1. Ligament Balancing in Total Knee Arthroplasty Section 3 | Surgical techniques – Part 2

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3. Colour coding of illustrations - reference

4. 3.3 –  Balancing the valgus knee, lateral releases Stabilizers of extension and flexion
[Fig 3.3.1a] The lateral structures grouped by ability to stabilize the joint in full extension or flexion. The structures that serve as predominant stabilizers in each knee position are written in bold letters.

5. 3.3 –  Balancing the valgus knee, lateral releases Stabilizers of extension and flexion
[Fig 3.3.1b] The lateral structures grouped by ability to stabilize the joint in full extension or flexion. The structures that serve as predominant stabilizers in each knee position are written in bold letters.

6. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in extension only
[Fig 3.3.2a] The ITB patellar attachment is dissected first, followed by a transverse extrasynovial dissection of the complete ITB.

7. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in extension only
[Fig 3.3.2a] The ITB patellar attachment is dissected first, followed by a transverse extrasynovial dissection of the complete ITB.

8. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in extension only
[Fig 3.3.2b] For an efficient release, ensure that all posterior fibers of the ITB as far as the biceps femoris tendon are cut.

9. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in extension only
[Fig 3.3.2c] If there is residual tightness in extension after ITB release, release the posterior capsule from the posterior aspect of the femur.

10. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in extension only
[Fig 3.3.2d] After additional release of the posterior capsule the knee can be fully extended. It is stabilized by the LCL and popliteal tendon.

11. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in extension only
[Fig 3.3.2e] Ligaments stabilizers involved in a release for lateral tightness in extension only.

12. 3.3 –  Balancing the valgus knee, lateral releases Selective release of the posterior portion of the ITB
[Fig 3.3.3] In cases of slight tightness in extension only, transversely cut the posterior portion of the ITB, leaving the anterior portion intact.

13. 3.3 –  Balancing the valgus knee, lateral releases Two-stage release for tightness in flexion and extension
[Fig 3.3.4a] This example shows a knee with a lateral contracted deformity which could be due to one or even both lateral structures.

14. 3.3 –  Balancing the valgus knee, lateral releases Two-stage release for tightness in flexion and extension
[Fig 3.3.4b] The knee is also tight in flexion. This flexion contracture is caused by the LCL, the popliteal tendon and sometimes by the posterolateral corner.

15. 3.3 –  Balancing the valgus knee, lateral releases Two-stage release for tightness in flexion and extension
[Fig 3.3.4c] In severe cases of lateral tightness in flexion and extension nearly all stabilizing lateral structures have to be released; the anterior portion of the ITB may be kept.

16. 3.3 –  Balancing the valgus knee, lateral releases Two-stage release for tightness in flexion and extension
[Fig 3.3.4d] Ligament stabilizers involved in the additional release of extension stabilizers for lateral tightness in extension and flexion.

17. 3.3 –  Balancing the valgus knee, lateral releases Release of flexion stabilizers for tightness in flexion and extension
[Fig 3.3.5a] Release the LCL. Here the ITB has been removed for better visualization. The popliteal tendon and the tendon of the lateral gastrocnemius muscle are still attached to the lateral femur.

18. 3.3 –  Balancing the valgus knee, lateral releases Release of flexion stabilizers for tightness in flexion and extension
[Fig 3.3.5a] Release the LCL. Here the ITB has been removed for better visualization. The popliteal tendon and the tendon of the lateral gastrocnemius muscle are still attached to the lateral femur.

19. 3.3 –  Balancing the valgus knee, lateral releases Release of flexion stabilizers for tightness in flexion and extension
[Fig 3.3.5b] In cases of constant contracture throughout full range of motion, the LCL is released first.

20. 3.3 –  Balancing the valgus knee, lateral releases Release of flexion stabilizers for tightness in flexion and extension
[Fig 3.3.5c] In cases of predominant contracture from early flexion onward, the popliteal tendon is released first.

21. 3.3 –  Balancing the valgus knee, lateral releases Release of flexion stabilizers for tightness in flexion and extension
[Fig 3.3.5d] Ligament stabilizers involved in a release of flexion stabilizers for lateral tightness in extension and flexion.

22. 3.3 –  Balancing the valgus knee, lateral releases Additional release of extension stabilizers for tightness in flexion and extension
[Fig 3.3.6a] In severe cases of lateral tightness in flexion and extension nearly all stabilizing lateral structures have to be released; the anterior portion of the ITB may be kept.

23. 3.3 –  Balancing the valgus knee, lateral releases Additional release of extension stabilizers for tightness in flexion and extension
[Fig 3.3.6b] Ligament stabilizers involved in the additional release of extension stabilizers for lateral tightness in extension and flexion.

24. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in flexion only
[Fig 3.3.7a] The femoral attachment of the popliteal tendon is dissected sharply by cutting from “front to back” in knee flexion.

25. 3.3 –  Balancing the valgus knee, lateral releases Release for tightness in flexion only
[Fig 3.3.7b] Ligament stabilizers involved in a release of the popliteal tendon for lateral tightness in flexion only.

26. 3.4 – Alternative lateral release techniques Pie-crusting for lateral tightness in extension
[Fig 3.4.1a] The posterior portion of the ITB – the part of the ITB that is contracted in extension – is connected to the LCL.

27. 3.4 – Alternative lateral release techniques Pie-crusting for lateral tightness in extension
[Fig 3.4.1a] The posterior portion of the ITB – the part of the ITB that is contracted in extension – is connected to the LCL.

28. 3.4 – Alternative lateral release techniques Pie-crusting for lateral tightness in extension
[Fig 3.4.1b] Pie-crusting of the posterior corner with a knife from inside the joint aiming for the posterior portion of the ITB may injure or intentionally transect the LCL.

29. 3.4 – Alternative lateral release techniques Pie-crusting for lateral tightness in extension
[Fig 3.4.1c] Ligament stabilizers involved in pie-crusting for lateral tightness in extension.

30. 3.4 – Alternative lateral release techniques Lateral approach
[Fig 3.4.2a] Lateral skin incision in the direct lateral approach.

31. 3.4 – Alternative lateral release techniques Lateral approach
[Fig 3.4.2b] In a lateral approach, a distal release of the ITB together with a bone chip from the Gerdy tubercle is an effective way to release the ITB.

32. 3.4 – Alternative lateral release techniques Lateral approach
[Fig 3.4.2c] Preserving the Hoffa fat pad and using it as interposing tissue can facilitate the closure of the lateral capsule.

33. 3.4 – Alternative lateral release techniques Lateral femoral sliding osteotomy
[Fig 3.4.3a] A release of the LCL and popliteal tendon off the lateral epicondyle would correct the deformity but would also destabilize the lateral aspect in flexion.

34. 3.4 – Alternative lateral release techniques Lateral femoral sliding osteotomy
[Fig 3.4.3b] A release of the LCL and popliteal tendon off the lateral epicondyle would correct the deformity but would also destabilize the lateral aspect in flexion.

35. 3.4 – Alternative lateral release techniques Lateral femoral sliding osteotomy
[Fig 3.4.3c] Lateral femoral sliding osteotomy: first shift the lateral epicondyle, with a wafer of bone, distally and dorsally.

36. 3.4 – Alternative lateral release techniques Lateral femoral sliding osteotomy
[Fig 3.4.3d] Lateral femoral sliding osteotomy: next reattach the bone.

37. 3.4 – Alternative lateral release techniques Optimizing with the distal femoral osteotomy
[Fig 3.4.4a] The bones are cut in an exact 90° angle perpendicular to the mechanical axis. The resulting extension gap is slightly trapezoid.

38. 3.4 – Alternative lateral release techniques Optimizing with the distal femoral osteotomy
[Fig 3.4.4b] To release the ligaments, re-cut the distal femur to alter the varus/valgus orientation.

39. 3.5 – Posterior release techniques Releases of the posterior cruciate ligament
[Fig 3.5.1a] Posterior aspect of a varus deformity with shortening of the PCL.

40. 3.5 – Posterior release techniques Releases of the posterior cruciate ligament
[Fig 3.5.1b] A tight PCL typically produces an excessive femoral roll-back.

41. 3.5 – Posterior release techniques Releases of the posterior cruciate ligament
[Fig 3.5.1c] A tight PCL typically produces an overly tight flexion gap with anterior lift-off of the trial insert.

42. 3.5 – Posterior release techniques PCL release with tibial bone block
[Fig 3.5.2a] For this type of PCL release, use a narrow osteotome to create a tibial bone block with attached PCL fibers.

43. 3.5 – Posterior release techniques PCL release with tibial bone block
[Fig 3.5.2b] For this type of PCL release, use a narrow osteotome to create a tibial bone block with attached PCL fibers.

44. 3.5 – Posterior release techniques PCL release with tibial bone block
[Fig 3.5.2c] After levering the bone block free, slide it proximally to allow the femur to position itself correctly on the tibia.

45. 3.5 – Posterior release techniques PCL release with tibial bone block
[Fig 3.5.2d] After levering the bone block free, slide it proximally to allow the femur to position itself correctly on the tibia.

46. 3.5 – Posterior release techniques Distal subperiosteal PCL release
[Fig 3.5.3] Partial distal release of tight PCL fibers subperiosteally done with a small knife.

47. 3.5 – Posterior release techniques Proximal or pie-crusting PCL release
[Fig 3.5.4a] Dissection of the anterior PCL fibers.

48. 3.5 – Posterior release techniques Proximal or pie-crusting PCL release
[Fig 3.5.4b] Pie-crusting of the anterior PCL fibers.

49. 3.5 – Posterior release techniques Proximal or pie-crusting PCL release
[Fig 3.5.5a] With mild contracture of the posterior capsule, a low inlay allows for full extension but does not adequately tension the collateral ligaments.

50. 3.5 – Posterior release techniques Proximal or pie-crusting PCL release
[Fig 3.5.5b] Release the attachment of posterior capsule by tapping an osteotome along the posterior border of the femur.

51. 3.5 – Posterior release techniques Proximal or pie-crusting PCL release
[Fig 3.5.5c] After sufficient release of the posterior capsule, a higher inlay can be inserted.