our study allows us to achieve
appropriate reliability at the level of constraint required
and thus to adapt intervention duration, implant and
ancillary stock.
Theoretically, navigation, which allows us to rene the
adjustment of cuts and better ligament balancing before
the cuts, should reduce the frequency of constrained pros-
theses [43,44]. If the orientation of cuts seems to be more
precise with navigation, the precision of ligament manage-
ment in some comparative studies seems as reliable with
classical ancillary components as with computer assistance
[43,45,46].
265
Conclusions
This study shows that, in choosing the level of constraint
to be applied in arthroplasty of a valgus knee deformity
of more than 5 , it is important to undertake preop-
erative radiographic quantications of convex laxity, the
only independent parameter. The four other classical fac-
tors, identied by univariate analysis (excessive slope, low
patella, valgus severity, valgus of tibial origin), were not
independent but their association should warn even more
surgeons about problems of ligament balancing. Respecting
these conditions should allow us to foresee, preoperatively
with serenity, the use of high-constraint prostheses for the
treatment of knee arthropathy with valgus deformity.
References
[1] DLima DJ, Patil S, Steklov N, Colwell Jr CW. An ABJS Best
Paper: Dynamic intraoperative ligament balancing for total
knee arthroplasty. Clin Orthop 2007;463:20812.
[2] Unitt L, Sambatakakis A, Johnstone D, Briggs TW, Balancer
Study Group. Short-term outcome in total knee replacement
after soft-tissue release and balancing. J Bone Joint Surg (Br)
2008;90:15965.
[3] Parratte S, Pagnano MW. Instability after total knee arthro-
plasty. J Bone Joint Surg (Am) 2008;90:18494.
[4] Hood RW, Vanni M, Insall JN. The correction of knee align-
ment in 225 consecutive total condylar knee replacements. Clin
Orthop 1981;160:94105.
[5] Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Bab-
hulkar S. Total knee arthroplasty for severe valgus deformity.
J Bone Joint Surg (Am) 2005;87(Suppl 1):27184. Pt 2.
[6] Stern SH, Moeckel BH, Insall JN. Total knee arthroplasty in
valgus knees. Clin Orthop 1991;273:58.
[7] Miyasaka KC, Ranawat CS, Mullaji A. 10- to 20-year follow up
of total knee arthroplasty for valgus deformities. Clin Orthop
1997;345:2937.
[8] Keblish PA. The lateral approach to the valgus knee. Surgical
technique and analysis of 53 cases with over two-year follow-up
evaluation. Clin Orthop 1991;271:5262.
[9] Bassaine M, Jeanrot C, Gagey O, Huten D. The compo-
site meniscal-capsular-fat pad ap in a lateral approach to
the xed valgus knee: an anatomical study. J Arthroplasty
2007;22:6014.
[10] Fiddian NJ, Blakeway C, Kumar A. Replacement arthroplasty
of the valgus knee. A modied lateral capsular approach
with repositioning of vastus lateralis. J Bone Joint Surg (Br)
1998;80:85961.
[11] Elkus M, Ranawat CS, Rasquinha VJ, Babhulkar S, Rossi R,
Ranawat AS. Total knee arthroplasty for severe valgus defor-
mity. Five to fourteen-year follow-up. J Bone Joint Surg (Am)
2004;86:26716.
[12] Clarke HD, Fuchs R, Scuderi GR, Scott WN, Insall JN. Clin-
ical results in valgus total knee arthroplasty with the pie
crust technique of lateral soft tissue releases. J Arthroplasty
2005;20:10104.
[13] Brilhault J, Lautman S, Favard L, Burdin P. Lateral femoral
sliding osteotomy lateral release in total knee arthroplasty
for a xed valgus deformity. J Bone Joint Surg (Br) 2002;84:
11317.
[14] Lonner JH, Siliski JM, Lotke PA. Simultaneous femoral
osteotomy and total knee arthroplasty for treatment of
osteoarthritis associated with severe extra-articular deformity.
J Bone Joint Surg (Am) 2000;82:3428.
266
[15] Donaldson 3rd WF, Sculco TP, Insall JN, Ranawat CS. Total
condylar III knee prosthesis. Long-term follow-up study. Clin
Orthop 1988;226:218.
[16] Easley ME, Insall JN, Scuderi GR, Bullek DD. Primary con-
strained condylar knee arthroplasty for the arthritic valgus
knee. Clin Orthop 2000;380:5864.
[17] Anderson JA, Baldini A, MacDonald JH, Pellicci PM, Sculco TP.
Primary constrained condylar knee arthroplasty without stem
extensions for the valgus knee. Clin Orthop 2006;442:199203.
[18] Walker PS, Manktelow AR. Comparison between a constrained
condylar and a rotating hinge in revision knee surgery. Knee
2001;8:26979.
[19] Sculco TP. The role of constraint in total knee arthroplasty. J
Arthroplasty 2006;21(Suppl. 1):546.
[20] Hartford JM, Goodman SB, Schurman DJ, Knoblick G. Complex
primary and revision total knee arthroplasty using the condylar
constrained prosthesis: an average 5-year follow-up. J Arthro-
plasty 1998;13:3807.
[21] Springer BD, Hanssen AD, Sim FH, Lewallen DG. The kinematic
rotating hinge prosthesis for complex knee arthroplasty. Clin
Orthop 2001;392:28391.
[22] Pour AE, Parvizi J, Slenker N, Purtill JJ, Sharkey PF. Rotating
hinged total knee replacement: use with caution. J Bone Joint
Surg (Am) 2007;89:173541.
[23] Lachiewicz PF, Soileau ES. Ten-year survival and clinical results
of constrained components in primary total knee arthroplasty.
J Arthroplasty 2006;21:8038.
[24] Naudie DD, Rorabeck CH. Managing instability in total knee
arthroplasty with constrained and linked implants. Instr Course
Lect 2004;53:20715.
[25] Yercan HS, Ait Si Selmi T, Sugun TS, Neyret P. Tibiofemoral insta-
bility in primary total knee replacement: a review. Part 1: Basic
principles and classication. Knee 2005;12:25766.
[26] Grifn FM, Insall JN, Scuderi GR. Accuracy of soft tissue balanc-
ing in total knee arthroplasty. J Arthroplasty 2000;15:9703.
[27] Insall JN, Dorr LD, Scott RD, Scott N. Rationale of the knee
society clinical rating system. Clin Orthop 1989;248:135.
[28] Ewald FC. The Knee Society total knee arthroplasty
roentgenographic evaluation and scoring system. Clin Orthop
1989;248:912.
[29] Brazier J, Migaud H, Gougeon F, Cotten A, Fontaine C, Duquen-
noy A. Evaluation of methods for radiographic measurement of
the tibial slope. A study of 83 healthy knees. Rev Chir Orthop
1996;82:195200.
[30] Blackburne JS, Peel TE. A new method of measuring patellar
height. J Bone Joint Surg (Br) 1977;59:2412.
[31] Mertl P, Jarde O, Blejwas D, Vives P. Lateral approach of the
knee with tibial tubercle osteotomy for prosthetic surgery. Rev
Chir Orthop 1992;78:2647.
[32] Matsuda Y, Ishii Y. In vivo laxity of low contact stress mobile-
bearing prostheses. Clin Orthop 2004;419:13843.
J. Girard et al.
[33] Besson A, Brazier J, Chantelot C, Migaud H, Gougeon F, Duquen-
noy A. Laxity and functional results of Miller-Galante total knee
prosthesis with posterior cruciate ligament sparing after a 6-
year follow-up. Rev Chir Orthop 1999;85:797802.
[34] Jardin C, Chantelot C, Migaud H, Gougeon F, Debroucker MJ,
Duquennoy A. Reliability of the KT-1000 arthrometer in mea-
suring anterior laxity of the knee: comparative analysis with
Telos of 48 reconstructions of the anterior cruciate ligament
and intra- and interobserver reproducibility. Rev Chir Orthop
1999;85:698707.
[35] Stubli HU, Noesberger B, Jakob RP. Stressradiography of the
knee. Cruciate ligament function studied in 138 patients. Acta
Orthop Scand 1992;249:127. Suppl.
[36] Hulet C, Brilhault J, Burdin P, Canciani JP, Courage O, Leteneur
J, et al. Les prothses totales de genou dans les grandes dvi-
ations axiales [Total knee prostheses in large axial deviations].
Ann Orthop Ouest 2004;36:25388.
[37] Whiteside LA. Selective ligament release in total knee arthro-
plasty of the knee in valgus. Clin Orthop 1999;367:13040.
[38] Krackow KA. Revision total knee replacement ligament balanc-
ing for deformity. Clin Orthop 2002;404:1527.
[39] Vince KG, Abdeen A, Sugimori T. The unstable total knee
arthroplasty: causes and cures. J Arthroplasty 2006;21(Suppl.
1):449.
[40] Desm D, Galand-Desm S, Besse JL, Henner J, Moyen B,
Lerat JL. Axial lower limb alignment and knee geometry in
patients with osteoarthritis of the knee. Rev Chir Orthop
2006;92:6739.
[41] Sheng PY, Jmsen E, Lehto M, Pajamki J, Halonen P, Kont-
tinen YT. Revision total knee arthroplasty with the total
condylar III system: a comparative analysis of 71 consecutive
cases of osteoarthritis or inammatory arthritis. Acta Orthop
2006;77:5128.
[42] Vince KG, Long W. Revision knee arthroplasty. The limits of
press t medullary xation. Clin Orthop 1995;317:1727.
[43] Viskontas DG, Skrinskas TV, Johnson JA, King GJ, Winemaker
MJ, Chess DG. Computer-assisted gap equalization in total knee
arthroplasty. J Arthroplasty 2007;22:33442.
[44] El Masri F, Rammal H, Ghanem I, El Hage S, El Abiad R, Kharrat
K, et al. Computer-assisted surgery in total knee replace-
ment. Preliminary results: report of 60 cases. Rev Chir Orthop
2008;94:2617.
[45] Song EK, Seon JK, Yoon TR, Park SJ, Cho SG, Yim JH. Compara-
tive study of stability after total knee arthroplasties between
navigation system and conventional techniques. J Arthroplasty
2007;22:110711.
[46] Saragaglia D, Picard F, Chaussard C, Montbarbon E, Leitner
F, Cinquin P. Computer-assisted knee arthroplasty: compar-
ison with a conventional procedure. Results of 50 cases in
a prospective randomized study. Rev Chir Orthop 2001;87:
1828.