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The “Inside-Out” Technique for Correcting a Fixed Varus Deformity with Flexion Contracture in Total Knee Arthroplasty
Chitranjan S. Ranawat, MD1; Morteza Meftah, MD1; Amar S. Ranawat, MD1
1 Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for M. Meftah: MeftahM@HSS.edu
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Based on an original article: J Bone Joint Surg Am. 2012 May 16;94(10):e66 1-6.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2012 Aug 22;2(3):1-8. doi: 10.2106/JBJS.ST.L.00002
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The inside-out technique is a safe and reproducible method to effectively correct a fixed varus-flexion deformity during total knee arthroplasty by performing a posteromedial capsular release and so-called pie-crust lengthening of the superficial medial collateral ligament (sMCL).

Step 1: Preoperative Planning

Analyze preoperative radiographs as a key step in planning the surgery for the required amount of osseous cuts and soft-tissue release.

Step 2: Exposure

Obtain adequate exposure for proper visualization and assessment.

Step 3: Tibial and Femoral Cuts

Adequate bone cuts with proper alignment are an essential step of this technique.

Step 4: Posteromedial Capsulotomy

This is the most important step for extension balancing in knees with flexion contracture; the posteromedial aspect of the capsule in varus deformity should be safely incised at the level of the tibial cut.

Step 5: Pie-Crusting of the sMCL

Perform pie-crusting followed by serial manipulations in a controlled manner to avoid overrelease of the sMCL.

Step 6: Flexion Gap Balancing

This is a key step for proper balancing, femoral sizing, rotation, lateralization, and patellofemoral tracking.


From October 2006 to December 2009, thirty-one consecutive patients (thirty-four knees) with a severe fixed varus-flexion deformity (varus alignment of ≥15° and flexion contracture of ≥5°) underwent total knee arthroplasty with the inside-out technique.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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