Objective: Achieving optimal ligament balance in total knee arthroplasty (TKA) requires a precise sequence of medial release techniques. While medial collateral ligament (MCL) release is often considered the first step, there is no consensus regarding the subsequent steps and their effectiveness. This study examines a stepwise medial release protocol for varus knees to determine its efficacy in improving intraoperative ligament balance and post-operative outcomes.
Materials and
Methods: A retrospective analysis was conducted on 60 patients (39 females, 21 males) who underwent primary TKA for varus deformity between January 2020 and December 2022. A structured medial release sequence was applied, consisting of the superficial MCL, deep MCL, posterior capsule, Pes Anserinus, and increased tibial resection. Gap balancer measurements were recorded at 0° and 90° flexion. Statistical analyses included paired t-tests and Chi-square tests to assess the impact of each release step on ligament balance.

Results: At 0° flexion, 85% of patients achieved optimal medial ligament balance after completing the release sequence. At 90° flexion, the optimal balance was achieved in 80% of cases. The mean Knee Society Score improved from 45.2±10.5 preoperatively to 88.7±8.9 at the 12-month follow-up (p<0.05). Range of motion increased from 95°±15° to 120°±10° (p<0.05).

Conclusion: The stepwise release protocol effectively improved medial ligament balance without excessive soft-tissue release, reducing the risk of post-operative instability. The sequence provided a reproducible and systematic approach, facilitating consistent intraoperative decision-making. The proposed stepwise medial release protocol effectively balances ligaments in varus knees during TKA, resulting in improved clinical outcomes and reduced post-operative complications. Future studies should assess the protocol’s applicability in diverse patient populations and compare its effectiveness with robotic-assisted techniques.