eMedicine Specialties > Orthopedic Surgery > Knee

Lateral Compartment Arthritis

Author: B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
Coauthor(s): Ashish Upadhyay, MD, MBMS, MRCS (Edinburgh), Research Fellow, Department of Orthopedics, University of Missouri at Columbia
Contributor Information and Disclosures

Updated: Jan 19, 2007

Introduction

Degenerative joint disease can affect any or all of the compartments of the knee joint. This article addresses arthrosis that is localized to the lateral compartment of the knee.

The typical radiographic signs that are associated with degenerative joint disease consist of narrowing of the joint space, subchondral cyst formation, bone sclerosis, and hypertrophic osteophytic spurring (Altman et al, 1987; Gresham and Rathey, 1975). Lateral compartment arthrosis is encountered less frequently than a genu varum deformity because the medial joint compartment of the knee is most commonly affected by degenerative changes, followed by the patellofemoral and lateral compartments (Johnson and Bodell, 1981).

Problem

During normal gait, adduction places forces predominantly on the medial compartment (Andriacchi, 1994; Goh et al, 1993; Harrington, 1983; Johnson et al, 1980; Maquet, 1976; Prodromos et al, 1985; Wada et al, 1998). As a result, a valgus deformity is necessary to shift the weight-bearing stresses to the lateral tibial plateau of the knee (Shaw and Moulton, 1996). The anatomic axis of the lower extremity is defined by the femorotibial angle, which averages 5° of valgus (Kettelkamp et al, 1976); the mechanical axis of the lower extremity is defined by a plumb line connecting the center of the femoral head to the mid ankle on a standing anteroposterior (AP) weight-bearing radiograph. The mechanical axis averages 1.2° of varus (Hsu et al, 1990), and it is more accurate than the anatomic axis in demonstrating load transmission across the knee joint, especially if femoral or tibial deformities contribute to limb malalignment (Hsu et al).

Etiology

Usually, a genu valgum deformity is the result of a dysplastic lateral femoral condyle that contributes to pathologic loading of the lateral compartment of the knee and subsequent bone and cartilage destruction (Washington, 1995). In such cases, genu valgum results from a valgus orientation of the distal part of the femur relative to its long axis (Cooke et al, 1994; Poilvache et al, 1996; Yoshioka et al, 1987). An experimental model (Goodman et al, 1991) has demonstrated that the mechanical overloading of a single compartment of the knee leads to degenerative change in that compartment.

The etiology of lateral compartment arthritis can also include degenerative changes caused by trauma, such as a lateral tibial plateau fracture. A discoid lateral meniscus reportedly is present in 1.4-15.5% of the population, with a wide variation in its prevalence among various races (Casscells, 1978; Dickhaut and DeLee, 1982; Ikeuchi, 1982). Complete arthroscopic resection of a discoid meniscus in children can lead to the subsequent development of degenerative changes in the lateral compartment (Aglietti et al, 1999; Washington et al, 1995). Removal of the lateral meniscus has been shown to lead to the development of lateral compartment arthritis in an animal model (Little et al, 1997).

Spontaneous osteonecrosis of the femoral condyle is a clinical entity that typically occurs in women older than 55 years, and it presents with the acute onset of pain (Ecker and Lotke, 1994; Lotke and Ecker, 1988; Lotke and Ecker, 1985). Lateral compartment degenerative disease may be the ultimate complication of spontaneous osteonecrosis of the lateral femoral condyle.

Pathophysiology

Arthritic destruction of the lateral compartment of the knee manifests as a genu valgum deformity. A valgus deformity is defined as a malalignment that exceeds the normal 7-10° femorotibial valgus angulation (Washington et al, 1995; Miyasaka et al, 1997; Whiteside, 1993).

Early in the disease process, a weight-bearing radiograph in the posteroanterior (PA) projection with the knee flexed at 45° can demonstrate lateral joint-space narrowing from erosion of the posterior femoral condyle that may not be apparent on the routine AP films (Dervin et al, 2001). With advanced disease, cartilage and bone erosion that lead to joint-space narrowing in the lateral compartment is observed on the weight-bearing AP radiographs as well. With progressive valgus malalignment, the medial soft tissues of the knee joint stretch, whereas the lateral soft-tissue structures of the knee, including the lateral collateral ligament, iliotibial band, and lateral capsule, contract. Over time, these deformities become fixed (see Image 1).

Presentation

Patients with lateral compartment arthritis of the knee joint typically have pain and grinding that are localized to the lateral aspect of the knee. Patellofemoral symptoms may or may not be present, depending on the degree of degenerative change at this articulation. With advanced disease and deformity, patients notice a valgus orientation of the knee joint. Abnormal gait patterns may manifest as a limp, back pain, and foot pain. The history may reveal contributing factors to lateral compartment gonarthrosis, such as previous trauma to the knee or a lateral meniscectomy.

Reproduction of symptoms is possible during physical examination by applying a valgus stress to the knee joint and taking the knee through a range of motion. Crepitation can usually be palpated along the lateral joint line during movement and may be associated with swelling and laxity of the joint, which can be detected by application of a varus stress (Shakespeare, 2006). Careful palpation of the patellofemoral joint can be used to isolate tenderness at this location. If arthritis is localized to the lateral compartment, the knee should have a smooth arc of motion when a varus stress is applied to it.

Examination of the other joints in the lower extremities (ie, hips, ankles, contralateral knee) and assessment of the neurovascular status of the limb contribute information that is useful in making the diagnosis of lateral compartment arthritis of the knee joint and formulating treatment options.

Indications

The surgical interventions that are available to treat lateral compartment degenerative disease of the knee are corrective osteotomy, hemiarthroplasty of the knee, and total knee replacement (TKR). For indications for each specific surgical procedure, see Treatment, Surgical therapy.

Relevant Anatomy

The anatomy that may be encountered in surgery for lateral compartment arthritis of the knee depends on the etiology of the degenerative changes. For example, with a history of a lateral tibial plateau fracture, deformity and deficiency of the lateral tibia can be expected. A unicompartmental knee or total knee arthroplasty (TKA) in such a knee joint may require augmentation of the deficient plateau with allograft or build-up of the prosthesis. During TKR, a hypoplastic femoral condyle may require augmentation with metal blocks on the femoral prosthesis. Contracted lateral soft tissues mandate sequential release during arthroplasty and may preclude corrective osteotomy. Abnormal patella biomechanics may be manifested by lateral patella tracking and degenerative changes along the lateral facet of the patella from a long-standing valgus deformity of the knee.

Knowledge of the etiology that led to lateral arthritis of the knee, careful physical examination, and evaluation of imaging studies will alert the surgeon to the anatomic changes that can be expected during surgery.

Contraindications

Contraindications to the surgical procedures used to treat lateral compartment arthritis are discussed in Treatment, Surgical therapy.

More on Lateral Compartment Arthritis

Overview: Lateral Compartment Arthritis
Workup: Lateral Compartment Arthritis
Treatment: Lateral Compartment Arthritis
Follow-up: Lateral Compartment Arthritis
Multimedia: Lateral Compartment Arthritis
References
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Further Reading

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Keywords

degenerative joint disease, knee arthrosis, gonarthrosis, genu valgum

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Contributor Information and Disclosures

Author

B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Ashish Upadhyay, MD, MBMS, MRCS (Edinburgh), Research Fellow, Department of Orthopedics, University of Missouri at Columbia
Ashish Upadhyay, MD is a member of the following medical societies: Royal College of Surgeons of Edinburgh and Royal Society of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Dennis P Grogan, MD, Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa
Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

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Managing Editor

Thomas M DeBerardino, MD, Director, John A Feagin, Jr Sports Medicine Fellowship at West Point, Clinical Instructor in Surgery, Orthopedic Surgery Service, Keller Army Community Hospital at West Point
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Arthrex, Inc. Grant/research funds None; Arthrex, Inc. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Nothing to disclose.

 
 
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