This document discusses the varus knee, including: 1. Classification of varus knee deformities into intraarticular, metaphyseal, extraarticular, and PAGODA deformity. 2. The sequential approach to correction involves assessing and classifying the deformity, performing a medial release through multiple structures, osteophyte removal, and bone realignment through techniques like shift and resect or pie crusting if needed. 3. Key steps are creating a medial sleeve through layered release of the MCL and other medial structures, complete removal of osteophytes that can impede correction, and balancing flexion and extension gaps.

1. Dr Vaibhav Bagaria
Consultant Joint Replacement & Sports Surgeon
Sir HN Reliance Foundation Hospital
Mumbai, India
THE VARUS KNEE

2. Welcome you all!
Simplifying
Complexities

3. Varus Knee
Understanding Anatomy
Classification
Soft Tissue Management
Bone Management
Tips Tricks and Traps

4. Medial Structures

5. MCL Attachments

6. Defining Varus
Maquet Line
Load Bearing Axis,
Passes from centre of
Femoral head to
Centre of Talus

7. Classification

8. Intraarticular

9. Metaphyseal

10. PAGODA deformity

11. Extra articular

12. Algorithmic approach
Think in terms of anatomy & Classify
Decide in terms of Soft tissue & Bone
deformity
Execute with tips tricks and traps of special
techniques.

13. Basic Tenets
Preoperative Plan
Assess & Classify
Medial Release
Osteophyetctomy
Metaphysical Bumpectomy
Quadrant of deformity & Bone Loss management
Avoid Over release

14. Medial releases
A sequential release is performed until the
medial structures reach a length equalizing
that of the lateral structures.
Create a Medial Sleeve - medial parapatellar
approach is preferred.

15. Creating Medial Sleeve
The periosteal elevator is passed deep to the
superficial MCL
Elevation should start 3 – 4 cm from the
medial tibial plateau where the tibial
metaphysis merges with the diaphysis
Bent Homan is inserted to create the sleeve

16. Creating Medial Sleeve

17. Order of Medial Release
Deep MCL
Posterior capsule
Superficial MCL
Posterior oblique ligament
Semimembranosous tendon
Pes tendon
Popliteus tendon

18. Medial Release

19. Semi Membranous release

20. Posterior Oblique Lig

21. Osteophyte removal
Remove all
osteophytes from
Femur & Tibia as
they can tent the
medial soft tissue
sleeve & shorten the
MCL

22. Osteophyte Removal
Remember to
check the Posterior
femoral condyle
and Posteromedial
tibia -> as they
tighten extension
gap.

23. Cruciate's
For severe deformities- it may be better to use
PS type Knees
PCL may prevent complete correction
Non functioning PCL with CR knees —> loss
of roll back functioning —> anterior opening
and loosening

24. PCL

25. Posterior Release
15mm or ¾ “ osteotome
is used to release the
posterior capsule and
remove the osteophytes.
By doing this maneuver
not only the flexion
deformity is corrected, it
also releases the medial
head of gastrocnemius
improving the varus
deformity medially

26. Check the Gaps

27. Shift & Resect
In case of severe deformities where the gap is
still not balanced, it may be a good idea to
undersize and laterlize the tibia and remove
the medial sclerotic bone.
After the cuts, an undersized trial tibial implant
is placed & medial boundaries of the implant
are marked with methylene blue. Excess bone
removed with saw or an osteotome

28. Shift And Resect

29. Shift & Resect

30. Shift & Resect

31. Pie Crusting
lengthen soft tissue under tension
use 16 G needle
Remember AF PE ( Atrial Fib - Pulmonary
Embolism) Mnemonic

34. Responsible Structures

35. Dealing - Residual laxity
Lateral laxity post balancing can be an issue
IT band is dynamic stabiliser
Medial release can be increased and thicker
poly can be used
LCL advancement is an alternative

36. Take Home
Assess & Plan
Create Medial Sleeve
Do complete osteophtectomy & lumpectomy
Sequential Release
Shift & Resect
Pie Crust