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INTRODUCTION
Anatomic reduction and stable fixation is the
gold standard in the treatment of displaced
tibial plateau fractures. However, this goal is
not always achievable, and extra-articular and
intra-articular malunions are often the result of
conservative and operative treatment. A proxi-
mal tibial osteotomy can restore the mechani-
cal axis or shift the mechanical axis to the
uninjured compartment. In almost all severe
AO type-C fractures, comminution and joint
depression occur in the lateral compartment. In
general, anatomic reconstruction of the large
depressed medial fragments is easier to per-
form secondary to an easier operative exposu-
re. Hence, the majority of primary and secon-
dary malunions after tibial plateau fractures
lead to a valgus (and intra-articular depres-
sion) malalignment. The combination osteoto-
my described in the present report restores
intra-articular anatomy and provides varus
correction, typically provides a good functio-
nal outcome, and preserves the salvage option
of total knee arthroplasty. Nevertheless, opti-
mal recovery requires a protracted period of
convalescence.
SURGICAL TECHNIQUE
Osteotomy of the fibula1: In order to achieve
full correction, a mid-third, oblique osteotomy
of the fibula is routinely performed, as long as
a fibular head osteotomy is not required to
approach the intra-articular malunion.
Exposure of the proximal part of the tibia1: A
straight lateral parapatellar incision is utilized.
The iliotibial tract is incised to the Gerdy
tubercle, and the fascia of the anterior tibial
muscle is opened 1cm from the tibial crest and
the muscle is detached from the bone.
Proximal tibial osteotomy [1, 2]: The neuro-
vascular bundle is protected by blunt
Hohmann retractors. A transverse or oblique
osteotomy is performed, starting 4 cm distal to
the lateral articular surface and finishing 1 to
2cm distal to the medial joint line, depending
on individual anatomy. The osteotomy is star-
ted laterally with use of an oscillating saw to
the depth of the medial cortex, which is then
perforated with several passes of a small drill-
bit and osteotomes, allowing bending of the
medial cortex by gentle osteoclasis to preserve
an osseous hinge. The medial hinge is protec-
ted, usually with reduction forceps, and a bone
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COMBINED INTRA-ARTICULAR AND VARUS
OPENINGWEDGE OSTEOTOMY FOR LATERAL
DEPRESSIONAND VALGUS MALUNION OF
THE PROXIMAL PART OF THE TIBIA
— SURGICAL TECHNIQUE—
GMMJ. KERKHOFFS, MV. RADEMAKERS, RK. MARTI