title: Lack of evidence to support present medial release methods in total knee arthroplasty.
abstract: OBJECTIVE
  The aim of this review was to identify a reliable sequential medial release protocol for restoration of soft tissue balance in total knee arthroplasty of the varus osteoarthritic knee and to allow for improved intraoperative decision-making.
  
  
  METHODS
  Current medial release sequences and applicability based upon pre-operative deformity have been reviewed. Furthermore, risks associated with over release, and the necessity of medial release, are discussed.
  
  
  RESULTS
  The different medial release sequences are discussed in relation to pre-operative deformity, along with potential complications associated with medial release. It was found that release sequences may include the deep and superficial components of the medial collateral ligament, the posteromedial capsule, the posterior oblique ligament, the pes anserinus (pes A), and tendons of the semimembranosus and medial gastrocnemius muscle. The sequences described were found to vary substantially between studies, and very few studies had systematically quantified the effect of each release on balance.
  
  
  CONCLUSIONS
  While medial release is the standard intraoperative mode of balancing, there is a lack of evidence to support current methods. The correct method for defining intraoperatively the sequence, extent and magnitude of releases required remains ill-defined. It could be argued that the classic extensive medial release may be unnecessary and may be associated with iatrogenic injury to the pes A and saphenous nerve, instability and abnormal knee kinematics. Minimal medial release may allow for improved soft tissue balancing leading ultimately to improved functional outcome.
  
  
  METHODS
  V (expert opinion).
authors.affiliation: Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle upon Tyne, NE2 4HH, UK, nicola.hunt@newcastle.ac.uk.
authors.forename: Nicola C
authors.initials: NC
authors.lastname: Hunt
authors.forename: Kanishka M
authors.initials: KM
authors.lastname: Ghosh
authors.forename: Kiron K
authors.initials: KK
authors.lastname: Athwal
authors.forename: Lee M
authors.initials: LM
authors.lastname: Longstaff
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Amis
authors.forename: David J
authors.initials: DJ
authors.lastname: Deehan
mesh_terms: D019645:Arthroplasty, Replacement, Knee / Q000379:methods*; D002985:Clinical Protocols; D003657:Decision Making; D006801:Humans; D007717:Knee / Q000503:physiopathology / Q000601:surgery; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D017888:Medial Collateral Ligament, Knee / Q000601:surgery*; D020370:Osteoarthritis, Knee / Q000601:surgery*