2. Do you do tis patient? What is your approach? How do you balance the knee? Which implant do you prefer?

3. Techniques : gap technique and the measured resection technique Gap technique may result in residual varus alignment in flexion( Whiteside et al)

4. Bone resections :according to the preoperative template on the long WB films Tibial cutting jig :according to the talus center distally and the plateau-to-anatomic axis intersection proximally. In constitutional metaphyseal varus deformities: usually facing the lateral tibial plateau spine

5. medial flap of tissue, which includes the meniscotibial fibers of the deep medial collateral ligament sublux the tibia forward in flexion and external rotation (RanSall maneuver) violating the posterior tibial osteophyte(pagoda)

6. tibial and femoral osteophytes are removed Do proximal tibial and distal femoral cuts Anteror and posterior femoral cuts Medial pivot if needed

9. PCL Posterior capsule Posteromedial corner with the posterior oblique Ligament (POL) Semimembranosus (direct tibial insertion) Posterior fibers of the superficial MCL All these structures can be released with the knee in Flexion

10. posterior capsule can be addressed by a periosteal elevator from the femoral side. figure four” position to release SM and POL

11. MCL Pie-crusted with a 16 Gauge needle with multiple Punctures Distal release

12. Shift and resect technique

14. Effect of medial epicondylar osteotomy on soft tissue balancing in total knee arthroplasty. Mihalko WM Mihalko WM, Saeki K, Whiteside LA.Saeki KWhiteside LA findings of this study question the need for an epicondylar osteotomy in severe varus osteoarthritic knees. Because the knee remains unstable in flexion after this technique, an implant with higher constraint should be used. Orthopedics. 2013 Nov 1;36(11):e1353-7

15. Results of total knee arthroplasty with medial epicondylar osteotomy to correct varus deformity. Engh GAEngh GA, Ammeen D.Ammeen D The results show that epicondylar osteotomy for varus knee deformity provides excellent patient satisfaction, knee stability, motion, and deformity correction. Clin Orthop Relat Res. 1999 Oct;(367):141-8.

16. Medial epicondyle osteotomy: a method of choice in severe varus knee arthroplasty Horia OrbanHoria Orban Gabriel Stan Mihaela Dragusanu Razvan Adam Gabriel StanMihaela DragusanuRazvan Adam Using medial epicondyle osteotomy for varus knee when performing total knee arthroplasty could be a useful ligament-balancing technique to achieve medial stability of the knee. In addition, it could have considerable advantages towards the additional resection of the tibial medial plateau. European Journal of Orthopaedic Surgery & Traumatology 2012 | 22 | 7 | 579-583

18. A 65 Y/o F Sever Bi varus deformity

20. End Results

21. Thank you