Proximal Open Wedge Valgus Osteotomy for High Energy Tibial Plateau Mal/Nonunions

Background: High energy tibial plateau fractures present a great challenge for the orthopaedic trauma surgeon. These are often associated with a high complication rate such as infection, nonunion, and posttraumatic arthritis. In some cases, varus collapse and nonunion can occur. We present a technique of proximal open wedge tibial extra-articular osteotomy to restore the alignment and knee function following such a complication.

Patients and Methods: Between 2010 and 2015, 5 cases of biocondylar tibial plateau fractures with a symptomatic varus mal/nonunion were identified. All cases failed within 6-9 months posteoperatively and manifested with painful weight bearing and clinical and radiographical varus malalignment. Surgical technique: Preoperative standing knee x-rays were obtained and preoperative planning of the desired osteotomy was done using TraumaCAD (BrainLab, Munich, Germany) system. All existing hardware was removed. Multiple deep soft tissue and bone cultures were obtained. An oblique cut from the medial metaphysis toward the juxta-articular lateral plateau was performed using an oscillating saw, leaving an intact lateral hinge. A wedge was open until the joint aligned to neutral matched the preoperative plan. Autologous iliac crest was used in the gap and the osteotomy was fixed with a medial 4.5 mm plate.

Results: All patients were male patients. Age range was 30 -58 (average 40.2). Average peroperative proximal mPTA was 80.4 (range 79-82). Postoperative mPTA was 88 degrees( range 87-92). Two cases had positive postoperative cultures requiring inteavenous antibiotic treatment and irrigation and debridement. All osteotomies healed and acceptable range of motion (0-120) was achieved, with maintenance of limb alignment and so far without significant arthritic changes (Maximal follow up of 5 years in 2 cases) Conclusion: Proximal open wedge osteotomy is a sound salvage solution for varus mal/nonunion after complex bicondylar tibial plateau fractures, but can be technically demanding.