Stabilising the PCL with a slope changing osteotomy

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This patient has had a slope changing osteotomy. He couldn't really walk too well before the surgery, and is now running 8 miles!

Charlie is a 23 year old gentleman who was referred through to me by Phil Chapman-Sheath in Southampton because he had a complex problem relating to his left knee. He was in the Marines and landed heavily in May 2015 and felt a click and immediate pain. He had some abnormality with his PCL detected by MRI scan and clinically, but the situation was not clear-cut. However, he was really was struggling day-to-day with simple activities such as running and his knee just felt generally unstable.

Clinical findings

On examining him there was some deficiency of his PCL but it was not grossly lax. It appeared that as a result of his injury he had also damaged the posterior capsule, and as a result he could back-knee or hyperextend significantly more on the damaged side than on the good side. There was not much in the way of pain, but the combination of the PCL laxity and the capsular insufficiency simply made his knee unstable. The X-rays also showed that he had a very flat tibial slope which further disadvantaged the PCL problem..

Slope-changing osteotomy

To improve the stability of the knee I decided to do an opening-wedge flexion osteotomy to change the slope of the tibial plateau. By doing this the PCL is tightened, but importantly one changes the arc of movement and gets rid of the hyperextension - and that is the key. We did the procedure from the anterior aspect, using the biological plating technique which we developed together with Ronald van Heerwaarden.

flat slope
after slope-changing osteotomy

The image on the left shows the flat tibial slope before the surgery. The image on the right shows the change in slope after the osteotomy

Via this direct anterior approach to the front of the knee,  we take the tibial tubercle off as a sliver of bone and then create a wedge at the front which tips the front of the knee upwards. This increases the slope as you look from the side, so that it is slightly steeper, which makes the femur roll back on the tibia.

It is a very powerful procedure to undertake and the results we have had have been fairly spectacular and Charlie is no exception. He is now back to running 8 miles. He is just getting some very mild irritation from the metal work which I am going to remove and after this I think he will be at 100%. I am delighted that he has done so well.

adrian wilson

Adrian Wilson


Ronald van Heerwaarden really came up with the idea and we just modified things slightly. We have now presented on our combined series between Basingstoke, Cardiff and Carlisle and in fact we have had a paper accepted on this.

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