Proximal tibial fracture with complex issues

falling down stairs

This very interesting patient - aged 27 - who recently had an osteotomy for post traumatic pain and deformity. The case was complex.

Muriel's story

Muriel had fallen down some stairs in Romania approximately six years before, ​and sustained a fracture to the upper (proximal) part of her left tibia bone. She was treated locally with an open reduction and internal fixation of the lateral tibial plateau.

Since the time of the first surgery she had always noted a valgus alignment to the knee but she says this is getting progressively worse. The knee has also, over the last six months or so, become increasingly unstable, but without frank giving way. She walks with an ache, but can walk good distances and is not really held up as a result of the knee. She has to be a little careful on the stairs, but has no major issues. There is no real swelling and no locking.

Her main concern on arrival at our clinic was medial knee pain, instability and this progressive valgus.

On examination

On examination, she had significant valgus on that left side and was neutral on the right. There was a scar consistent with her previous surgery. She was non-tender laterally. Medially, she was a little tender over the anteromedial joint line and slightly more proximal in the region of the MPFL (medial patellofemoral ligament). The patella was sitting tilted and high, and she has an 'end point' to lateral excursion, but there was some increased laxity in the MPFL compared to the normal side.

The knee was stable in terms of the cruciates, collaterals and had a full range of motion from 0-130° with no increased recurvatum (backwards bending).

Imaging

pre-op long leg x-ray
previous tpf

The patient's left knee is in valgus alignment (knock-kneed)

Her long leg films showed her to be in significant valgus. There was slight external rotation in the patella. I went ahead with further investigations with a view to planning for a closing wedge osteotomy to straighten her to neutral.

The MRI scan showed quite significant osteitis medially and some joint surface deficiency. She clearly also had severe trochlear dysplasia, but I thought this was a 'red herring'. There was some possible bony deficiency to the lateral femoral condyle. There appeared also to have been a previous lateral collateral ligament reconstruction.

Surgery

Post op tibial osteotomy
post op high tibial osteotomy

The patient's left knee after high tibial osteotomy

We did a proximal tibia closing wedge osteotomy in August 2016, and she will return around September 2017 for removal of hardware.

adrian wilson

Adrian Wilson


There were a number of issues to resolve in this knee.


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