Sequential two stage release for genu valgum correction in total knee replacement


  • Rahul Gopikishan Jaju Assistant Professor, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India
  • Ansari Muqtadeer Abdul Aziz Associate Professor, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India
  • Mahesh R. Kade Aastha Accident Hospital, Parbhani, Maharashtra, India
  • Sharad K. Salokhe Resident Doctor, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India



Total knee replacement, Lateral release, Valgus deformity, PL capsule, IT band


Background: Valgus deformity presents a major challenge in total knee replacement, especially in moderate or severe cases. Many surgical techniques have been described to balance the soft tissues in correction of a severe valgus deformity during total knee replacement. The structures most commonlyreleased in a valgus knee include the posterolateralaspect of the capsule, iliotibial band (IT band), the lateral collateral ligament (LCL), the popliteustendon, and the lateral head of the gastrocnemius muscle.

Methods: thirty two patients undergoing unilateral total knee replacement were followed for the evaluation of study. There were 22 female (68%) and 10 males (32%) with an age of 62.7±6.9 years (range 50-75) with valgus deformity of 18.59˚±8.32˚ (range 10-40˚). Preoperative diagnosis was rheumatoid arthritis in 23 patients (72%) and osteoarthritis in 9 patients (28%). Posterior stabilizing cemented implants were used.

Results: Based on total knee score we achieved 21 (63.64%) excellent, 10 (31.82%) good and 1 (4%) fair results. With the total functional score we had 16 (50%) excellent, 15 (45.45%) good and 1 (4%) fair results. In patients with only step1 release (17 patients) we achieved 84% (15 pts) excellent, 8% (1 pt) good, 8% (1 pt) fair with knee score; and 67% (11pts) excellent, 33% (6pts) good with functional score. In step 2 release group (15 pt) we achieved 10% (1 pt) excellent, 90% (14 pts) good with knee score; and 10% (1pt) excellent, 80% (13 pts) good and 10% (1 pt) fair with functional score.

Conclusions: Good to excellent results can be achieved with two step sequential lateral release of posterolateral capsule and IT band pie-crusting which has direct correlation with severity of valgus deformity. The safety, simplicity, and high success rate of the two step sequential lateral release of posterolateral capsule and pie-crusting of IT band justify its routine use to correct every valgus deformity in total knee replacement.

Author Biography

Ansari Muqtadeer Abdul Aziz, Associate Professor, Department of Orthopaedics, Government Medical College, Aurangabad, Maharashtra, India



Ranawat AS, Ranawat CS, Elkus M, Rasquinha VJ, Rossi R, Babhulkar S. Total knee arthroplasty for severe valgus deformity. J Bone Joint Surg Am. 2005;87(Suppl 1)(Pt 2):271-84.

Favorito PJ, Mihalko WM, Krackow KA. Total knee arthroplasty in valgus knee. J Am Acad Orthop Surg. 2002 ;10(1):16-24.

Keblish PA. Valgus deformity in TKR: The lateral retinacular approach. Orthop Trans 1985;9-28.

Keblish PA. The lateral approach to the valgus knee: Surgical technique and analysis of 53 cases with over two-year follow-up evaluation. Clin Orthop 1991;271:52-62.

Insall J, Scott WN, Ranawat CS. The total condylar knee prosthesis. A report of two hundred and twenty cases. J Bone Joint Surg Am. 1979;61(2):173-80.

Ranawat CS, Rose HA, Rich DS. Total condylar knee arthroplasty for valgus and combined valgus-flexion deformity of the knee. Instr Course Lect. 1984;33:412-6.

Karachalios T, Sarangi PP, Newman JH. Severe varus and valgus deformities treated by total knee arthroplasty. J Bone Joint Surg Br. 1994;76(6):938-42.

Buechel FF. A sequential three-step lateral release for correcting fixed valgus knee deformities during total knee arthroplasty. Clin Orthop Relat Res. 1990;(260):170-5.

Fiddian NJ, Blakeway C, Kumar A. Replacement arthroplasty of the valgus knee. A modified lateral capsular approach with repositioning of vastus lateralis. J Bone Joint Surg Br. 1998;80: 859 -61.

Healy WL, Lorio R, Lemos DW. Medial reconstruction during total knee arthroplasty for severe valgus deformity. Clin Orthop.1998;356:161 -9.

Peters CL, Mohr RA, Bachus KN. Primary total knee arthroplasty in the valgus knee: Creating a balanced soft tissue envelope. J Arthroplasty. 2001;16:721–9.

Politi J, Scott R. Balancing severe valgus deformity in total knee arthroplasty using a lateral cruciform retinacular release. J Arthroplasty. 2004;19(5):553-7.

Elkus M, Ranawat CS, Rasquinha VJ, Babhulkar S, Rossi R, Ranawat AS. Total knee arthroplasty for severe valgus deformity. Five to fourteen-year follow-up. J Bone Joint Surg Am. 2004;86-A(12):2671-6.

Stehlík J, Musil D, Held M, Stárek M. Z-plasty for valgus deformity in total knee arthroplasty [Article in Czech] Acta Chir Orthop Traumatol Cech. 2006;73(3):169-75.

Aglietti P, Lup D, Cuomo P, Baldini A, De Luca L. Total knee arthroplasty using a pie-crusting technique for valgus deformity. Clin Orthop Relat Res. 2007;464:73-7.

Hadjicostas PT, Soucacos PN, Thielemann FW. Computer-assisted osteotomy of the lateral femoral condyle with non-constrained total knee replacement in severe valgus knees. J Bone Joint Surg Br. 2008;90(11):1441-5.

Lüring C, Beckmann J, Haiböck P, Perlick L, Grifka J, Tingart M. Minimal invasive and computer assisted total knee replacement compared with the conventional technique: a prospective, randomised trial. Knee Surg Sports Traumatol Arthrosc. 2008;16(10):928-34.

Bellemans J, Vandenneucker H, Vanlauwe J. The total knee arthroplasty in valgus knee using standard medial approach, Interact Surg. 2008;3:2-5.

Boyer P, Boublil D, Magrino B, Massin P, Huten D. Group G. Total knee replacement in the fixed valgus deformity using a lateral approach: role of the automatic iliotibial band release for a successful balancing. Int Orthop. 2009;33(6):1577-83

Liu J, Sun Z, Zhang Y, Tian M, Tian Z, Wang L, Cao J, Sun Y, Wang P. Treatment of valgus deformity by total knee arthroplasty with modified Ranawat soft tissue balance technique. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009;23(9):1034-7.

Koskinen E, Remes V, Paavolainen P, Harilainen A, Sandelin J, Tallroth K, et al. Results of total knee replacement with a cruciate-retaining model for severe valgus deformity-A study of 48 patients followed for an average of 9years. Knee. 2010.

Apostolopoulos AP, Nikolopoulos DD, Polyzois I, Nakos A, Liarokapis S, Stefanakis G, Michos IV. Total knee arthroplasty in severe valgus deformity: Interest of combining a lateral approach with a tibial tubercle osteotomy. Orthop Traumatol Surg Res. 2010.

Miyasaka KC, Ranawat CS, Mullaji A. 10-12 Year Followup of Total Knee arthroplasty for valgus deformities. Clin Orthop Relat Res. 1997;(345):29-37.

Whiteside LA. Correction of ligament and bone defects in total arthroplasty of the severely valgus knee. Clin Orthop Relat Res. 1993;(288):234-45.

Krackow KA, Jones MM, Teeny SM. Primary total knee arthroplasty in patientes with fixed valgus deformity. Clin Orthop. 1991;273:9-18.

Dunbar RP, Taitsman LA, Sangeorzan BJ, Hansen Jr. Technique tip: use of “ pie crusting of the dorsal skin in severe foot injury. Foot Ankle Int. 2007;28(7):851-3.

Helms J. Head and Neck Surgery. Volume 3. Georg Thieme Verlag; 1998.

Sancheti KH, Laud NS, Bhende H, Reddy G. The INDUS knee prosthesis - Prospective multicentric trial of a posteriorly stabilized high-flex design: 2 years follow-up. IJO 2009;43:367-74.

Clarke HD, Schwartz JB, Math KR, Scuderi GR. Anatomic risk of peroneal nerve injury with the "pie crust" technique for valgus release in total knee arthroplasty. J Arthroplasty. 2004;19(1):40-4.






Original Research Articles