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Ligament Balancing in Total Knee Arthroplasty
Section 3 | Surgical techniques – Part 1

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Colour coding of illustrations - reference

[Fig 3.0.1a] Femur first technique: Ligament
balancing with trials inserted.
3 – Introduction
The Instrumentation technique sequence

[Fig 3.0.1b] Tibia first technique: Ligament
balancing before bone cuts.
3 – Introduction

[Fig 3.0.1c] Extension gap first technique:
Ligament balancing after creating the extension
gap.
3 – Introduction

[Fig 3.0.2a] Medial releases are performed distally
from the tibia in a subperiosteal technique.
3 – Introduction
The different aspects of releases

[Fig 3.0.2b] Lateral releases are performed
proximally from the femur by sharp dissection or
transection.
3 – Introduction
The different aspects of releases

3.1 – Balancing the varus knee, medial releases
The medial release grade system
[Fig 3.1.1] Overview of the medial release grades 1 to 4 and the expected effect on the
medial side in extension.

[Fig 3.1.2a] Subperiosteal release of the deep MCL.
Medial release grade 1

[Fig 3.1.2b] Subperiosteal release of the deep MCL.

[Fig 3.1.2c] Osteophytes must be removed before
advancement to higher degrees of ligament releases.

[Fig 3.1.2d] Osteophytes must be removed before
advancement to higher degrees of ligament releases.

[Fig 3.1.2e] Ligament stabilizers involved in a grade 1 medial release.

[Fig 3.1.3a] Grade 2a release of
semimembranosus and posteromedial corner for
moderate imbalance.
Medial releases grade 2a and 2b

[Fig 3.1.3b] Grade 2b release of superficial MCL
for marked imbalance.
Medial releases grade 2a and 2b

Medial release grade 2a
[Fig 3.1.4a] Anatomic specimen showing the direct tibial attachment of the semimembranosus tendon.
The medial capsule, parts of the vastus medialis muscle, and the pes anserinus have been removed
for better visualization.

[Fig 3.1.4a] Anatomic specimen showing the direct tibial attachment of the semimembranosus tendon.
The medial capsule, parts of the vastus medialis muscle, and the pes anserinus have been removed
for better visualization.

[Fig 3.1.4b] Grade 2a release: subperiosteal
release of the direct tibial attachment of the
semimembranosus.

[Fig 3.1.4c] Ligament stabilizers involved in a grade 2a medial release.

[Fig 3.1.5a] Osteotome is used to first detach the anterior fibers of the superficial MCL.
Medial release grade 2b

[Fig 3.1.5b] Posterior fibers of the superficial MCL are then detached further dorsally. Here,
only the pes anserinus has been removed for better visualization.

[Fig 3.1.5c] Selective release of the superficial
MCL. For medial tightness only in extension:
selective release of the posterior fibers.

[Fig 3.1.5d] Selective release of the superficial MCL.
For medial tightness only in flexion: selective
release of the anterior fibers.

[Fig 3.1.5e] Ligament stabilizers involved in a grade 2b medial release.

[Fig 3.1.6a] Anatomic specimen showing the direct tibial attachment of the semimembranosus
tendon. The medial capsule, parts of the vastus medialis muscle, and the pes anserinus have
been removed for better visualization.

[Fig 3.1.6b] Medial release grade 3: the remaining
main stabilizers of the medial side
(semimembranosus tendon and the superficial
MCL) are subperiosteally released.

[Fig 3.1.6c] Medial release grade 3: the remaining
main stabilizers of the medial side
(semimembranosus tendon and the superficial
MCL) are subperiosteally released.

[Fig 3.1.6d] Ligament stabilizers involved in a grade 3 medial release.

[Fig 3.1.7a] Medial release grade 4: the pes anserinus
is dissected from the anterior tibial attachment.

[Fig 3.1.7b] Ligament stabilizers involved in a grade 4 medial release.

[Fig 3.1.8a] Lateral tightness in extension after an
extensive medial release.
Compensatory lateral releases

[Fig 3.1.8b] A compensatory release of the ITB
creates space for a thicker tibial inlay.

[Fig 3.1.8c] Lateral tightness in extension following
a high degree medial release.

[Fig 3.1.8d] Lateral tightness in flexion following a
high degree medial release.

[Fig 3.1.8e] More lateral space in flexion: the LCL
is dissected, and a thicker tibial inlay compensates
for less ligament restraint.

[Fig 3.1.8f] More lateral space in extension: the
LCL is dissected, and a thicker tibial inlay
compensates for less ligament restraint.

[Fig 3.2.1a] Shift-and-resect technique: Tibial
trial is moved as laterally as possible; the
uncovered bone cut of the tibial plateau is marked.
3.2 – Alternative medial release techniques
Shift-and-resect technique

[Fig 3.2.1b] Shift-and-resect technique: The
uncovered area is resected vertically.

[Fig 3.2.1c] Shift-and-resect technique: Tension
on the superficial MCL is reduced; Bone gaps
opened a few millimeters medially.

[Fig 3.2.2] Pie-crusting of the MCL.
Pie-crusting of the MCL

[Fig 3.2.3a] The bones are cut in an exact 90°
angle perpendicular to the mechanical axis. The
resulting extension gap is slightly trapezoid.
Optimizing with the distal femoral osteotomy

[Fig 3.2.3b] To release the ligaments, medially re-cut
the distal femur to alter the varus/valgus orientation.
Optimizing with the distal femoral osteotomy

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