Comparative Study of Two Techniques for Ligament Balancing in Total Knee Arthroplasty for Severe Varus Knee: Medial Soft Tissue Release vs. Bony Resection of Proximal Medial Tibia

Abstract

PurposeBony resection of the proximal medial tibia, an alternative technique for soft tissue balancing in total knee arthroplasty (TKA), was compared to the conventional medial soft tissue release technique.Materials and MethodsFrom June 2005 to June 2007, we performed 40 TKA in 27 patients with ≥10° tibio-femoral varus deformity. The conventional, medial soft tissue release technique was applied in 20 cases and bony resection of proximal medial tibia in the other 20 cases (vertical osteotomy group). Total operation time, knee range of motion (ROM), hospital for special surgery (HSS) scores, and tibio-femoral medial-lateral gap ratio in 0°, 90°, and 130° flexion at postoperative 6 months were compared between the groups.ResultsThe total operation time was shorter in the vertical osteotomy group. Tibio-femoral medial-lateral gap ratio in 130° flexion was closer to 1 in the vertical osteotomy group (p=0.000). There was no significant difference in the ROM, HSS score, or tibio-femoral medial-lateral gap ratio in 0° and 90° flexion at postoperative 6 months.ConclusionsIn severe varus knees, bony resection of proximal medial tibia can be considered as an alternative technique, in order to decrease total operation time and to obtain medial-lateral, soft-tissue balance in deep flexion.

Efficacy and Safety of a Novel Three-Step Medial Release Technique in Varus Total Knee Arthroplasty

“…By applying the novel stepwise release technique to our patients with severe varus deformity, there was a concern as to whether other procedures beyond the three-step release technique would balance the deformity. Some surgeons recommended proximal tibial osteotomy as the final step of the procedure in patients with severe varus deformity [13,15]. We agree that an additional osteotomy can be performed for the knees with a combined severe varus angulation and bony deformity.…”

“…Mullaji et al [13] described more complicated balancing techniques, including sequential releases of dMCL, semimembranosus, posteromedial capsule, and pes anserinus, tibia reduction osteotomy, and extra-articular correction. In addition to the above mentioned studies, various and complex protocols of medial release have been reported [15][16][17][18][19]. Somewhat extensive release techniques can lead to complications such as instability and neurovascular injury [12].…”

“…Instability which leads to pain, walking difficulty, abnormal polyethylene wear, patellofemoral maltracking, and early loosening is still one of the major causes of TKA failure [6,[20][21][22]. Even though medial soft tissue release has been accepted as an essential step for gap balancing, there exists a controversy in methods and the order of soft tissue release to achieve balanced gap during TKA of varus deformed osteoarthritic knee [8,[15][16][17][18][19][23][24][25]. There is still a lack of evidence supporting the current numerous medial release techniques for varus TKA [12].…”

Length-Change Patterns of the Collateral Ligaments During Functional Activities After Total Knee Arthroplasty

“…The importance of proper tensioning of the collateral ligaments for the clinical success of total knee arthroplasty (TKA) has been comprehensively established. 1,5,35 A number of different methods for intraoperative ligament balancing have been introduced, targeting tension balance in the medial and lateral collateral ligaments (MCL and LCL) at full extension as well as at 90°of knee flexion. 12,33,35 However, the optimal ligament tension (or indeed laxity), during TKA is generally judged based on subjective manual evaluation by the surgeon rather than quantitative metrics.…”

Medial Tibial Reduction Osteotomy is Associated with Excellent Outcomes and Improved Coronal Alignment

“…In some cases, this is associated with downsizing of the tibial tray. The utilization of the MTRO may result in a decrease in operative times when compared to soft tissue releases alone [10] and typically lessens the amount of medial soft tissue releasing required to correct the varus deformity. Additionally, aggressive medial soft tissue release can lead to attenuation of the medial collateral ligament [11] (MCL).…”