J Knee Surg 2024; 37(02): 104-113
DOI: 10.1055/a-2194-0970
Special Focus Section

Correction of Coronal Deformity and Intercompartmental Imbalance through Bone Resection

Martin Roche
1   Department of Orthopedic Surgery, Hospital for Special Surgery, West Palm Beach, Florida
Tsun Yee Law
1   Department of Orthopedic Surgery, Hospital for Special Surgery, West Palm Beach, Florida
› Author Affiliations


This review discusses the correction of coronal deformity and intercompartmental imbalance through bone resection in total knee arthroplasty (TKA). To achieve functional knee balance, coronal, rotational, and sagittal alignment are critical to successful patient outcomes. Though variations in coronal alignment are debated as a correlate to positive results, advancements in utilizing implant position, alignment, and soft tissue balance to improve patient outcomes and function are an evolving discussion. This study draws upon existing literature, clinical studies, and surgical techniques related to TKA, including advancements in navigation and robotics. The study highlights the importance of individualized alignment strategies for varus and valgus knees. While mechanical neutral alignment has shown excellent long-term data, reevaluating the anatomic recreation of the patient's joint line obliquity is now being studied extensively. Sensor data and navigation systems contribute to improved outcomes and patient satisfaction. The evolution of navigation and robotics has led surgeons to achieve their target angles consistently and accurately; now, the discussion is around the most effective alignment targets. The classification of various phenotypes assists in the proposed starting points for implant position, but soft tissue tension is required in the input data to achieve global balance and stable motion. Each approach's advantages and limitations are considered. In conclusion, achieving optimal coronal alignment, joint line obliquity, and soft tissue balance is crucial for successful TKA outcomes. Personalized alignment philosophies, supported by three-dimensional data and sensor technology, are evolving to minimize critical errors and enhance functional results. Robotic assistance and future advancements in artificial intelligence and machine learning hold promise for further improving TKA outcomes in the quest for soft tissue stabilization.

Publication History

Received: 13 September 2023

Accepted: 17 October 2023

Accepted Manuscript online:
18 October 2023

Article published online:
12 December 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Victor JM, Bassens D, Bellemans J, Gürsu S, Dhollander AA, Verdonk PC. Constitutional varus does not affect joint line orientation in the coronal plane. Clin Orthop Relat Res 2014; 472 (01) 98-104
  • 2 Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res 2012; 470 (01) 45-53
  • 3 Oussedik S, Abdel MP, Victor J, Pagnano MW, Haddad FS. Alignment in total knee arthroplasty. Bone Joint J 2020; 102-B (03) 276-279
  • 4 Goyal T, Paul S, Schuh A, Choudhury AK. Pie-crusting of proximal medial collateral ligament for correcting varus deformity in total knee arthroplasty. Eur J Orthop Surg Traumatol 2021; 31 (07) 1305-1309
  • 5 Matsuda S, Ito H. Ligament balancing in total knee arthroplasty-medial stabilizing technique. Asia Pac J Sports Med Arthrosc Rehabil Technol 2015; 2 (04) 108-113
  • 6 Dixon MC, Parsch D, Brown RR, Scott RD. The correction of severe varus deformity in total knee arthroplasty by tibial component downsizing and resection of uncapped proximal medial bone. J Arthroplasty 2004; 19 (01) 19-22
  • 7 Clark GW, Steer RA, Khan RN, Collopy DM, Wood D. Maintaining joint line obliquity optimizes outcomes of functional alignment in total knee arthroplasty in patients with constitutionally varus knees. J Arthroplasty 2023; 38 (7, Suppl 2): S239-S244
  • 8 Fang D, Ritter MA. Malalignment: forewarned is forearmed. Orthopedics 2009 ;32(9):orthosupersite.com/view.asp?rID=42850
  • 9 Meneghini RM, Grant TW, Ishmael MK, Ziemba-Davis M. Leaving residual varus alignment after total knee arthroplasty does not improve patient outcomes. J Arthroplasty 2017; 32 (9S): S171-S176
  • 10 Zheng K, Sun H, Zhang W. et al. Mid-term outcomes of navigation-assisted primary total knee arthroplasty using adjusted mechanical alignment. Orthop Surg 2023; 15 (01) 230-238
  • 11 Farooq H, Deckard ER, Carlson J, Ghattas N, Meneghini RM. Coronal and sagittal component position in contemporary total knee arthroplasty: targeting native alignment optimizes clinical outcomes. J Arthroplasty 2023; 38 (7, Suppl 2): S245-S251
  • 12 Vanlommel L, Vanlommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 2013; 21 (10) 2325-2330
  • 13 Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclerq V, Hess S. Functional knee phenotypes: a novel classification for phenotyping the coronal lower limb alignment based on the native alignment in young non-osteoarthritic patients. Knee Surg Sports Traumatol Arthrosc 2019; 27 (05) 1394-1402
  • 14 Hirschmann MT, Moser LB, Amsler F, Behrend H, Leclercq V, Hess S. Phenotyping the knee in young non-osteoarthritic knees shows a wide distribution of femoral and tibial coronal alignment. Knee Surg Sports Traumatol Arthrosc 2019; 27 (05) 1385-1393
  • 15 Moser LB, Hess S, Amsler F, Behrend H, Hirschmann MT. Native non-osteoarthritic knees have a highly variable coronal alignment: a systematic review. Knee Surg Sports Traumatol Arthrosc 2019; 27 (05) 1359-1367
  • 16 Cooke D, Scudamore A, Li J, Wyss U, Bryant T, Costigan P. Axial lower-limb alignment: comparison of knee geometry in normal volunteers and osteoarthritis patients. Osteoarthritis Cartilage 1997; 5 (01) 39-47
  • 17 Insall JN, Binazzi R, Soudry M, Mestriner LA. Total knee arthroplasty. Clin Orthop Relat Res 1985; (192) 13-22
  • 18 Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clin Orthop Relat Res 1985; (192) 23-33
  • 19 Laende EK, Richardson CG, Dunbar MJ. A randomized controlled trial of tibial component migration with kinematic alignment using patient-specific instrumentation versus mechanical alignment using computer-assisted surgery in total knee arthroplasty. Bone Joint J 2019; 101-B (08) 929-940
  • 20 Howell SM, Hull ML, Mahfouz MR. Kinematic alignment in total knee arthroplasty. In: W Scott, ed. Insall and Scott Surgery of the Knee. 6th ed.. Philadelphia, PA: Elsevier; 2017: 1784-1796
  • 21 Clark GW, Esposito CI, Wood D. Individualized functional knee alignment in total knee arthroplasty: a robotic-assisted technique. Tech Orthop 2022; 37 (03) 185-191
  • 22 Walker P, Meere P, Bell C. The importance of 2 mm and 2 degrees in total knee balancing. Orthop Proc 2013; 95 (34) 193
  • 23 Vakharia RM, Rodriguez HC, Roche MW. Medial varus proximal tibial resection is superior to pie-crusting of the medial collateral ligament during primary total knee arthroplasty. J Arthroplasty 2023; 38 (6S): S169-S176
  • 24 Ahn JH, Lee SH, Kang HW. Quantification of the effect of vertical bone resection of the medial proximal tibia for achieving soft tissue balancing in total knee arthroplasty. Clin Orthop Surg 2016; 8 (01) 49-56
  • 25 Vigdorchik JM, Wakelin EA, Koenig JA. et al. Impact of component alignment and soft tissue release on 2-year outcomes in total knee arthroplasty. J Arthroplasty 2022; 37 (10) 2035-2040.e5
  • 26 Roche M, Gustke KA. The utilization of smart trials in PCL retaining knees. In: Seminars in Arthroplasty. 26th ed.. WB Saunders; 2015: 218-228
  • 27 Moore R, Roche M. Balancing the Valgus Knee Through an Arcuate Release. Oral Presentation at International Society of Technology in Arthroplasty, Toronto, Canada: 2019
  • 28 MacDessi SJ, Griffiths-Jones W, Harris IA, Bellemans J, Chen DB. Coronal Plane Alignment of the Knee (CPAK) classification. Bone Joint J 2021; 103-B (02) 329-337
  • 29 Anderson C, Roche M, Golladay G, Elson L. Bony cuts or soft-tissue release? Using intra-operative sensors to refine balancing techniques in TKA. Orthop Proc 2016; 98 (01) 16
  • 30 Joo PY, Chen AF, Richards J. et al. Clinical results and patient-reported outcomes following robotic-assisted primary total knee arthroplasty : a multicentre study. Bone Jt Open 2022; 3 (08) 589-595
  • 31 Nguyen TP, Chae DS, Park SJ, Kang KY, Lee WS, Yoon J. Intelligent analysis of coronal alignment in lower limbs based on radiographic image with convolutional neural network. Comput Biol Med 2020; 120: 103732
  • 32 Steele JR, Jang SJ, Brilliant ZR. et al. Deep learning phenotype automation and cohort analyses of 1,946 knees using the coronal plane alignment of the knee classification. J Arthroplasty 2023; 38 (6S): S215 , 221.e1