Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 22, Issue 12, pp 3100–3112 | Cite as

Lack of evidence to support present medial release methods in total knee arthroplasty

  • Nicola C. Hunt
  • Kanishka M. Ghosh
  • Kiron K. Athwal
  • Lee M. Longstaff
  • Andrew A. Amis
  • David J. Deehan



The aim of this review was to identify a reliable sequential medial release protocol for restoration of soft tissue balance in total knee arthroplasty of the varus osteoarthritic knee and to allow for improved intraoperative decision-making.


Current medial release sequences and applicability based upon pre-operative deformity have been reviewed. Furthermore, risks associated with over release, and the necessity of medial release, are discussed.


The different medial release sequences are discussed in relation to pre-operative deformity, along with potential complications associated with medial release. It was found that release sequences may include the deep and superficial components of the medial collateral ligament, the posteromedial capsule, the posterior oblique ligament, the pes anserinus (pes A), and tendons of the semimembranosus and medial gastrocnemius muscle. The sequences described were found to vary substantially between studies, and very few studies had systematically quantified the effect of each release on balance.


While medial release is the standard intraoperative mode of balancing, there is a lack of evidence to support current methods. The correct method for defining intraoperatively the sequence, extent and magnitude of releases required remains ill-defined. It could be argued that the classic extensive medial release may be unnecessary and may be associated with iatrogenic injury to the pes A and saphenous nerve, instability and abnormal knee kinematics. Minimal medial release may allow for improved soft tissue balancing leading ultimately to improved functional outcome.

Level of evidence

V (expert opinion).


Total knee arthroplasty Varus deformity Medial collateral ligament Ligament balancing 



We would like to acknowledge Stryker Corp. for funding and Newcastle Surgical Training Centre for technical assistance.

Conflict of interest



  1. 1.
    Aglietti P, Lup D et al (2007) Total knee arthroplasty using a pie-crusting technique for valgus deformity. Clin Orthop Relat Res 464:73–77PubMedGoogle Scholar
  2. 2.
    Ahn JH, Back YW (2013) Comparative study of two techniques for ligament balancing in total knee arthroplasty for severe varus knee: medial soft tissue release vs. bony resection of proximal medial tibia. Knee Surg Relat Res 25:13–18PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Alcelik I, Sukeik M, Pollock R, Misra A, Shah P, Armstrong P, Dhebar MI (2012) Comparison of the minimally invasive and standard medial parapatellar approaches for primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 20:2502–2512PubMedCrossRefGoogle Scholar
  4. 4.
    Argenson JN, Boisgard S, Parratte S et al (2013) Survival analysis of total knee arthroplasty at a minimum 10 years’ follow-up: a multicenter French nationwide study including 846 cases. Orthop Traumatol Surg Res 99:385–390PubMedCrossRefGoogle Scholar
  5. 5.
    Athwal KK, Hunt NC et al (2014) Clinical biomechanics of instability related to total knee arthroplasty. Clin Biomech 29(2):119–128CrossRefGoogle Scholar
  6. 6.
    Aunan E, Kibsgard T, Clarke-Jenssen J et al (2012) A new method to measure ligament balancing in total knee arthroplasty: laxity measurements in 100 knees. Arch Orthop Trauma Surg 132:1173–1181PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Babazadeh S, Stoney JD et al (2009) The relevance of ligament balancing in total knee arthroplasty: how important is it? A systematic review of the literature. Orthop Rev 1:70–78CrossRefGoogle Scholar
  8. 8.
    Bellemans J, Colyn W et al (2012) The Chitranjan Ranawat Award: is neutral mechanical alignment normal for all patients?: the concept of constitutional varus. Clin Orthop Relat Res 470:45–53PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Bellemans J, Vandenneucker H et al (2010) A new surgical technique for medial collateral ligament balancing multiple needle puncturing. J Arthroplasty 2:1151–1156CrossRefGoogle Scholar
  10. 10.
    Bottros J, Gad B et al (2006) Gap balancing in total knee arthroplasty. J Arthroplasty 21:11–15PubMedCrossRefGoogle Scholar
  11. 11.
    Brown EC, Clarke HD, Scuderi GR (2006) The painful total knee arthroplasty: diagnosis and management. Orthopaedics 29:129–136Google Scholar
  12. 12.
    Burke DW, O’Flynn H (2000) Primary total knee arthroplasty. In: Chapman MW (ed) Chapman’s orthopaedic surgery, Chap 108, 3rd edn. Lippincott Williams and Wilkins, PhiladelphiaGoogle Scholar
  13. 13.
    Chen W, Nagamine R et al (2011) Effect of medial soft-tissue releases during posterior-stabilised total knee arthroplasty. J Orthop Surg (Hong Kong) 19:230–233Google Scholar
  14. 14.
    Chon JG, Sun DH et al (2011) Rotational alignment of femoral component for minimal medial collateral ligament release in total knee arthroplasty. Knee Surg Relat Res 23:153–158PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Clarke HD, Fuchs R et al (2005) Clinical results in valgus total knee arthroplasty with the “pie crust” technique of lateral soft tissue releases. J Arthroplasty 20:1010–1014PubMedCrossRefGoogle Scholar
  16. 16.
    Clayton ML, Thompson TR, Mack RP (1986) Correction of alignment deformities during total knee arthroplasty—staged soft-tissue releases. Clin Orthop Relat Res 202:117–124PubMedGoogle Scholar
  17. 17.
    Cohen M, Astur DC, Branco RC et al (2011) An anatomical three-dimensional study of the posteromedial corner of the knee. Knee Surg Sports Traumatol Arthrosc 19:1614–1619PubMedCrossRefGoogle Scholar
  18. 18.
    Crottet D, Kowal J et al (2007) Ligament balancing in TKA: evaluation of a force-sensing device and the influence of patellar eversion and ligament release. J Biomech 40:1709–1715PubMedCrossRefGoogle Scholar
  19. 19.
    Dosset HG, Swartz GJ et al (2012) Kinematically versus mechanically aligned total knee arthroplasty. Orthopedics 35:E160–E169Google Scholar
  20. 20.
    Engh GA, Ammeen D (1999) Results of total knee arthroplasty with medial epicondylar osteotomy to correct varus deformity. Clin Orthop Relat Res 367:141–148PubMedGoogle Scholar
  21. 21.
    Engh GA (2003) The difficult knee—severe varus and valgus. Clin Orthop Relat Res 416:58–63PubMedCrossRefGoogle Scholar
  22. 22.
    Ghosh KM, Blain AP, Longstaff L, Rushton S, Amis AA, Deehan DJ (2013) Can we define envelope of laxity during navigated knee arthroplasty? Knee Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-013-2574-0 PubMedGoogle Scholar
  23. 23.
    Griffin FM, Insall JN, Scuderi GR (2000) Accuracy of soft tissue balancing in total knee arthroplasty. J Arthroplasty 15:970–973PubMedCrossRefGoogle Scholar
  24. 24.
    Grood ES, Noyes FR et al (1981) Ligamentous and capsular restraints preventing straight medial and lateral laxity in intact human cadaver knees. J Bone Joint Surg Am 63:1257–1269PubMedGoogle Scholar
  25. 25.
    Gustke K (2012) Use of smart trials for soft-tissue balancing in total knee replacement surgery. J Bone Joint Surg Br 94B:147–150CrossRefGoogle Scholar
  26. 26.
    Haimes JL, Wroble RR et al (1994) Role of the medial structures in the intact and anterior cruciate deficient knee—limits of motion in the human knee. Am J Sports Med 22:402–409PubMedCrossRefGoogle Scholar
  27. 27.
    Hakki S, Coleman S, Saleh K, Bilotta VJ, Hakki A (2009) Navigational predictors in determining the necessity for collateral ligament release in total knee replacement. J Bone Joint Surg Br 9:1178–1182CrossRefGoogle Scholar
  28. 28.
    Howell SM, Howell SJ et al (2013) Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res 471:1000–1007PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Incavo SJ, Schmid S et al (2013) Total knee arthroplasty using anatomic alignment can produce mid-flexion laxity. Clin Biomech 28:429–435CrossRefGoogle Scholar
  30. 30.
    Insall JN (1993) Surgery of the knee, 2nd edn. Churchill Livingstone, New YorkGoogle Scholar
  31. 31.
    Kadoya Y, Kobayashi A et al (2001) Effects of posterior cruciate ligament resection on the tibiofemoral joint gap. Clin Orthop Relat Res 391:210–217PubMedCrossRefGoogle Scholar
  32. 32.
    King JJ, Chakravarty R, Cerynik DL, Black A, Johanson NA (2013) Decreased ratios of lateral to medial patellofemoral forces and pressures after lateral retinacular release and gender knees in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2770–2778PubMedCrossRefGoogle Scholar
  33. 33.
    Koh HS, In Y (2013) Semimembranosus release as the second step of soft tissue balancing in varus total knee arthroplasty. J Arthroplasty 28:273–278PubMedCrossRefGoogle Scholar
  34. 34.
    Krackow KA (1990) Varus deformity. In: The technique of total knee arthroplasty. CO Mosby Company, St Louis, pp 317–340 Google Scholar
  35. 35.
    Lin KH, Sathappan SS, Wong HP (2008) Persistent knee instability following revision total knee arthroplasty. Singapore Med J 49:E347–E349PubMedGoogle Scholar
  36. 36.
    Liu F, Yue B et al (2010) Morphology of the medial collateral ligament of the knee. J Orthop Surg Res 5:69–76PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Luring C, Bäthis H, Hüfner T, Grauvogel C, Perlick L, Grifka J (2006) Gap configuration and anteroposterior leg axis after sequential medial ligament release in rotating-platform total knee arthroplasty. Acta Orthop 77:149–155PubMedCrossRefGoogle Scholar
  38. 38.
    Magnussen RA, Weppe F et al (2011) Residual varus alignment does not compromise results of TKAs in patients with preoperative varus. Clin Orthop Relat Res 469:3443–3450PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Matsueda M, Gengerke TR et al (1999) Soft tissue release in total knee arthroplasty—cadaver study using knees without deformities. Clin Orthop Relat Res 366:264–273PubMedCrossRefGoogle Scholar
  40. 40.
    Matsumoto T, Muratsu H et al (2011) The influence of preoperative deformity on intraoperative soft tissue balance in posterior-stabilized total knee arthroplasty. J Arthroplasty 26:1291–1298PubMedCrossRefGoogle Scholar
  41. 41.
    Matsumoto T, Kubo S et al (2013) Different pattern in gap balancing between the cruciate-retaining and posterior-stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 21:2338–2345PubMedCrossRefGoogle Scholar
  42. 42.
    Matsumoto T, Muratsu H et al (2009) Soft tissue balance measurement in posterior-stabilized total knee arthroplasty with a navigation system. J Arthroplasty 24:358–364PubMedCrossRefGoogle Scholar
  43. 43.
    Meftah M, Blum YC, Raja D, Ranawat AS, Ranawat CS (2012) Correcting fixed varus deformity with flexio contracture during total knee arthroplasty: the “Inside-Out” technique. J Bone Joint Surg Am 94:1–6Google Scholar
  44. 44.
    Meneghini RM, Daluga AT, Sturgis LA, Lieberman JR (2013) Is the pie-crusting technique safe for MCL release in varus deformity correction in total knee arthroplasty? J Arthroplasty 28:1306–1309PubMedCrossRefGoogle Scholar
  45. 45.
    Moon YW, Kim JG et al (2013) Factors correlated with the reducibility of varus deformity in knee osteoarthritis: an analysis using navigation guided TKA. Clin Orthop Surg 5:36–43PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Mullaji AB, Padmanabhan V, Jindal G (2005) Total knee arthroplasty for profound varus deformity—technique and radiological results in 173 knees with varus of more than 20 degrees. J Arthroplasty 20:550–561PubMedCrossRefGoogle Scholar
  47. 47.
    Namba RS, Inacio MC, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 95:775–782PubMedCrossRefGoogle Scholar
  48. 48.
    Norris M, Gill K, Karadaglis D, Chauhan S (2009) The envelope of laxity and balancing of total knee replacements using navigation. J Bone Joint Surg Br 91-B:426CrossRefGoogle Scholar
  49. 49.
    Orban H, Stan G, Dragusanu M et al (2012) Medial epicondyle osteotomy: a method of choice in severe varus knee arthroplasty. Eur J Orthop Surg Traumatol 22:579–583CrossRefGoogle Scholar
  50. 50.
    Parratte S, Pagnano MW, Trousdale RT et al (2010) Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am 92A:2143–2149CrossRefGoogle Scholar
  51. 51.
    Picard F, Deakin AH, Clarke IV, Dillon JM, Kinninmonth AW (2007) A quantitative method of effective soft tissue management for varus knees in total knee replacement surgery using navigational techniques. Proc Inst Mech Eng H 221:763–772PubMedCrossRefGoogle Scholar
  52. 52.
    Robinson JR, Sanchez-Ballester J et al (2004) The posteromedial corner revisited—an anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Joint Surg Br 86B:674–681CrossRefGoogle Scholar
  53. 53.
    Romero J, Staehelin T et al (2007) The clinical consequences of flexion gap asymmetry in total knee arthroplasty. J Arthroplasty 22:235–240PubMedCrossRefGoogle Scholar
  54. 54.
    Schnurr C, Stolzenberg I et al (2012) Soft tissue balanced navigation of total knee arthroplasties. Oper Orthop Traumatol 24:140–151PubMedCrossRefGoogle Scholar
  55. 55.
    Scuderi GR, Insall JN (2003) Fixed varus and valgus deformities. In: Lotke PA, Lonner JH (eds) Master techniques in orthopaedic surgery: knee arthroplasty, 2nd edn. Lippincott Williams & Williams, Philadelphia, pp 95–109Google Scholar
  56. 56.
    Sikorski JM (2008) Alignment in total knee replacement. J Bone Joint Surg Br 90B:1121–1127CrossRefGoogle Scholar
  57. 57.
    Spahn G, Hofmann GO, von Engelhardt LV, Li M, Neubauer H, Klinger HM (2013) The impact of a high tibial valgus osteotomy and unicondylar medial arthroplasty on the treatment for knee osteoarthritis: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 21(1):96–112PubMedCrossRefGoogle Scholar
  58. 58.
    Tang H, Bai L (2009) Anatomy and biomechanical research progress of knee posteromedial corner. Chin J Repar Reconstr Surg 23:1058–1061Google Scholar
  59. 59.
    Unitt L, Sambatakakis A, Johnstone D et al (2008) Short-term outcome in total knee replacement after soft-tissue release and balancing. J Bone Joint Surg Br 90B:159–165CrossRefGoogle Scholar
  60. 60.
    Vanlommel L, Vanlommel J, Claes S, Bellemans J (2013) Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 21:2325–2330PubMedCrossRefGoogle Scholar
  61. 61.
    Verdonk PCM, Pernin J et al (2009) Soft tissue balancing in varus total knee arthroplasty: an algorithmic approach. Knee Surg Sports Traumatol Arthrosc 17:660–666PubMedCrossRefGoogle Scholar
  62. 62.
    Walker PS, Heller Y et al (2011) Preclinical evaluation method for total knees designed to restore normal knee mechanics. J Arthroplasty 26:152–160PubMedCrossRefGoogle Scholar
  63. 63.
    Whiteside LA, Saeki K, Mihalko WM (2000) Functional medial ligament balancing in total knee arthroplasty. Clin Orthop Relat Res 380:45–57PubMedCrossRefGoogle Scholar
  64. 64.
    Whiteside LA (2002) Soft tissue balancing—the knee. J Arthroplasty 17:23–27PubMedCrossRefGoogle Scholar
  65. 65.
    Wijdicks CA, Ewart DT, Nuckley DJ et al (2010) Structural properties of the primary medial knee ligaments. Am J Sports Med 38:1638–1646PubMedCrossRefGoogle Scholar
  66. 66.
    Yagishita K, Muneta T, Ikeda H (2003) Step-by-step measurements of soft tissue balancing during total knee arthroplasty for patients with varus knees. J Arthroplasty 18:313–320PubMedCrossRefGoogle Scholar
  67. 67.
    Yasgur DJ, Scuderi GR, Insall JN (2002) Medial release for fixed varus deformity surgical techniques. In: Scuderi GR, Tria AJ (eds) Total knee arthroplasty. Springer, New York, pp 189–196Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Nicola C. Hunt
    • 1
    • 2
  • Kanishka M. Ghosh
    • 1
  • Kiron K. Athwal
    • 3
  • Lee M. Longstaff
    • 4
  • Andrew A. Amis
    • 3
    • 5
  • David J. Deehan
    • 1
    • 2
  1. 1.Department of Orthopaedic SurgeryNewcastle Freeman University HospitalNewcastle upon TyneUK
  2. 2.Institute of Cellular Medicine, Medical SchoolFramlington Place Newcastle UniversityNewcastle upon TyneUK
  3. 3.Department of Mechanical EngineeringImperial College LondonLondonUK
  4. 4.Department of Orthopaedic SurgeryUniversity Hospital of North DurhamDurhamUK
  5. 5.Orthopaedic Surgery Group, Imperial College London School of MedicineCharing Cross HospitalLondonUK

Personalised recommendations