Techniques for symmetrical balancing in flexion and extension have been described; however, the ideal technique is unclear. This study aimed to clarify whether resection of peripheral osteophytes could restore neutral hip-knee-ankle (HKA) angle of varus deformity of arthritic knees. Data from 90 varus arthritic knees that had undergone total knee arthroplasty (TKA) using a nonimage-based navigation system were analyzed. The change in the coronal mechanical axis, while applying manual valgus stress at extension and 90 degrees of knee flexion, was recorded after the following sequential procedures: (1) anterior cruciate ligament (ACL) sectioning, (2) subperiosteal stripping of the deep medial collateral ligament (MCL) from the underlying osteophytes on the medial tibia, and (3) complete removal of peripheral osteophytes from the proximal medial tibia and distal medial femoral condyle. Repeated measures of analysis of variance (ANOVA) were performed to compare the varus angle among each step, and a post hoc analysis by paired t-test was utilized to compare the parameters between baseline and each step. The varus alignment with valgus stress at extension and 90 degrees of flexion (mean: 6.0 ± 3.6 and 5.2 ± 3.9 degrees of varus, respectively) was significantly corrected to a near-neutral mechanical axis (mean: 0.9 ± 2.4 and 1.4 ± 4.2 degrees of varus, respectively) after peripheral osteophyte resection (p < 0.01, both). In many cases, varus deformity of arthritic knees could be corrected to near-neutral HKA angle by applying manual valgus stress after complete peripheral osteophyte resection. These procedures could facilitate soft tissue balancing in TKA, minimizing the risk of overrelease of the medial soft tissues.
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