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Extended report
Varus and valgus alignment and incident and progressive knee osteoarthritis
  1. Leena Sharma1,
  2. Jing Song1,
  3. Dorothy Dunlop1,
  4. David Felson2,
  5. Cora E Lewis3,
  6. Neil Segal4,
  7. James Torner4,
  8. T Derek V Cooke5,6,
  9. Jean Hietpas7,
  10. John Lynch7,
  11. Michael Nevitt7
  1. 1Northwestern University, Chicago, Illinois, USA
  2. 2Boston University, Boston, Massachusetts, USA
  3. 3University of Alabama at Birmingham, Birmingham, Alabama, USA
  4. 4University of Iowa, Iowa City, Iowa, USA
  5. 5Queens University, Kingston, Ontario, Canada
  6. 6OAISYS, Inc, Kingston, Ontario, Canada
  7. 7University of California, San Francisco, California, USA
  1. Correspondence to Dr Leena Sharma, Division of Rheumatology, Feinberg School of Medicine, Northwestern University, 240 East Huron, McGaw M300, Chicago, IL 60611, USA; l-sharma{at}


Objective Varus and valgus alignment increase medial and lateral tibiofemoral load. Alignment was associated with tibiofemoral osteoarthritis progression in previous studies; an effect on incident osteoarthritis risk is less certain. This study tested whether alignment influences the risk of incident and progressive radiographic tibiofemoral osteoarthritis.

Methods In an observational, longitudinal study of the Multicenter Osteoarthritis Study cohort, full-limb x-rays to measure alignment were acquired at baseline and knee x-rays were acquired at baseline and knee x-rays at baseline and 30 months. Varus alignment was defined as ≤178° and valgus ≥182°. Using logistic regression and generalised estimating equations, the associations of baseline alignment and incident osteoarthritis at 30 months (in knees without baseline osteoarthritis) and alignment and osteoarthritis progression (in knees with osteoarthritis) were examined, adjusting. For age, gender, body mass index, injury, laxity and strength, with neutral knees as referent.

Results 2958 knees (1752 participants) were without osteoarthritis at baseline. Varus (adjusted OR 1.49, 95% CI 1.06 to 2.10) but not valgus alignment was associated with incident osteoarthritis. 1307 knees (950 participants) had osteoarthritis at baseline. Varus alignment was associated with a greater risk of medial osteoarthritis progression (adjusted OR 3.59, 95% CI 2.62 to 4.92) and a reduced risk of lateral progression, and valgus with a greater risk of lateral progression (adjusted OR 4.85, 95% CI 3.17 to 7.42) and a reduced risk of medial progression.

Conclusion Varus but not valgus alignment increased the risk of incident tibiofemoral osteoarthritis. In knees with osteoarthritis, varus and valgus alignment each increased the risk of progression in the biomechanically stressed compartment.

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  • Funding This study was funded by NIH NICHD RO1 HD43500; NIA U01 AG18820, AG18832, AG18947, AG19069.

  • Competing interests None.

  • Ethics approval The study protocol was approved by the institutional review boards at each participating site.

  • Provenance and peer review Not commissioned; externally peer reviewed.