Siong FT, et al. - In this study, researchers sought to describe their functional step-wise multiple needle puncturing (MNP) technique as the final step in medial ligament balancing during total knee arthroplasty (TKA). In addition, they examined whether sufficient medial release with safety could be achieved with this technique. In this prospective cohort study, they included 137 patients with 212 consecutive knees on which TKA was performed with or without functional step-wise MNP of superficial MCL. The final assessment comprised 81 patients with 129 knees that performed serial stress radiographs. Depending on the site and degree of tightness, selective and sequential puncturing of superficial MCL (anteriorly or posteriorly or both) was performed. Additional step-wise MNP was required in 55 TKAs (anterior needling 19, posterior needling 3, both anterior and posterior needling 33). Outcomes suggest that in TKA with varus aligned knee, sufficient medial release could be achieved safely with functional medial ligament balancing with step-wise MNP without clinical deterioration or complication such as instability.