The Journal of Arthroplasty xxx (2014) xxxxxx

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Medial Over-Resection of the Tibia in Total Knee Arthroplasty for Varus

Deformity Using Computer Navigation
Kenneth A. Krackow, MD b, Sivashanmugam Raju, MS Ortho b, Mohan K. Puttaswamy, MBBS, MS Ortho a
a
b

Department of Orthopedic Surgery, Fortis Hospital, Bangalore, India

Department of Orthopedic Surgery, Buffalo General Hospital, Buffalo, NY

a r t i c l e

i n f o

Article history:
Received 24 June 2013
Accepted 25 November 2014
Available online xxxx
Keywords:
medial overresection
varus OA knee
navigated TKA
reduction osteotomy
tension stress examination

a b s t r a c t
We are reporting a series of 35 cases in which downsizing, lateralizing of the tibial baseplate and resection of the
uncovered medial plateau bone releases the medial collateral ligament and tightens the lateral collateral ligament. Result in excellent ligamentous balance and correction to neutral mechanical axis. The mean follow up
was 32.8 months (11-95 months) and the average pre-operative varus was 9.47 (3.5-15) with the average
post-operative alignment was 0.65 varus. We obtained a mean correction of 0.45 for every mm (millimeter)
of bone resected. We did not have any varus collapse or instability. Medial Over-resection could be employed
as a technique in the management of varus OA knee with 2 mm of resection giving about 10 correction
of deformity
2014 Elsevier Inc. All rights reserved.

Varus deformity that is not passively correctable at the time of total

knee arthroplasty requires sequential soft tissue releases on the concave
(medial) side [1]. A technique of resection of the medial edge of the cut
surface of the tibia to decompress the medial soft tissue sleeve was practiced independently by the senior author (KAK) for the past 10 years.
Dixon et al. described a case series using this technique and reported
that it was possible to correct varus deformity of 20- 40 without releasing medial soft tissues other than the deep medial collateral ligament [2].
The tibial tray was downsized and lateralized and the uncapped medial
tibial bone was resected, which corrected the varus deformity.
The object of the present paper is to present our experience with this
technique of posteromedial over-resection of the tibial plateau using
computer navigation for correction of varus deformity and quantify
the amount of correction obtained with the size of resection of nonosteophytic bone.
Materials and Methods
This is a retrospective review of 35 cases of navigated cemented Total
Knee Arthroplasty (TKA) using only the technique of posteromedial tibial bone resection for varus deformity correction operated between
2004 and 2009. The Stryker TKA triathlon system used permits
downsizing of the tibial component by one size and thus helps us to lateralize the tibial tray. The only soft tissue release done was the deep
Medial Collateral Ligament (MCL).
The Conict of Interest statement associated with this article can be found at http://
dx.doi.org/10.1016/j.arth.2014.11.034.
Reprint requests: Dr. Mohan K. Puttaswamy, Fortis Hospitals, Bannerghatta Road,
Bangalore, India-560 076.

The Clinical data analyzed consisted of patient demographics, Knee

Society Functional score (KFS), Clinical Scoring (KSS) and Lower Extremity Activity Scale (LEAS). 32 patients had complete data and were
used for calculating the correction of deformity, while 26 patients who
had complete scores for KFS, KSS and LEAS was used to assess the functional status. The radiological analysis consisted of preoperative and
post-operative assessment of Long Standing Lower Extremity (LSLE)
for estimating amount of varus deformity. Individual knee joint X rays
were used to analyze evidence of component subsidence & loosening.
Intraoperative data analyzed includes the Navigation data recording of
Maximum varus, Tension Stress and amount of bone resected.The relationships between medial bone resection (mm) and degree of correction was investigated using Pearson product-moment correlation
coefcient. Linear regression analysis was done do nd out the relationship between variables like maximum varus and amount of bone resection.Preliminary analyses were performed to ensure no violation of the
assumptions of normality, linearity, and homoscedasticity.
Surgical Technique
The standard skin incision used by the senior author is a lateral Muller incision extending from the midline above the patella to the lateral
border of the middle of the patella, to a point just lateral to the anterior
tibial crest. The joint is exposed through a standard medial parapatellar
capsular exposure with release of deep MCL as part of the exposure.
Threaded pins for the trackers of the navigation system (Stryker,
Mahwah, NJ) are inserted into the femur just proximal to the articular
surface and into the tibia potentially out of the way of the tibial external
alignment jig. Registration of the hip center is done.The distal end of the
femur, the articular surface of the tibia and the center of the ankle joint

http://dx.doi.org/10.1016/j.arth.2014.11.034
0883-5403/ 2014 Elsevier Inc. All rights reserved.

Please cite this article as: Krackow KA, et al, Medial Over-Resection of the Tibia in Total Knee Arthroplasty for Varus Deformity Using Computer
Navigation, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.11.034

K.A. Krackow et al. / The Journal of Arthroplasty xxx (2014) xxxxxx

are registered as per the navigation protocol. The resting position of the
knee, maximum varus, maximum valgus and deformity on the TensionStress exam and knee range of motion are recorded [1]. In Tension stress
examination tibia is held distracted from the femur and the capsularligamentous complex is taut in both medial and lateral aspects. This
gives the true deformity to be addressed to achieve proper balance.
Correction achieved by medial resection alone was calculated by
subtracting tibio-femoral alignment in tension stress from the preoperative varus deformity. Tension stress measures the amount of correction
contributed by the soft tissues and eliminates the risk of any over estimation of the correction by medial bony resection.
Medial and posteromedial osteophytes are removed. No medial soft
tissue release is done except for the deep medial collateral ligament. Ligament balance is assessed using the tension-stress exam. Trial femoral
and tibial components are inserted and deformity and stability are
assessed in extension and exion, using navigation. If there is persistent
varus, the trial components are removed and a tibial tray that is one size
smaller is placed at the lateral edge of the cut surface of the tibia. The prosthesis used (Triathlon, Stryker, Mahwah, NJ) allows tibial components
one size smaller for every size of the femoral component. We used
metal backed tibial component in all cases. The uncovered tibial condylar
bone medial to the tibial tray is resected using a saw oriented in a plane
parallel to the mid-sagittal plane from a proximal-to-distal direction(90
to the tibial plateau), with the knee held in maximum exion. The bone
fragment is freed from its soft tissue attachments and is removed. Alignment is assessed again using navigation till zero mechanical alignment
is obtained. Further medial soft tissue release, which has not been necessary in our series, may be done at this time. Once satisfactory alignment is
achieved, the trial components are removed and nal implants are
cemented in routine fashion. The femoral component is cemented in relatively medial position on the femur. Final alignment and range of motion
are recorded. The wound is closed in routine fashion over a suction drain.
Standard pain and rehabilitation protocols were followed in all patients.

Table 1
Patient Raw Data for Medial-Overresection and Outcomes.
Pre-Op
Varus
Deformity
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
AA
AB
AC
AD
AE
AF
AG
AH
AI

15.5
9.5
8
8.5
11
8
4.5
5
5.5
8.5
12
15
8.5
15.5
11.5
11.5
14
9
6.5
9.5
9
14
4.5
13
8
3.5
11
6
16
7.5
11.5
11.5
14.5
8
6.5

Correction per
mm of
Resection

Final
Alignment

15
9.5

1.4
1.0

0.5
0

8.5
10
8
4.5
3.5
3.5
7.5
11.5

0.8
0.9
1.1
0.5
0.7
0.6
0.9
0.6

8
11
10.5
8

0.6
0.8
1.1
1.1

0
0
0.5
0
0
1
0.5
0
1.5
0.5
2.5
2
1

4.5
5
6
8
11.5
4
10
7.5
2.5
5.5
5
14
5.5
9
6.5
10.5
6
7.5

0.6
0.8
0.8
0.8
3.8
1.3
1.0
1.3
0.4
0.9
2.5
0.7
0.6
1.3
1.3
0.9
2.0
2.5

2
0.5
0.5
0.5
0.5
0
2
0
0.5
1.5
0
0
0.5
0.5
1
1.5
0
0

Tension
Medial
Stress Resection Correction
15.5
9.5
7
8.5
10
8.5
4.5
3.5
4.5
8
11.5
8.5
13.5
12.5
9
11.5
6.5
5.5
6.5
8.5
12
4
12
7.5
3
8
5
14
6
9.5
7.5
12
6

11
10
6
11
11
7
10
5
6
8
19
15
13.5
13
10
7
17
8
6
8
10
3
3
10
6
6
6
2
20
10
7
5
12
3
3

Results
35 patients were part of the study. Follow-up was for an average of
32.8 months (range: 11-95 months). The average pre-operative deformity was 9.47 varus (range: 3.5-15.5 varus). The average post-operative
alignment was 0.65 varus (range 0- 2.5 varus). No patient in the
study was lost to follow-up. Complete KSS and KFS data was present in
26/35 of patients and has been used in the nal analysis. The KSS improved from 38(10-83) to 89.2 (57-100) while the KFS improved from
51.45(30-90) to 76.55 (45-100). There was improvement in the activity
scores on LEAS from a mean of 8 (6-11) to 9.68(6-12). Two patients expired during follow-up due to unrelated causes. There were no revisions
during the follow-up period. There was one patient with acute infection
who was treated with debridement and liner exchange. Table 1 shows
the data of our patients with correction achieved. The salient statistical
outcomes in the patients are mentioned in Table 2. There was no evidence
of component loosening, functional instability in any of our patients.
The navigation data indicate that all the correction was achieved
through the resection of uncapped medial tibial bone.At last follow-up,
none of the knees had x-ray evidence of component migration. There
was a strong positive correlation between the two variables, r = 0.62,
n = 32, p b .0001, with 38.1% shared variance.The equation listed on
the scatter plot below shows that every 1 mm of medial bone resection
there is a Varus deformity correction of 0.45 as shown in Fig. 1.
We were unable nd out if any one soft tissue variable that determines the amount of bone needed to be resected because all the soft tissue variables were inter-related and shows multi-collinearity.
Discussion
Varus gonarthrosis can be corrected at total knee replacement surgery by a combination of various methods, including soft tissue release

that can be done as a periosteal sleeve off the tibia [1,3] discrete release
of the medial supercial collateral ligament and pes anserine tendons
[4], pie-crusting of the supercial medial collateral ligament [5]and femoral medial epicondylar osteotomy [6]. Each technique has its own advantages and disadvantages. Extensive sub-periosteal stripping of the
proximal medial tibial soft tissue sleeve can result in more bleeding
and discrete release of medial ligaments and tendons can destabilize
the knee [4,7,8]. Dixon et al [2] described a technique of resecting the
uncapped medial tibial bone after downsizing and lateralizing the tibial
tray, that was used to correct severe varus deformities. The senior author(KAK) of this paper has practiced this technique independently
for over 10 years. In this paper, we examine the effect of this technique
on varus deformities as evaluated by computer-assisted navigation.
The concept involved in this technique is that the intact medial soft
tissue sleeve is decompressed by resecting the medial tibial bone. Soft
tissue stripping is limited to the deep medial collateral ligament and
that attached to the resected bone fragment. The advantage is less
bleeding and little or no risk of instability. The tibial tray is downsized
by one, which is possible for every femoral component size in the system we used (Triathlon, Stryker, Mahwah, NJ), and the smaller tray is
pushed to the lateral edge of the cut tibial surface. The medial soft tissue
sleeve undergoes a relative lengthening after the resection of the bone
thus uncovered. This lengthening was enough to completely correct
the varus deformities that we have presented in this paper. Deformities
that are of a higher varus angle might possibly need a concomitant standard graduated medial sleeve release.
It was noticed during surgery that the effect of lateralizing the tibial
tray was two-fold as shown in the illustration (Fig. 2). It causes a medial
translation of the entire tibia (Fig. 2. 2-3) in order to center the tibial tray
under the femoral component, which is now made possible by the

Please cite this article as: Krackow KA, et al, Medial Over-Resection of the Tibia in Total Knee Arthroplasty for Varus Deformity Using Computer
Navigation, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.11.034

K.A. Krackow et al. / The Journal of Arthroplasty xxx (2014) xxxxxx

Table 2
Statistical Analysis With Important Outcomes in our Series.
Parameters

Range

Correction ()
Correction per mm of Resection (/mm)
Difference Between Tension Stress &
Pre-op Varus Deformity ()
Final Alignment ()
Maximum Valgus ()
Maximum Varus ()
Medial Bone Resected (mm)
Pre-op Varus Deformity ()
Tension Stress ()

32
32
33

12.5
3.4
5

Minimum
2.5
0.4
-1

15
3.8
4

7.734
1.113
1.227

3.0743
0.7029
1.1531

33
35
35
35
35
33

2.5
14.5
13.5
18
12.5
12.5

0
0.5
5.5
2
3.5
3

2.5
15
19
20
16
15.5

0.652
6.886
12.357
8.786
9.757
8.47

0.7233
3.6884
3.7858
4.4611
3.4966
3.2281

decompressive effect of the medial resection. We found that cementing

the femoral component relatively medially on the femur helps in this
medial translation of the proximal tibia. It also, thus takes up any redundancy that may be present in the lateral ligament complex, as may be
the case in Krackow Types II, III and IV deformities. This has the effect
of increasing the overall stability of the knee, as opposed to the potentially destabilizing effects of medial ligament release. In the case
where the lateral sleeve is redundant to such an extent that translation
does not improve stability, a posterior-stabilized knee could be used for
a certain lateral translational constraint that is inherent in that design
When the medial uncapped bone is resected, the extension space
often looks like a trapezoid on tension stress examination, giving the
impression of persistent deformity. We have found that this corrects
when the trial components are inserted and then the knee becomes perfectly balanced both and in extension. This correction could be an effect
of the medial translation of the entire tibia with the tibial tray to center
itself under the femoral component, thus evenly stretching out both collateral sleeves.It could also be an effect of balancing- or lling-out the
entire soft tissue envelope in three dimensions.
One concern of lateralizing the tibial tray is that the medial edge of
the tray will now rest on the central core of the tibial plateau, which
consists of softer bone, potentiating the risk of subsidence. We have
not found that to be the case, as we have consistently observed that
the bone under the medial tibial articular surface, even after the standard tibial cut, has become hard and eburnated from abnormal weight
bearing due to the varus malalignment and the arthritic process. This
sclerotic bone extends toward the midline, more often than not. Thus,
the risk of subsidence is minimized and indeed, we have not seen subsidence in any of our cases. Mullaji et al found 3 subsidences in their series of 173 knees in 117 patients after using an all poly tibia out of which
just one patient needed revision [9]. This difference could possibly be
because of bony quality in different races. In a recent publication by
Mullaji et al looking into the amount of correction in 71 patients using
navigation, approximately 2 mm of bone resection was needed to
achieve 1 degree of correction [10]. The difference in our technique

Varus Deformity Correction ()

Relationship of Amount of Medial Bone Resection (mm)

Resulting in Correction of Varus Deformity ()
16
14
12
10

Maximum

Mean

Std. Deviation

with their study was we lateralized the tibial component and resected
the uncapped bone till a perfect correction was obtained but Mullaji
et al hypothesized that 1 degree correction was obtained with 2 mm
of resection and resected bone based on their hypothesis. If correction
was not obtained then in 12/71 patients additional soft tissue release
was done in their study, we did not undertake any soft tissue release;
the need for soft tissue release was probably due to the larger deformity
in their patient population. Our result conrms their conclusion of
obtaining 1 degree correction for every 2 mm of bone resection.
It was found that a 1-mm width of medial tibial bone resection resulted in the correction of nearly 0.45 degree of varus. There is some
variation in the amount of correction obtained in different patients, as
was shown during navigation, with a range of 0.41 to 2 per millimeter
of width resected from the tibia. We think that this variation could be a
function of the size of the soft tissue envelope of the knee, the relative
sizes of the femur and the tibia and the give of the medial and lateral
soft tissue sleeves. We tried to determine which variable(like varus
stress..) was associated most with correction but our linear regression
model testing showed that we need atleast 90 patients to support this
model. In the given data set it was found that all the variables were
closely related and we were not able to determine an independent relationship with the amount of bone resection but all the variables were
strongly correlated with amount of bone resected. This indicates that
the translation of tibia is based on the state of the collateral ligaments
on either side.
It is the practice of the senior author to use the smallest possible
femoral component for a given knee without creating a substantial anterior notching [11]. In combination with that, the benet of a smaller
tibial tray would be a smaller prosthetic volume implanted, which improves comfort and range of motion by avoiding an overstufng of the
joint. Some surgeons claim that the femoral component should t the
cut distal surface of the femur to have good xation. This is not necessary, as even if the medial-lateral dimension of the femoral component
is smaller than the cut surface of the femur, it does not loosen and the
exposed bone at either edge does not cause problems.
This technique can be used as a primary method of correcting all
varus deformities as it has the potential to correct signicant amounts
of deformity without disturbing the soft tissue sleeve. This in turn
could reduce the risk of instability, bleeding and pain and thereby improve range of motion and function. In principle we think that this technique can also be used to correct sagittal plane deformities (Fixed
Flexion or Recurvatum) by moving the base plate either anteriorly or
posteriorly and removing the corresponding uncovered bone.

y = 0.4468x + 3.9711
R = 0.3806

6
4

Conclusion

2
0
0

10

15

20

25

Medial Bone Resection (mm)

Fig. 1. Scatter Plot showing the correlation of the amount of bone resection and the correction obtained.

Correction of varus deformity in a total knee arthroplasty can be

done by downsizing the tibial tray, lateralizing it and resecting the
uncapped medial tibial bone. Our study demonstrates that approximately on average 1 degree correction can be obtained on resection of
2 mm of non-osteophytic bone. This technique helps in minimizing
soft tissue releases but also obtain a stable correction of varus deformity.

Please cite this article as: Krackow KA, et al, Medial Over-Resection of the Tibia in Total Knee Arthroplasty for Varus Deformity Using Computer
Navigation, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.11.034

K.A. Krackow et al. / The Journal of Arthroplasty xxx (2014) xxxxxx

Fig. 2. Medial Reduction Osteotomy & lateralization of tibial base plate with soft tissue balance.

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Please cite this article as: Krackow KA, et al, Medial Over-Resection of the Tibia in Total Knee Arthroplasty for Varus Deformity Using Computer
Navigation, J Arthroplasty (2014), http://dx.doi.org/10.1016/j.arth.2014.11.034