Lateral approach for total knee arthroplasty in patients with valgus deformity: A step-by-step surgical technique

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Table 2

Step-by-step technique of the lateral approach for total knee arthroplasty in valgus knees.

Step-by-step surgical technique
Patient setting and positioning	1. Patient in supine position.
	2. With or without a tourniquet.
	3. Position the knee in approximately 90 degrees of flexion.
Incision and exposure	4. Lateral parapatellar approach.
	5. Two-layer capsulotomy.
	6. Leave a 1 cm overlap between the two layers of joint capsule for final capsular closure.
Hoffa pad management	7. Dissect the Hoffa fat pad from the underside of the patellar tendon, releasing its medial attachment while preserving its attachment to the lateral retinaculum and maintaining blood supply. Retention of the Hoffa fat pad may facilitate closure of the lower retinacular incision, particularly after substantial correction of a valgus deformity.
Joint access	8. Revert the patella with the knee in extension, then flex the knee to 90 degrees.
Joint access	9. Adequate exposure can be achieved without the need for tibial tubercle osteotomy.
Bone cuts and preparation	10. Measure the gap between the distal femoral cutting guide and the lateral femoral condyle (caused by dysplasia or wear) to match later during gap balancing with the posterior lateral femoral condyle.
	11. After completing the distal femoral cut, place the femoral guide aligned with the Whiteside line. Use an osteotome to match the previously measured gap between the distal femoral and posterior lateral femoral condyles.
	12. To perform the tibial cut, utilize a contralateral cutting guide to protect the patellar tendon and facilitate access across the tibia.
	13. Perform the cuts using an intramedullary guide for the femur and intra- or extramedullary guides for the tibia.
	14. Shift the tibial cutting guide proximally by 2 mm to account for the medial plateau’s lower reference point compared to the lateral plateau.
	15. Maximize knee flexion, anteriorly sublux the tibia, and externally rotate it to expose the posteromedial tibial plateau.
	16. Thoroughly remove osteophytes, including those on the posteromedial side, and excise the menisci.
Implantation of the prostheses	17. Ensure clear visualization of the posteromedial tibial plateau to avoid excessive lateral rotation of the tibial component.
	18. Pay special attention to the mediolateral positioning of the femoral component, as the lateral approach may increase the risk of misalignment for surgeons accustomed to a medial approach.
	19. Perform patellar resurfacing as appropriate based on patient characteristics and surgeon preference.
	20. Confirm gap balancing, overall alignment, and perform appropriate soft tissue releases.
	21. Position the final implants.
Closure	22. Close the joint with the knee flexed at 90 degrees. Close the angular position first, then proceed proximally. Use the overlapped two layers of capsule proximal and any remaining fat pad distally to reinforce joint closure, creating a “tight seal” for the knee joint. Finally, excise the excess fat pad.

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