Surgical Discussion

Patient positioning:  The patient was positioned supine on a radiolucent operating table with the right knee flexed to approximately 30 degrees over a carbon fiber roll, supporting the distal aspect of the thigh. A tourniquet was applied to the proximal aspect of the ipsilater

Anatomical surgical approach:  A longitudinal incision was made over the lateral aspect of the joint line. The iliotibial tract fibers were identified and split to the level of Gerdy's tubercle. Subperiosteal elevation of the iliotibial fibers from Gerdy's tubercle was performed, along with splitting of the proximal aspect of the fascia of tibialis anterior, exposing the anterolateral tibial cortex. Subperiosteal dissection continued anteriorly to the level of the patellar tendon. A submeniscal arthrotomy in the anterior aspect demonstrated an intra-articular anterior step, which was reduced through direct manipulation and secured with two anterior-to-posterior Kirschner wires (K-wires). Mobilization of both medial and lateral plateaus en bloc was performed to reduce anterior tibial tilt. Multiple 2.0 mm K-wires were introduced from anterior to posterior, engaging both medial and lateral plateaus. A broad osteotome was used to facilitate sequential levering of the proximal joint, restoring approximately zero to five degrees of posterior tibial tilt.

The bone substance at the anterior aspect of the tibial articular surface was very soft, making primary screw fixation poor. Therefore, two anterior-posterior K-wires were left in position pending later plate osteosynthesis of the lateral tibial plateau. Minimally invasive installation of a long 3.5 mm proximal lateral tibial plate bent to conform to the anterolateral cortical contour followed. This plate was secured distally with a single 3.5 mm cortical screw. Through active reduction maneuvers over in situ K-wires, four locking screws were introduced into subchondral bone from the anterolateral side, securing restoration of posterior tibial tilt. A limited medial longitudinal incision provided access for minimally invasive insertion of a medial 3.5 mm plate, which was secured with bicortical screws distally and four 4.0 mm proximal locking screws engaging the joint block proximally.

Postoperative protocol:   Not specified

Follow up:   Not specified

Orthopaedic implants used:   Long 3.5 mm proximal lateral + medial tibial plates (Synthes)