**5. Conclusion**

(b) Hirschmann et al. showed that the lateral parapatellar approach with TTO leads to at least comparable functional results and less pain after TKA at 2 years follow-up. The burning question for the researchers, however, remained if this can outweigh the higher risk of

(c) Sekiya et al. [35] reported the clinical and radiological results in two randomized groups of patients (medial vs. lateral without TTO) after performing a TKA in valgus knees. They found no significant differences in ROM between the groups, but better postoperative

Hay et al. had randomly divided 32 patients into two groups, the one in which the lateral subvastus approach combined with a TTO was performed and the other with the medial parapatellar approach. No significant differences were found between the groups in the parameters of clinical outcome, as the ROM, the VAS score, the Western Ontario McMasters University Osteoarthritis index, and the KSS at 2-year follow-up. It was found significant better patellar tracking in the group of lateral subvastus approach combined with TTO. Due to complications related with TTO and longer surgical time (10–15 min) in the lateral approach, the researchers did not support its routine use of the except for the patients in whom problems

Several complications have been reported in valgus knee arthroplasties. More specifically, Favorito et al. [6] presented in a review article the main complications referred in the literature. The most commonly reported complications are tibiofemoral instability (2–70%), recurrent valgus deformity (4–38%), postoperative motion deficits which requires manipulation under anesthesia (1–20%), wound problems (superficial or deep infection) (4–13%), patellar stress fracture or osteonecrosis (1–12%), patellar tracking problems (2–10%), and peroneal nerve palsy (1–4%) [1, 2, 4, 8, 10]. Nikolopoulos et al. also referred one case of a 5 mm proximal migration of the osteotomized fragment occurred which was stabilized with screws only, without the use of wire loops. However, this did not affect the final outcome, despite breakage of one screw

One more very important complication after TKA for VD that has been cited is the peroneal nerve palsy. Due to the femorotibial axis deformation and the elongation of the lateral side, the nerve is stretched and is placed at risk for indirect injury via traction or induced ischemia [4, 6, 23]. Other indirect mechanisms of injury may include compression or crushing from tight dressings [66]. Also, the "pie crust" technique as part of the lateral release when is used puts the peroneal nerve in hazard, so greater deal of safety concern should be accomplished [28, 36, 38]. According to the literature, Idusuyi and Morrey [67] reported 32 postoperative peroneal nerve palsies in more than 10,000 consecutive TKAs. Ten out of the 32 palsies had 12° or more of preoperative VD. The lengthening of the lateral aspect during lateral stabilizer release and subsequent traction to the peroneal nerve presumably caused the palsy. That is

early complications and revisions [36].

flexion was mentioned in the lateral group.

with patellar tracking were anticipated [65].

**4. Complications**

72 Primary Total Knee Arthroplasty

(**Figure 8**) [3].

TKA is a well-established procedure and has proven to be durable and effective for the treatment of advanced arthritis of the knee joints; however, the long-term follow-up in VD arthritic knees was relatively inferior to those of varus counterparts. The main reason for poor prognosis is the difficulty to achieve good soft-tissue balance during the operation, and this is the challenge for every orthopedic surgeon in knee arthroplasties. In this chapter, we analyzed in detail the valgus knee philosophy, the approaches and surgical techniques proposed both for bone cuts and soft tissue management analyzing in detail the pros and cons of each proposed technique. The surgeon in valgus knee should more confidently achieve soft tissue balancing, resulting in better load distribution and enhancing component stability and longevity.
