This document discusses the surgical anatomy and treatment of varus knee deformities. It describes Maquet's line and how it is medialized in varus knees. It then classifies varus deformities into 5 categories and details the surgical steps to correct it, including: creating a medial sleeve; removing osteophytes; checking and releasing ligaments like PCL, semimembranosus, and superficial MCL if gaps remain tight; and lateralizing the tibial component by shifting and reducing it. The goal is to create symmetrical extension and flexion gaps and restore the mechanical axis.

1. The VARUS KNEE
Dr Vaibhav Bagaria
Sir HN Reliance Foundation Hosp
Mumbai India

2. Surgical Anatomy
Pes Anserinus
Superficial MCL
Deep MCL
Joint Capsule
Semi Membranous
Posterior Oblique
ligament

4. MCL

6. Goal - Symmetrical Gaps

7. What is a Varus Knee
Maquet’s Line- Load Bearing Axis, Passes
from centre of femoral head to Centre of
Talus.
Ideally through the centre of Knee
Medial to Centre in case of Varus deformity

8. Maquet's Line
Maquet’s Line- Load
Bearing Axis, Passes
from centre of femoral
head to Centre of
Talus

9. Classification

10. Case1

12. Case 2

13. Case 3

14. Case 4

15. Case 5

16. Medial Exposure
Using Scalpel -Subperisoteal elevation of the
medial sleeve
Includes Joint Capsule and deep MCL
Continue with perisoteal elevator to elevate till
Meta-physeal flare of tibia.
RanSall Manouveur: flexion- ER @ tibia

17. Medial Sleeve Creation

18. Step 1: Osteophytes
Remove all osteophytes from Femur & Tibia
as they can tent the medial soft tissue sleeve
and consequently shorten the MCL.
Remember to check the Posterior femoral
condyle and Posteromedial tibia -> as they
tighten extension gap.

19. Osteophyte Removal

20. Step 2: PCL
Make sure PCL is resected before balancing
PCL is 2ry medial stabiliser so care should be
taken not to release the entire sleeve of the
tibia because it may cause medial instability
In CR PCL is left intact

21. PCL Release

22. Cuts and Balancing

23. Step 3: Semi
Membranosus
If the tightness remains medially, the
semimembranosus and posteromedial
capsule can be released off the proximal tibia.

24. Semi Membranosus
release

25. Step 4 - Posterior Oblique
Lig
If the gap is tight only medially in the extension
during varus valgus stress -> posterior Oblique
Ligament can be subperiosteally released.
Is best done in a figure of 4 position

27. Step 5: Superficial MCL
Assess the flexion extension gap using
Lamina Spreader/ Trial Component/ Spacer
block - Varus Valgus.
If tight in both - release sub-periosteally SMCL
off proximal tibia but not completely of distal
tibia

28. Superficial MCL Release

29. Pie Crusting
AF PE ( Atrial
fibrillation -
Pulmonary
Embolism)

32. Structures Responsible

33. step 6 Pes Release

34. Step 7: Shift and Resect
Initial conservative tibial resection
Based on lateral side: 10mm
Angle perpendicular to long axis with 3 - 5
slope
Measure for size of tray
Downsize and lateralise

35. Shift & Resect

36. Shift & Resect

37. Shift & Resect

38. Lateralizing the component

39. Residual LCL laxity
IT band can usually dynamically restore the
stability in most cases.
1st options: increase medial release/ medial
cut and use thicker Poly
2nd: LCL advancement

40. Algorithm
Create a Medial Subperiosteal Sleeve with DMCL
Remove the osteophytes
Take the cuts -remember ER may need to be increased
Check the Gaps
Release Semimembranosus, POL
SMCL ant or Post
Shift and Resect