Arthroplasty 
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Make the initial exposure using your preferred surgical approach (medial parapatellar, intermedius, midvastus, subvastus) to include release of the deep medial collateral ligament off the tibia at the joint line to the posteromedial corner of the knee.
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Make the bone cuts using the preferred technique (intramedullary or extramedullary guide, computer navigation, custom cutting blocks).
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Remove all osteophytes on the femur and the tibia because they can tent the medial soft tissue sleeve and effectively shorten the medial collateral ligament. Be certain to check the posterior condylar region of the femur and the posteromedial aspect of the tibia since these osteophytes can contribute significantly to keeping the extension gap tight ( Figure 11-1 ).
Figure 11-1
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Make sure the posterior cruciate ligament (PCL) is resected before balancing. Because the PCL is a secondary medial stabilizer, take care not to release the entire soft tissue sleeve off the tibia because it may result in medial instability ( Figure 11-2 ). In general, less soft tissue release is needed to balance a varus knee once the PCL is resected. With a cruciate-retaining technique, the PCL is left intact.
