Total knee arthroplasty (TKA) surgery is a reliable and safe procedure with reproducible long-term results at severe varus deformity. The success of TKA depends in part on proper soft tissue management to balance the knee, restoration of neutral limb alignment and managing bone defects. Techniques used to mediolateral balance the severe varus knee during primary TKA include classical medial release, pie crusting, tibia reduction osteotomy, medial epicondylar osteotomy, femoral origin release of the superficial medial collateral ligament, release of the deep and superficial medial collateral ligaments at the joint level. In the repair of defects; depending on the size, more bone cutting, cement, cement and screw, bone graft (autograft or allograft, block or morselized), metal, free trabecular, porous metaphyseal conical supports and custom-made prostheses can be used. Decreasing component constraint reduces stresses at bone prosthesis interface and longevity of the prosthesis will be increased. If adequate stability and balance can not be achieved components constrained must be increased.