Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table to facilitate access to both medial and lateral aspects of the proximal tibia.

Anatomical surgical approach:  A combined approach was utilized: initially addressing the lateral aspect through removal of distal screws from the existing plate, followed by a mini-open medial approach for buttress plating. Percutaneous osteoclasis was performed through the nonunion site to aid in deformity correction and stimulate healing.

The surgeon noted that the primary issue was mechanical rather than biological, with the initial implant strategy being suboptimal for the patient's build. A lateral plate alone was insufficient due to lack of medial load sharing, leading to fatigue and varus deformity. Sequential correction techniques were employed, including distraction and compression methods, followed by stabilization with a nail and medial buttress plating. The intra-articular malunion was deemed irrelevant to the patient's outcome, and precise correction without over-correction into valgus was prioritized.

Postoperative protocol:   Postoperative rehabilitation included weight-bearing as tolerated with gradual progression based on pain and stability. Emphasis was placed on maintaining alignment and encouraging early mobilization to promote healing.

Follow up:   Not specified

Orthopaedic implants used:   Lateral locking plate, medial buttress plate, intramedullary nail, bicortical screw, articulated tension device (ATD).