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

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3. Colour coding of illustrations - reference

4. 3 – Introduction The Instrumentation technique sequence
[Fig 3.0.1a] Femur first technique: Ligament balancing with trials inserted.

5. 3 – Introduction The Instrumentation technique sequence
[Fig 3.0.1b] Tibia first technique: Ligament balancing before bone cuts.

6. 3 – Introduction The Instrumentation technique sequence
[Fig 3.0.1c] Extension gap first technique: Ligament balancing after creating the extension gap.

7. 3 – Introduction The different aspects of releases
[Fig 3.0.2a] Medial releases are performed distally from the tibia in a subperiosteal technique.

8. 3 – Introduction The different aspects of releases
[Fig 3.0.2b] Lateral releases are performed proximally from the femur by sharp dissection or transection.

9. 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.

10. 3.1 – Balancing the varus knee, medial releases Medial release grade 1
[Fig 3.1.2a] Subperiosteal release of the deep MCL.

11. 3.1 – Balancing the varus knee, medial releases Medial release grade 1
[Fig 3.1.2b] Subperiosteal release of the deep MCL.

12. 3.1 – Balancing the varus knee, medial releases Medial release grade 1
[Fig 3.1.2c] Osteophytes must be removed before advancement to higher degrees of ligament releases.

13. 3.1 – Balancing the varus knee, medial releases Medial release grade 1
[Fig 3.1.2d] Osteophytes must be removed before advancement to higher degrees of ligament releases.

14. 3.1 – Balancing the varus knee, medial releases Medial release grade 1
[Fig 3.1.2e] Ligament stabilizers involved in a grade 1 medial release.

15. 3.1 – Balancing the varus knee, medial releases Medial releases grade 2a and 2b
[Fig 3.1.3a] Grade 2a release of semimembranosus and posteromedial corner for moderate imbalance.

16. 3.1 – Balancing the varus knee, medial releases Medial releases grade 2a and 2b
[Fig 3.1.3b] Grade 2b release of superficial MCL for marked imbalance.

17. 3.1 – Balancing the varus knee, medial releases 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.

18. 3.1 – Balancing the varus knee, medial releases 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.

19. 3.1 – Balancing the varus knee, medial releases Medial release grade 2a
[Fig 3.1.4b] Grade 2a release: subperiosteal release of the direct tibial attachment of the semimembranosus.

20. 3.1 – Balancing the varus knee, medial releases Medial release grade 2a
[Fig 3.1.4c] Ligament stabilizers involved in a grade 2a medial release.

21. 3.1 – Balancing the varus knee, medial releases Medial release grade 2b
[Fig 3.1.5a] Osteotome is used to first detach the anterior fibers of the superficial MCL.

22. 3.1 – Balancing the varus knee, medial releases Medial release grade 2b
[Fig 3.1.5a] Osteotome is used to first detach the anterior fibers of the superficial MCL.

23. 3.1 – Balancing the varus knee, medial releases 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.

24. 3.1 – Balancing the varus knee, medial releases 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.

25. 3.1 – Balancing the varus knee, medial releases Medial release grade 2b
[Fig 3.1.5c] Selective release of the superficial MCL. For medial tightness only in extension: selective release of the posterior fibers.

26. 3.1 – Balancing the varus knee, medial releases Medial release grade 2b
[Fig 3.1.5d] Selective release of the superficial MCL. For medial tightness only in flexion: selective release of the anterior fibers.

27. 3.1 – Balancing the varus knee, medial releases Medial release grade 2b
[Fig 3.1.5e] Ligament stabilizers involved in a grade 2b medial release.

28. 3.1 – Balancing the varus knee, medial releases Medial release grade 3
[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.

29. 3.1 – Balancing the varus knee, medial releases Medial release grade 3
[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.

30. 3.1 – Balancing the varus knee, medial releases Medial release grade 3
[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.

31. 3.1 – Balancing the varus knee, medial releases Medial release grade 3
[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.

32. 3.1 – Balancing the varus knee, medial releases Medial release grade 3
[Fig 3.1.6d] Ligament stabilizers involved in a grade 3 medial release.

33. 3.1 – Balancing the varus knee, medial releases Medial release grade 4
[Fig 3.1.7a] Medial release grade 4: the pes anserinus is dissected from the anterior tibial attachment.

34. 3.1 – Balancing the varus knee, medial releases Medial release grade 4
[Fig 3.1.7b] Ligament stabilizers involved in a grade 4 medial release.

35. 3.1 – Balancing the varus knee, medial releases Compensatory lateral releases
[Fig 3.1.8a] Lateral tightness in extension after an extensive medial release.

36. 3.1 – Balancing the varus knee, medial releases Compensatory lateral releases
[Fig 3.1.8b] A compensatory release of the ITB creates space for a thicker tibial inlay.

37. 3.1 – Balancing the varus knee, medial releases Compensatory lateral releases
[Fig 3.1.8c] Lateral tightness in extension following a high degree medial release.

38. 3.1 – Balancing the varus knee, medial releases Compensatory lateral releases
[Fig 3.1.8d] Lateral tightness in flexion following a high degree medial release.

39. 3.1 – Balancing the varus knee, medial releases Compensatory lateral releases
[Fig 3.1.8e] More lateral space in flexion: the LCL is dissected, and a thicker tibial inlay compensates for less ligament restraint.

40. 3.1 – Balancing the varus knee, medial releases Compensatory lateral releases
[Fig 3.1.8f] More lateral space in extension: the LCL is dissected, and a thicker tibial inlay compensates for less ligament restraint.

41. 3.2 – Alternative medial release techniques Shift-and-resect technique
[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.

42. 3.2 – Alternative medial release techniques Shift-and-resect technique
[Fig 3.2.1b] Shift-and-resect technique: The uncovered area is resected vertically.

43. 3.2 – Alternative medial release techniques Shift-and-resect technique
[Fig 3.2.1c] Shift-and-resect technique: Tension on the superficial MCL is reduced; Bone gaps opened a few millimeters medially.

44. 3.2 – Alternative medial release techniques Pie-crusting of the MCL
[Fig 3.2.2] Pie-crusting of the MCL.

45. 3.2 – Alternative medial release techniques Optimizing with the distal femoral osteotomy
[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.

46. 3.2 – Alternative medial release techniques 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.