SE M I N A R S I N A R T H R O P L A S T Y 29 (2018) 27–35

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Ligament balancing in the valgus knee

Elie Mansour, MD, and Leo A. Whiteside, MD*
Missouri Bone and Joint Center, Missouri Bone and Joint Research Foundation, 1000 Des Peres Rd, Suite 150, St. Louis,
MO 63131

article info abstra ct

Keywords: Total knee arthroplasty in the knee with valgus deformity is a challenge for surgeons.
Total knee arthroplasty Making distal and posterior femoral and tibial bone cuts perpendicular to the mechanical
Surgical alignment axis are essential for obtaining alignment throughout the flexion–extension arc of motion.
Ligament balancing A well-balanced knee assures correct function, which is realized by a functional approach
for releasing the ligaments that are found to be tight in flexion and/or extension while
testing the knee after bone cuts have been made. Special attention to normalized tracking
of the patella and quadriceps mechanism is crucial at the end of the surgical procedure.
& 2018 Elsevier Inc. All rights reserved.

1. Introduction medial side, the medial collateral ligament is often stretched

Extreme preoperative malalignment of the knee predisposes
a total knee arthroplasty (TKA) to greater risk of failure when
compared with well-aligned knees unless deformity correc-
tion is addressed in the procedure. Correcting a knee with
valgus deformity is technically challenging, and if managed
incorrectly, can lead to an unsatisfactory clinical outcome [1].
The valgus knee presents a number of unique challenges to
the surgeon. A valgus deformity may be the result of a
combination of anatomical variations including lateral fem-
oral condylar hypoplasia, lateral cartilage erosion, and meta-
physeal femoral and tibial plateau remodeling [2]. The two
basic goals for the surgeon is to restore the knee joint line
perpendicular to the mechanical axis and manage medial and
lateral collateral ligaments so that the knee is balanced
throughout the entire arc of motion in both flexion and
extension. Both lateral and medial soft tissues around the
knee are affected; the lateral structures typically are con-
tracted whereas the medial structures are stretched. The
affected lateral soft tissues include the lateral collateral
ligament (LCL), popliteus tendon (PT), posterolateral corner
(PLC) capsule with the lateral gastrocnemius tendon, iliotibial
(IT) band, biceps femoris and lateral posterior capsule. On the
and attenuated. The posterior cruciate ligament, due to its
medial position, is vulnerable to stretching as well. These
deformities can lead to external rotation of the tibia and to a
tendency for lateral patellar subluxation [3].
In this article, we describe a step-by-step technique for
performing a TKA in the valgus knee with an established
protocol based on the tightness or laxity of the collateral
ligaments throughout the flexion–extension arc.
2. Surgical procedure
2.1. Surgical approach
The medial parapatellar approach is our preferred approach
for the valgus knee. The medial parapatellar approach allows
the patella and the quadriceps to be displaced laterally in the
same direction as they are pulled by the vectors of force in
the quadriceps and patellar tendons; these lateral forces are
exaggerated by the valgus malalignment. This approach is
safe, as it permits better and more secure soft-tissue closure
after alignment correction when compared with the lateral
parapatellar approach. A theoretical disadvantage of the

*
Corresponding author. Tel.: þ1 314 205 2223; fax: þ1 314 775 0524.
E-mail address: whiteside@whitesidebio.com (L.A. Whiteside).

https://doi.org/10.1053/j.sart.2018.04.004
1045-4527/& 2018 Elsevier Inc. All rights reserved.
28 SEM I N A R S I N A R T H R O P L A S T Y
medial approach is the aggravation of lateral subluxation and
the potential devascularisation of the patella when the
medial approach is associated with a lateral release to correct
patella maltracking. However, in many series, no patella
fracture or avascular necrosis has been reported [4] and the
clinical results of using this approach in valgus knees remain
satisfactory with good short- and long-term outcomes [5].
2.2. Bone resection
Accurate bone resection is the cornerstone for establishing a
well-aligned knee. Transforming a valgus knee into a straight
mechanically aligned knee must follow basic principles. The
native knee moves in flexion and extension in the sagittal
plane, a plane that passes through the center of the femoral
head, the deepest point of the trochlear groove, the deepest
point of the intercondylar notch, and the center of the ankle.
This plane represents the mechanical axis of the lower limb
as well as the anterior–posterior (AP) axis and the epicondylar
axis is perpendicular to the sagittal plane [6].
For a TKA to succeed, bone cuts must place the femoral and
tibial joint surfaces parallel to each other and place the joint
line perpendicular to the sagittal plane (parallel to the
epicondylar axis), throughout the flexion–extension arc. In
the extended position, the anatomic axis of the femoral shaft
is usually in 5° of valgus to the mechanical axis. Using a 5°
valgus cutting angle on an intramedullary rod for the distal
femoral resection results in a femoral distal surface that is
perpendicular to the mechanical axis. Some authors propose
a distal cut at 3° to counteract any tendency for valgus
recurrence [3].
In the valgus knee, the more prominent and more distal
medial femoral condyle should be considered as reference for
the distal resection. If the hypoplastic lateral femoral condyle
was used as a reference for distal femoral resection, an
excessively thick medial condyle cut would result, which
might damage the medial collateral ligament; also, the
thicker polyethylene insert may cause impingement of the
patella anteriorly during flexion. In addition, flexion–exten-
sion gap imbalance may occur, which would lead to extreme
tightness of the ligaments in flexion.
A crucial technical point to consider is that the valgus knee
often is associated with other deformities of the lower
extremity. Usually the shaft of the femur has a valgus
curvature [7], and the anatomical axis of the femur, which
follows the medullary canal, crosses the distal surface medial
to the deepest point of the patellar groove. An entry point of
the intramedullary rod of 5–10 mm medial to the deepest
point of the patellar groove allows access to the medullary
canal of the femur in direct alignment with the long axis of
the diaphysis and produces correct valgus alignment for the
distal femoral resection. The thickness of the femoral
implant is resected distally from the medial side, sometimes
with minimal or no resection from the lateral side of the
distal femur (Fig. 1) [8]. This can result in a lack of contact of
the lateral side of the femoral implant, but this is not a
problem as long as the femoral component sits on the
anterior or posterior bevel surface. Porous-coated augmenta-
tions can be used to maintain bone-to-metal contact on the
distal lateral surface.
29 (2018) 27–35
Figure 1 – This illustration shows the knee with correct
valgus angle of resection facilitated by the slight
medialization of the entry point. Thickness of resection is
measured from the intact medial side of the distal surface of
the femur. Reprinted with permission.
In the flexed position, obtaining posterior femoral surfaces
parallel to the AP plane implies a cutting guide perpendicular
to the AP axis, defined by the line passing through the
deepest point of the patellar groove and the center of the
intercondylar notch. This AP axis appears to be more reliable
and easier to identify than the epicondylar axis [9]. The AP
axis is co-planar with the sagittal plane, and cutting anterior
and posterior femoral surfaces perpendicular to the AP axis
creates a joint line perpendicular to the sagittal plane. A cut
perpendicular to the sagittal plane sustains correct rotation
of the femur and places the patellar groove in the sagittal
plane, allowing optimal patellar tracking as the tibia swings
through this same sagittal plane during flexion and
extension.
We start by measuring the anteroposterior size of the
femur from the anterior cortex of the femur to the posterior
condylar joint surfaces. The medial condyle is referenced,
since the lateral one usually is hypoplastic in the valgus knee.
Following selection of the appropriate anteroposterior-sized
femoral cutting guide, the guide is aligned so that the
surfaces are resected perpendicular to the femoral AP axis,
resecting the thickness of the femoral implant from the intact
posterior medial femoral condyle and much less from the
deficient lateral side (Fig. 2). This resection corrects the valgus
position in flexion and places the patellar groove within the
mechanical axis of the lower extremity (Fig. 3). Conversely, if
equal amounts are resected from the posterior femoral
condyles in the valgus knee, excessive internal rotational
malposition of the femoral component and medialization of
the patellar groove would be expected. The tibial surface is
resected perpendicular to the long axis of the tibia, which is
colinear with the mechanical axis of the lower limb and co-
planar with the sagittal plane, and thus is parallel to the
 S E M I N A R S I N AR
Figure 2 – The cutting guide is placed so that the femoral
bone cuts are made perpendicular to the anteroposterior
axis of the femur, and the thickness of the posterior
condylar portion of the femoral component is resected from
the posterior medial condylar surface so that less than the
thickness of the femoral component is resected from the
lateral surface. This corrects the angular deformity of the
anterior and posterior surfaces of the femur in the coronal
plane. Reprinted with permission.
epicondylar axis. An extramedullary cutting guide is used for
the tibia. This guide is aligned with the tibial tuberosity
proximally and the center of the anterior ankle distally. The
surgeon must be aware that the foot often is externally
rotated in the valgus lower extremity, and that this may lead
to excessive lateralization of the upper tibial reference point,
and thus result in a valgus cut of the upper surface of the
tibia. The tibial resection also is sloped 4° posteriorly in the
sagittal plane. As is done for the femur, the thickness of the
tibial implant is resected from the intact plateau surface.
As a consequence of the bone cuts, the distal femoral
surface is perpendicular to the mechanical axis facing a tibial
surface also perpendicular to the same mechanical axis,
which establishes parallel joint surfaces and correct align-
ment in the extended position. By the same reasoning, a
posterior femoral cut perpendicular to the AP axis results in
parallel joint surfaces of the femur and tibia and correct
alignment in flexion.
Considering that the medial side of the valgus knee is
relatively intact, resecting the same thickness of the implant
distally and posteriorly positions the surfaces correctly so
that normal ligament tension will be restored in flexion and
extension, usually without adjusting the medial ligaments.
Correct alignment of the bone resections results in a well-
aligned knee in the coronal plane if no deforming ligament
contractures are present, and positions the patellar groove in
T H R O P L A S T Y 29 (2018) 27–35 29
Figure 3 – This illustration shows the knee alignment is
correct in flexion. The anteroposterior plane passes through
the femoral head, center of the patellar groove, and down
the central axis of the tibia with the knee flexed 90°.
Reprinted with permission.
the median sagittal plane, optimal for stable tracking. This
patellar position also places the quadriceps mechanism
optimally for powering the knee. Furthermore, these femoral
cuts correct femoral rotation, placing the femoral neck at its
natural anteversion angle, and foster optimal hip function.
However, with a fixed valgus deformity, the lateral soft
tissues remain tight, and the knee is held in valgus malalign-
ment by the ligament contractures even after the femoral
surfaces are resected in correct alignment (Fig. 4) [6]. The next
step after correct surface resections is to assess and then
adjust the ligamentous contractures that remain. Tensioners,
spacers, or trial components may be used to assess the
tension in the medial and lateral ligaments. Using the trial
components has the advantage of allowing ligament assess-
ment through the entire arc of flexion, and also offers the
advantage of demonstrating flexion contracture, recurvatum,
and rotational abnormalities, all of which must be corrected
to gain optimal function of the knee.
2.3. Soft-tissue balancing
Femoral and tibial resection is not sufficient for normal
function after TKA. Good knee function requires soft-tissue
balancing around the knee through the entire arc of flexion.
Our approach for soft-tissue balancing around the knee is
based on a functional approach in light of current knowledge
of mechanics and kinematics of the knee. Bone surface
resections should not be made based on tension of abnormal
ligaments, otherwise deformity will be built into the knee
alignment. No ligaments should be released until all bone
cuts are made and osteophytes removed, otherwise the
30 SEM I N A R S I N A R T H R O P L A S T Y 29 (2018) 27–35

abnormally lax, whereas an opening less than 2 mm on either

Figure 4 – Even after correct bone resection, the tight lateral
soft tissues retain the knee in valgus. Reprinted with
permission.
side is considered abnormally tight. Next, the knee is
extended and stability is tested by stressing the knee in
valgus to test the medial ligaments and in varus to test the
lateral ligaments. Medial opening between 2 and 4 mm, and
lateral opening between 3 and 5 mm, is considered to be
normal.
Soft-tissue release cannot be successful without a carefully
planned release based on a good understanding of the
function of every structure contributing to knee stability.
Ligaments attaching near the lateral epicondyle are effective
through the entire arc of flexion (Figs. 5 and 6). The LCL is
regarded as a stabilizing structure both in flexion and exten-
sion but is usually tighter in full extension than in flexion; it
has rotational as well as varus stabilizing effects. The PT
complex has passive varus stabilizing effects and is especially
tight in flexion; it also has a prominent role in external
rotation stabilization of the tibia on the femur. The PLC
capsule, which is joined to the lateral gastrocnemius tendon,
is tightest in extension; it also has some effect in flexion,
especially when the other two epicondylar attaching struc-
tures (LCL and PT) have been released. After careful assess-
ment, these three structures can be released from their bone
attachments or elongated by pie-crusting to achieve correct
balance in flexion and extension.
The ligaments that attach to the tibia posteriorly and to the
femur far from the center of rotation of the knee are effective

surgeon is likely to have an unpleasant surprise when the

effect of osteophyte release is seen and the ligaments already
have been released. Once the bone resections have been
made in correct alignment based on bony landmarks and
the ligaments are assessed, the ligaments should be released
and balanced based on their function rather than on an
arbitrary protocol. Release according to an arbitrary protocol
not considering the specific soft-tissue function in flexion and
extension can cause complex instability. Therefore, a knee
tight in flexion and extension requires different ligament
releases than a knee that is tight only in extension or only in
flexion.
Soft-tissue release should be done after removing every
osteophyte from around the knee joint and following the
insertion of the trial implants (or tensioners or spacers based
on the surgeon’s preference). Using the trial implants as
tensioners is recommended so the surgeon can assess
varus/valgus, rotational, and anterior/posterior stability, as
well as flexion contracture, rotational contracture, and recur-
vatum, in a step-wise manner without changing the hard-
ware multiple times. Knee balance is tested first in flexion
and then in extension.
To test the knee in flexion, the ankle is grasped with one
hand while the other hand steadies the knee; the hip then is
rotated externally until the lateral ligaments are stressed, Figure 5 – The three stabilizing structures that attach to the
then rotated internally until the medial ligaments are lateral epicondylar area behave differently in flexion and
stressed. Next the knee is placed in full extension and the extension. The posterior lateral corner capsular tissue and
tests are repeated. In general, a medial opening greater than the lateral collateral ligament tighten in extension while the
4 mm and a lateral opening greater than 6 mm is considered popliteus tendon loosens. Reprinted with permission.
 S E M I N A R S I N AR
Figure 6 – When the knee flexes, the popliteus tendon
tightens, the lateral collateral ligament slackens slightly,
and the posterolateral corner capsule slackens further.
Reprinted with permission.
only in extension. The posterior portion of the IT band is
aligned perpendicular to the joint surface when the knee is
extended, and therefore can provide lateral knee stability
when the knee is extended (Fig. 7). However, when the knee is
flexed to 90°, the posterior IT band is slackened and cannot
stabilize the knee against varus stress. The anterior portion of
the IT band is held taut by its attachments to the patella and
the quadriceps mechanism and can be an effective secondary
lateral stabilizer in flexion. The lateral posterior capsule (LPC)
structures are tight only in full extension and are slack when
the knee is flexed. Release of either the LPC or the IT band
would have a rational basis only for a knee that is tight
laterally in extension or has a persistent flexion contracture
after lateral ligament balance is achieved. Release of either
would have little effect on lateral knee stability in flexion.
In a valgus deformity, the knee usually is tight laterally and
loose medially, and the tibia also pivots around the lateral
ligament structures. The tightness might be in flexion, in
extension or in both flexion and extension. Addressing the
tightness in flexion should be done first since the structures
released for flexion balance affect extension balance as well,
and release of the structures affecting just extension stability
may not be necessary.
Different situations may be encountered after testing knee
stability.
2.3.1. Tight laterally in flexion and in extension
The PT is evaluated first by palpation. If it is tight and holds
the tibia in internal rotation, it should be released. The PT is
released directly from the femur with a knife blade and
allowed to retract; it retracts not more than 5–10 mm because
of its secondary attachments to the capsule and LCL. The
knee is tested again. If the knee is still tight on the lateral
side in flexion, the LCL should be evaluated and released
if it is tight. The LCL is easily visible, and may be released by
T H R O P L A S T Y 29 (2018) 27–35 31
Figure 7 – The iliotibial (IT) band is aligned perpendicular to
the joint surface in the extended knee, and can provide
lateral knee stability. Reprinted with permission.
pie-crusting with an 18-gauge needle, or it can also be
released directly from its bone attachment (Fig. 8). The
anterior portion of the LCL and its surrounding fibrous
synovial tissue should be released first, then the knee should
be tested again. If this is not enough, the rest can be pie
crusted or released from the bone, leaving it adherent to the
PLC. If releasing the LCL is not sufficient, the PLC capsule is
the last epicondylar structure to be released and conservative
pie-crusting is more prudent for this last structure.
Release of the PT, LCL and PLC capsule always corrects
lateral tension in flexion because these are the only struc-
tures that stabilize the lateral side of the knee in flexion.
The knee is now tested in extension. If the knee remains
tight laterally in extension, the posterior portion of the IT
band should be released. The release is done extrasynovially
just above the joint line. To expose the IT band, subcutaneous
dissection is done over the patella. The tight posterior portion
is identified by palpation and a longitudinal incision is made
in the IT band at about the mid-point. Blunt dissection then is
done between the IT band and synovial membrane and the
posterior portion of the IT band is transected until the muscle
32 SEM I N A R S I N A R T H R O P L A S T Y 29 (2018) 27–35

Figure 8 – In this illustration, the popliteus tendon and the

lateral collateral ligament are released with a knife blade
directly from their bone attachments. The posterolateral
corner also can be released, but very conservatively,
preferably with pie-crust technique. Reprinted with
Figure 9 – For knees that remain tight in extension, the
permission.
posterior portion of the iliotibial band is exposed and
released extrasynovially, leaving the synovial membrane
intact if possible. Reprinted with permission.
fibers of the biceps femoris are encountered, leaving the
upper and lower portion still attached to the synovial mem- 2.3.2. Tight laterally in extension with normal stability in
brane so that a gap forms and functional elongation occurs flexion
(Fig. 9). The IT band transected this way continues supporting The initial step in this scenario is to release the posterior
the lateral side of the knee in extension. This release also can portion of the IT band by transaction or by pie-crusting.
be done percutaneously or in some cases, from inside the
knee, with pie-crusting technique. The LPC and biceps fem-
oris remain as lateral stabilizers in extension.
At this stage, if the knee remains tight in extension after IT
band release, the LPC is the next structure to be addressed.
Access to the LPC is gained by removing the tibial spacer and
distracting the joint with the knee flexed 90°. The capsule
either can be transected at the joint line or released from the
posterior surface of the femur with a curved half-inch
osteotome tapped gently with a hammer or the heel of the
hand (Fig. 10). Release of the LPC from the tibia is contra-
indicated because of high risk of damaging the peroneal
nerve.
After all these releases, the knee is now most probably
balanced in flexion and extension, but is likely to be loose
medially and laterally due to medial ligament stretching and
lateral ligament release, and therefore will require a thicker
tibial polyethylene component. The lateral ligaments are
lengthened to match the medial structures in flexion and Figure 10 – The posterior capsule may be released from the
extension. posterior femoral surface, as in this illustration, with the
In some cases, the knee is tight laterally in flexion and knee flexed and a sharp, curved 1/2-in osteotome applied to
extension but moreso in extension. As the LCL is most the capsule attachment to bone. The posterior capsule must
effective in extension, and the PT is most effective in flexion; be released to fully correct the knee in extension, especially
in this specific case, the LCL is released first. The rest of the if a flexion contracture persists after iliotibial band release.
procedure is the same as described previously. Reprinted with permission.
 S E M I N A R S I N AR
Occasionally, the biceps femoris also is tight in full extension
and can be released partially under direct vision after releas-
ing the IT band. The peroneal nerve lies directly behind the
biceps femoris muscle and tendon, so care should be taken
not to extend the dissection posterior to the muscle fibers of
the biceps. If the knee is still tight in extension or has a
flexion contracture; the LPC is the next structure to be
released.
In rare cases, further release in extension is necessary and
the PLC capsule is released using pie-crusting technique
(Fig. 11).
2.3.3. Tight laterally in flexion with normal stability in
extension
This is an unusual situation. Because the PT is more effective in
flexion than in extension, it is released first. The knee should be
tested again and if the latter release seems not enough to correct
lateral stability in flexion, the LCL can be released partially.
Finally, if the knee is not lax enough laterally, the PLC capsule
and conjoined lateral head of the gastrocnemius can be released
using pie-crusting technique.
Figure 11 – Rarely the posterolateral corner (arrow) must be
pie-crusted to correct persistent lateral tightness in
extension. Reprinted with permission.
T H R O P L A S T Y 29 (2018) 27–35 33
It should be noted that, when the PT, LCL and PLC capsule
are released from their attachments to the lateral femoral
condyle, these structures remain attached to the surrounding
dense fibrous capsule and synovial membrane and continue
providing some sort of lateral stabilization even after their
release; the anterior portion of the IT band, through its
attachments to the patella and tibia, also stabilizes the knee
laterally in flexion.
2.4. Potential risks to manage after soft-tissue releases
After obtaining a well-aligned and a well-balanced knee, we
should pay special attention to patellar tracking. The patella, in
the valgus knee, has a high tendency for lateral subluxation
because of the lateral forces applied to it by the quadriceps
mechanism, bone architecture and femoral and tibial rotation. At
this point, patellar tracking is examined by the “no thumb”
technique; if lateral patellar release is still necessary after
correcting the lower limb alignment and femoral rotation, a
careful release of the patellar lateral retinaculum or of the
patellar attachment of the vastus lateralis can be performed.
These structures are approached by dissection over the patella.
Often, the patellar branch of the superior lateral genicular artery
can be identified and preserved during the release [10]. Beginning
with minimal release of the patellofemoral ligament, the patellar
retinaculum is released and patellar tracking is tested repeatedly
along with further release as needed until the patella drops into
the patellar groove automatically at 20° knee flexion, and stays in
the track through the rest of the flexion arc without tilting
upward on the medial side. Medial transfer of the tibial tubercle
might be indicated if, even after all this release, the patella
continues to dislocate or the angle between the quadriceps
tendon and patellar tendon (Q angle) is greater than 20°.
The posterior cruciate ligament is a medial structure, and
often is deficient in the valgus knee. Releasing the popliteus
tendon, the LCL, and to a certain extent the PLC capsule,
which are secondary posterior stabilizers, may unmask defi-
ciency in the PCL. The combined effect of this posterior laxity
may cause posterior tibial subluxation, which places the
quadriceps at a disadvantage. Also, release of the lateral
epicondylar structures may cause the tibia to rotate exter-
nally under load bearing (Fig. 12). This external rotation of the
tibia, as well as its posterior instability, can be managed by
using a highly conforming polyethylene component. This
deep-dish polyethylene component holds the tibia forward
and prevents posterior tibial subluxation, so it improves
quadriceps function. Also, the rotational stabilization pro-
vided by the conforming polyethylene component prevents
external tibial rotation and allows the tibial tubercle to
maintain its normal central position, helping to normalize
patellar tracking.
3. Complications
Many complications have been described following TKA for a
valgus knee, including tibio-femoral instability; recurrent
valgus deformity (4–38%); poor postoperative range of motion
(2–20%); wound problems such as hematomas, blisters, diffi-
cult healing and skin necrosis (4–13%); patellar stress fracture
34 SEM I N A R S I N A R T H R O P L A S T Y
Figure 12 – External rotational instability may occur due to
loss of the epicondylar ligaments, and can lead to
lateralization of the tibial tubercle and thus cause patellar
tracking problems. Reprinted with permission.
and osteonecrosis (1–12%); patellar subluxation or dislocation
(2–10%); peroneal nerve palsy (0.3–9.5%); and proximal migra-
tion of the osteotomized fragment of the tibial tubercle
following nonunion [11]. It should be noted that peroneal
nerve palsy after TKA for valgus deformity is not a rare
complication. Elongation of the lateral side of the knee after
alignment correction places the peroneal nerve at risk via
traction and induced ischemia [12]. Also, “pie-crusting” tech-
nique, for lateral structure release, raises concern regarding
peroneal nerve safety and the surgeon should be very careful
while using this technique [13]. If peroneal nerve palsy
symptoms are detected following TKA, the knee should be
flexed to shorten the stretched peroneal nerve, with no
immediate surgical intervention indicated at this stage [14].
4. Discussion
Safe and effective correction of the valgus knee with TKA
starts with the medial parapatellar surgical approach. This
29 (2018) 27–35
approach provides excellent exposure of the knee and poses
minimal risk to the quadriceps mechanism. The next step is
bone resection based on reliable bone landmarks to achieve a
well-aligned knee both in flexion and extension. A well-
aligned knee is the essential condition for a functional
approach to soft-tissue balancing that will result in a well-
balanced knee.
The lateral parapatellar approach [3] also can be used
effectively by expert surgeons, with the rationale that it
affords better access to the tight lateral structures and
improves patellofemoral mechanics without compromising
patellar blood supply. Medial subluxation of the patella is
required with this approach, which is difficult due to the
valgus angulations of the quadriceps and patellar tendons
and the laterally directed vectors of forces of the knee when
actively extended. This necessitates tibial tubercle osteotomy
or partial transection of the quadriceps tendon, procedures
that are seldom needed when a medial approach is used in
the valgus knee. Closure of the capsule and skin after lateral
approach to the valgus knee also is challenging. The capsule
often cannot be closed, and a fat pad flap must be fashioned
to fill the soft-tissue gap.
Also, reducing the distal femoral valgus degree cut from 5°
to 3° has been proposed in the literature for valgus knee
[2,3,15]. Although comparative studies have not been pub-
lished to evaluate this assertion, it does seem reasonable
since valgus diaphysis curvature of the femur and tibia
remain uncorrected in the standard resection of five degrees
in the valgus knee. Reducing the valgus cut to 3° may protect
against under-correction and reduces the tendency for valgus
recurrence.
Applying a fixed sequence of ligament releases for manag-
ing the ligaments of all knees is discouraged because it could
lead a surgeon to release ligaments that are not tight, and
leave unreleased those that are tight. Each knee is unique and
anatomically different from every other knee and the only
way to determine which ligaments should be released is to
examine the knee carefully in flexion and extension; at this
stage, the ligaments may be chosen carefully for release or for
tensioning using a thicker spacer.
The technique of using ligament tensioners [5] to position
the anterior and posterior surface resections of the femur
should be addressed in a complete discussion of treatment of
the valgus knee. In this technique, lamina spreaders or other
tensioning devices are placed on the resected surface of the
tibia, and femoral joint surfaces are lifted until the medial
and lateral ligaments are equally tensioned. This produces a
rectangular joint space, but it is made rectangular based on
ligaments that remain contracted. This maneuver tightens
the medial ligaments and rotates the femur externally at the
hip. When resection is done parallel to the tibial surface,
more is resected from the lateral side than should be
resected, and results in a rectangular flexion gap that is not
perpendicular to the mechanical axis, but rather in valgus
position. When the hip returns to its neutral rotational
position, the knee keeps its valgus position in flexion and
the patella is pulled laterally by the valgus alignment of the
quadriceps vectors in flexion.
In cases of severe valgus knee deformity (Ranawat Grade
III) where the medial soft tissues are no longer functional, a
 S E M I N A R S I N AR
constrained prosthesis may be mandatory for achieving a
stable knee [16]. However, when stability can be obtained by
using a posterior-cruciate substituting (PS) or posterior-cru-
ciate retaining (PR) prosthesis design, constrained prostheses
should be avoided because of their higher rate of loosening
and exposure to technical difficulties in case of revision [17].
Recent studies suggest that survival rate is better for PR
prostheses compared with PS at 15 years, so it follows that
every effort should be made to obtain a well-balanced knee
with the least constraint possible [18].
Patellar ligament balance also is an essential part of valgus
knee management. After the final components are in place,
patellar balance and posterior laxity can be assessed together.
Correcting posterior sag with a highly conforming tibial
articular surface often corrects patellar tracking problems
by eliminating external rotational malposition of the tibia.
Careful observation of the patella in flexion and extension,
and releasing only enough of the lateral retinaculum to
prevent patellar tilt and subluxation, establishes a reliable
patellofemoral joint.
This described technique produced a high rate of success in
correcting valgus angle and maintaining the correction at 6 years
follow-up with no secondary short- or long-term laxity [19].
5. Conclusion
Total knee arthroplasty for a valgus knee is a challenge for
surgeons. Detailed understanding of knee mechanics and
kinematics is required to deal with every step of the knee
replacement procedure. Use of the medial parapatellar
approach, bone resection to restore alignment of the knee,
and meticulous soft-tissue releases for balanced ligament
tension are paramount for a functional knee. This system for
managing the valgus knee usually obviates constrained
prostheses and more complex procedures.
6. Disclosure
The authors report no proprietary or commercial interest in
the concept discussed in this article. The senior author has
partial ownership interest in Signal Medical Corporation, an
orthopaedic implant manufacturer, and receives royalties
from Smith and Nephew, Inc., for total knee replacement
sales.
Acknowledgment
The authors thank William C. Andrea, MS, CMI, for prepara-
tion of the illustrations, and Diane J. Morton, MS, for assis-
tance with manuscript preparation.
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