Flexion-extension Joint Gap Changes After Lateral Structure Release for Valgus Deformity Correction in Total Knee Arthroplasty: a Cadaveric Study

At the time of total knee arthroplasty, the surgeon generally corrects excessive valgus knee alignment to anatomic valgus through release of lateral supporting structures. This study used a cadaveric model to i) study the amount of correction achieved with each release step in 2 sequences of lateral release, ii) compare the amount of release in extension versus flexion, and iii) measure any associated rotational changes of the tibia. Six fresh-frozen cadaveric knees were used to test the amount of change into varus after sectioning the iliotibial band (ITB), the popliteus tendon (Pop), the lateral collateral ligament (LCL), and the tendon of the lateral head of the gastrocnemius (LG). This sequence was then compared with a second sequence in another 6 cadavers as follows: LCL, Pop, ITB, and LG. The amount of valgus correction was tested in 90 degrees, 45 degrees flexion, and full extension. At each flexion angle, the corresponding releases were assessed with the tibia oriented vertically under its own weight, under tibial distraction with equal support from the lateral and medial soft tissues, and under a maximal varus deforming stress. Results showed that complete lateral structure release provides limited correction into a varus direction with a balanced distracted soft tissue gap or extension space (8.9 degrees with the LG released), and the lateral aspect of the flexion gap opens more than the extension gap (8.9 degrees compared with 18.1 degrees in flexion). Early LCL release provided a more uniform release of the joint gap, and rotational changes were variable, tending toward external rotation of the tibia (6.0 degrees in full extension with release of the LCL). We suggest that when severe valgus deformities are present, the LCL should be considered first for release and the Pop and ITB be used to grade the release.