Soft tissue balancing in varus total knee arthroplasty: an algorithmic approach.

We present an algorithmic release approach to the varus knee, including a novel pie crust release technique of the superficial MCL, in 359 total knee arthroplasty patients and report the clinical and radiological outcome. Medio-lateral stability was evaluated as normal in 97% of group 0 (deep MCL), 95% of group 1 (pie crust superficial MCL) and 83% of group 2 (distal superficial MCL). The mean preoperative hip-knee angle was 174.0, 172.1, and 169.5 and was corrected postoperatively to 179.1, 179.2, and 177.6 for groups 0, 1, and 2, respectively. A satisfactory correction in the coronal plane was achieved in 82.9% of all-comers falling within the 180 degrees +/- 3 degrees interval. An algorithmic release approach can be beneficial for soft tissue balancing. In all patients, the deep medial collateral ligament should be released and otseophytes removed. The novel pie crust technique of the superficial MCL is safe, efficient and reliable, provided a medial release of 6-8 mm or less is required. The release of the superficial MCL on the distal tibia is advocated in severe varus knees. Preoperative coronal alignment is an important predictor for the release technique, but should be combined with other parameters such as reducibility of the deformity and the obtained gap asymmetry.