Extra-articular deformity is always correctable intra-articularly: to the contrary

Abstract

The operative word in this debate is "always." In my opinion, there are some cases better served by extra-articular correction. The question then becomes which ones, and how does the surgeon determine? There are 4 considerations: the magnitude of the deformity, the relationship of the deformity to the knee, the side of the deformity (varus or valgus), and whether the femur or the tibia is affected by the deformity. A larger deformity is more important, but just as important is its relationship to the knee. Large deformities distant to the knee have little impact on the knee. Varus deformities require lateral intra-articular overresection, which produces lateral instability. Valgus deformities require medial overresection, which produces medial instability. Lateral instability is stabilized by the dynamic lateral stabilizers (popliteus, lateral head of the gastrocnemius, biceps femoris, and iliotibial tract) and is better tolerated than medial instability. The best way to determine the consequence of the malalignment in question is to template the knee by drawing the mechanical axis from the femoral head or ankle to the center of the knee, and then the resection level that will be required. This will demonstrate the amount of overresection required to correct the extra-articular deformity, and in some cases will indicate the advantage of an extra-articular correction.