1. Total Knee Arthroplasty in Varus Knee
H.Makhmalbaf MD
Consultant Orthopaedic & Knee
Surgeon
Ghaem Hospital Medical School

2. The most important factor in maintaining satisfactory long-term outcome in TKA is anatomic alignment This depends significantly on ligamentous balance

3. The most favorable results are observed with femorotibial angle 3-7ovalgus , the tibial component in neutral,& the femoral component in 4-6o valgus

4. The typical patient Severe varus deformity
Some varus alignment since childhood
H/O medial menisectomy
Gradually progresses
Lateral subluxation of the tibia on the femur

5. Exposure Standard medial parapatellar arthrotomy
Resect medial meniscus
Release deep MCL
Resect ACL
Externally rotate & deliver the tibia
Remove all osteophytes

6. Mediolateral Balancing
Ligament balance in flexion & extention are interrelated (unlike valgus knee)
In a varus knee , the knee should be balanced in extention first then in flexion

7. Shift & resect technique
Tibia is delivered in front of the tibia
Initial conservative tibial resection
Based on the intact lateral side
10mm lateral resection
Angle of resection is perpendicular to the long axis of the tibia & 3-5o posterior slope
Choose tibia one size smaller

8. Shift & resect Choose tibia one size smaller &
Shifted laterally to the edge of tibia
Align tibial rotation with tibial tubercle
Outline the nucapped portion of tibia
Free the MCL from bone
Resect bone perpedicular

11. Formal MCL release from the tibia
Release deep MCL
Posteromedial capsule
Remove osteophytes
Release PCL
Resect PCL & put PS knee

12. Distal femoral resection
Pre-op X-ray
Varus in the femoral shaft ?
Usually 5-7deg.cut
More resection of medial fem. condyle
The amount of resection depends on the thickness of metallic femoral component

13. Femoral component rotation
Establish a balanced, symmetric flexion gap to maximize flex. Stability
In varus knee balance in ext.1st
Use the Whiteside line or trans epi.
30 external rotation
Then posterior condyles in flexion

14. Tibial bone stock deficiency
Medial tibial plateau is always deficient in varus knee
Resect enough bone not too much
Bone graft
Cement & screws
Metal wedges
Allograft

15. Residual lateral laxity
How much laxity is acceptable
The bony alignment should not be in varus
The lateral should not gap open on the tab
Correct significant laxity
More medial release
Fibula head advancement?

16. summary Tibia is responsible for varus Release MCL, remove osteopytes
Bone resection, undersize, sift
Balance flexion gap
PCL retention in severe varus?
Release PCL ?
Accept some residual laxity if
Fill bony defects in tibia

17. Thank you