History
This 34 year old female sustained an injury to her knee in 1994. The mechanism was vague, and the initial outcome minor. She continued to be active in the military. Over the past 3-4 years she complained of pain and giving way. She underwent MRI that was unremarkable. The arthroscopy was normal. She now uses a brace with a hyperextension block. She walks normally in the brace.
Physical Examination
Her gait in the brace is normal, but obviously there is hyperextension without the brace. She has slight valgus alignment, and no lateral thrust. The degree of hyperextension is shown below. The lateral x-ray hyperextension weight bearing view is shown below. Click on the photos for a large view.
Clinical Photo The lateral standing view of her knee hyperextension. Note, there is no ligament laxity.
The lateral X-ray examination in weight bearing
Diagnosis
It is felt that this lady has sustained a posterior soft tissue injury to her knee. This may also be caused by an anterior compression fracture of the tibial plateau, but there is no x-ray evidence of this.
Management
Is this lady a candidate for a open anterior tibial wedge osteotomy.? Or, should we continue the brace treatment?
Treatment
After considerable debate and discussion, it was decided to do an open anterior wedge osteotomy. of the proximal tibia. In my experience, it has been impossible to correct this deformity with a soft tissue procedure.
The preop view of her localized right knee hyperextension
The opening anterior wedge osteotomy was performed above the tibial tubercle. It was held open with bicortical bone graft from the iliac crest.
Note how this open wedge osteotomy eliminated the hyperextension.
Post x-ray
After 5 months, the osteotomy has healed. She walks with a normal gait, with no pain and full normal extension. The posterior inclination of the tibia plateau is still a concern.
