Total knee arthroplasty in the valgus knee poses specific problems to the surgeon, such as the presence of ligament tightness on the lateral side. It has been claimed in the past that approaching the knee from the lateral side through a lateral parapatellar arthrotomy may therefore be a more logical and easier technique than the standard medial approach used conventionally. Many surgeons however do not wish to change their routine practice and therefore wish to stick to the classical medial approach they are used to, even in the presence of an underlying valgus deformity. In this paper, we therefore report the technical considerations that one should take into account when addressing the valgus knee through a standard medial approach. These include tightness of the lateral soft tissues, stretching of the medial collateral ligament, lateral bowing of the femoral shaft, and a tendency for lateralized patellar tracking. A review of 125 consecutive valgus knees treated at our institution through a standard medial approach while using these principles, has demonstrated an excellent operative outcome in the majority of cases.