Management of Knee with Positive Valgus and Negative Varus Deformity
The management of a knee with positive valgus deformity requires comprehensive radiographic assessment with standing anteroposterior (AP) and lateral views, followed by appropriate surgical intervention if conservative measures fail to improve symptoms or prevent progression.
Diagnostic Evaluation
Initial Imaging
- Standing AP and lateral radiographs are the first-line imaging modalities for assessing knee alignment 1
- Include a tangential axial view of the patellofemoral joint
- Standing long-leg (hip-to-ankle) radiographs provide optimal assessment of overall limb alignment 1
- These views provide accurate information on the weight-bearing mechanical axis in patients with suspected lower limb malalignment
Alignment Assessment
- Measurement of intercondylar and/or intermalleolar distance helps quantify the severity of valgus deformity 1
- Radiographic assessment of the tibiofemoral angle and component alignment (if prosthesis present)
- AP views obtained in 10° of internal rotation improve interpretation of valgus alignment compared to neutral AP views 1
Conservative Management
Physical Therapy
- Strengthening exercises focusing on quadriceps and hamstrings to improve knee stability
- Gait training to optimize weight distribution and reduce stress on the lateral compartment
- Note: Evidence does not support the use of insoles or casts to improve valgus deformity 1
Pain Management
- NSAIDs for symptomatic relief
- Activity modification to reduce stress on the knee joint
- Assistive devices (canes, walkers) to reduce weight-bearing as needed
Surgical Management
Indications for Surgery
- Persistent pain limiting daily activities
- Progressive deformity
- Joint instability
- High risk of developing secondary complications (osteoarthritis, ligament damage)
Surgical Options
For Moderate to Severe Valgus Deformity
Fixation Methods
- 95° AO blade-plate or straight plate fixation for femoral osteotomies 3
- Fixator Assist Nailing (FAN) technique with distal femur osteotomy shows promising results 4
- Allows for minimal invasive approach
- Provides stable fixation with intramedullary nailing
For Patients with Advanced Osteoarthritis
- Total knee arthroplasty may be considered when there is significant joint destruction
- Requires careful soft tissue balancing to address the valgus deformity 5
- Selective ligament release of contracted soft tissues is essential for proper alignment
Special Considerations
Associated Ligament Injuries
- Valgus deformity may be associated with anterior cruciate ligament (ACL) deficiency
- Assessment of varus-valgus instability in ACL-deficient knees requires application of posterior tibial load for accurate evaluation 6
Post-Surgical Monitoring
- Regular radiographic follow-up every 1-2 years 1
- After baseline hip-to-ankle radiograph, further follow-up can be based on targeted knee radiographs 1
Pitfalls and Caveats
- Failure to adequately release contracted ligaments or overzealous release can result in instability 5
- Patient selection is crucial for successful outcomes with osteotomy procedures 3
- Valgus deformity correction requires precision in surgical technique to avoid overcorrection or undercorrection
- Careful assessment of bone quality is essential, particularly in patients with metabolic bone disorders
By following this management approach, patients with valgus knee deformity can achieve improved alignment, reduced pain, and better functional outcomes.