Research Article
Volume 11 Issue 9 - 2020
Multiple Puncturing of Medial Collateral Ligament in Extension with Trial Implants and Valgus Stress: An Excellent Method for Coronal Plane Balancing in Severe Genu Varus
Sharath Kittanakere Ramanath1, Rahul Hemant Shah2*, Jay Palak3, Sandesh Patil2 and Sarayoo Ravishankar Vaidya4
1Associate Professor, Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bengaluru, India
2Junior Resident, Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bengaluru, India
3Arthroplasty Fellow, Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bengaluru, India
4Intern, Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bengaluru, India
*Corresponding Author: Rahul Hemant Shah, Junior Resident, Department of Orthopaedics, Ramaiah Medical College and Hospitals, Bengaluru, India.
Received: July 08, 2020; Published: August 29, 2020


Background: Success of total knee arthroplasty (TKA) depends on lower limb alignment and soft tissue balancing. It is unusual to have higher degrees of genu varus deformity in the western countries unlike the Indian subcontinent. Here, we describe a method involving multiple puncturing of medial collateral ligament of the knee in patients with more than 20° varus.

Methods: We included 55 patients in the study (27 males and 28 females). Pre-operative varus deformity on radiographs, knee flexion and Knee Society Score (KSS) were compared with post-operative valgus, knee flexion and KSS in all the patients. Medial parapatellar approach was performed in all the patients. Puncturing of the MCL was performed after taking the bone cuts and inserting trial implants. Intra-operative stability and range of motion was checked.

Results: Minimum follow-up period was 3 years. There was a significant improvement in the deformity (from mean varus of 27.67° to mean valgus of 4.82°), range of motion (from mean flexion of 86.65° to mean flexion of 119.2°) and KSS (from mean score of 25.35 to 97.22) in all the patients. A ratio between the number of punctures to pre-operative varus (3.983) was noted. All the patients were operated using unconstrained and semi-constrained implants.

Conclusion: Multiple puncturing of the MCL is a reliable method to achieve correction and soft tissue balancing in genu varus > 20°. It helps to balance the knee in both flexion and extension so that the level of constrained can be kept to as minimum as possible.

Keywords: Total Knee Arthroplasty; Genu Varus; Osteoarthritis; Medial Collateral Ligament; Multiple Puncturing


  1. Bellemans J., et al. “A new surgical technique for medial collateral ligament balancing: multiple needle puncturing”. The Journal of Arthroplasty7 (2010): 1151-1156.
  2. Röhner E., et al. “Good clinical and radiological results of total knee arthroplasty using varus valgus constrained or rotating hinge implants in ligamentous laxity”. Knee Surgery, Sports Traumatology, Arthroscopy5 (2019): 1665-1670.
  3. Mullaji AB., et al. “Total knee arthroplasty for profound varus deformity: technique and radiological results in 173 knees with varus of more than 20”. The Journal of Arthroplasty5 (2005): 550-561.
  4. Whiteside L. “Compensatory lateral release”. In: Whiteside L, editor. Ligament balancing in total knee arthroplasty. An instructional manual. Berlin: Springer (2004): 55.
  5. Mirzatolooei F., et al. “Primary Results of Medial Epicondylar Osteotomy in Patients with Severe Bilateral Varus Knee Candidate for Total Knee Replacement”. The Journal of Knee Surgery (2019).
  6. Engh GA. “The difficult knee: severe varus and valgus”. Clinical Orthopaedics and Related Research® 416 (2003): 58-63.
  7. Athwal KK., et al. “The superficial medial collateral ligament is the primary medial restraint to knee laxity after cruciate-retaining or posterior-stabilised total knee arthroplasty: effects of implant type and partial release”. Knee Surgery, Sports Traumatology, Arthroscopy8 (2016): 2646-2655.
  8. Amundsen SH., et al. “Variability in Elongation and Failure of the Medial Collateral Ligament After Pie-Crusting With 16-and 18-Gauge Needles”. The Journal of Arthroplasty8 (2018): 2636-2639.
  9. Koh IJ., et al. “How effective is multiple needle puncturing for medial soft tissue balancing during total knee arthroplasty? A cadaveric study”. The Journal of Arthroplasty12 (2014): 2478-2483.
  10. Herschmiller T., et al. “Stepwise medial collateral ligament needle puncturing in extension leads to a safe and predictable reduction in medial compartment pressure during TKA”. Knee Surgery, Sports Traumatology, Arthroscopy6 (2018): 1759-1766.
  11. Jacobs WC., et al. “Retention versus removal of the posterior cruciate ligament in total knee replacement: a systematic literature review within the Cochrane framework”. Acta Orthopaedical6 (2005): 757-768.
  12. Ha CW., et al. “Selective medial release technique using the pie-crusting method for medial tightness during primary total knee arthroplasty”. The Journal of Arthroplasty5 (2016): 1005-1010.
  13. Kwak DS., et al. “The pie-crusting technique using a blade knife for medial collateral ligament release is unreliable in varus total knee arthroplasty”. Knee Surgery, Sports Traumatology, Arthroscopy1 (2016): 188-194.
  14. Meneghini RM., et al. “Is the pie-crusting technique safe for MCL release in varus deformity correction in total knee arthroplasty?” The Journal of Arthroplasty8 (2013): 1306-1309.
Citation: Rahul Hemant Shah., et al. “Multiple Puncturing of Medial Collateral Ligament in Extension with Trial Implants and Valgus Stress: An Excellent Method for Coronal Plane Balancing in Severe Genu Varus”. EC Orthopaedics 11.9 (2020): 14-23.

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