Management of a knee instability after ski trauma in a young woman

19th September 23

Knee

Osteotomy

Sport related injury

Management of a knee instability after ski trauma in a young woman

The goals of this clinical case are to discuss the different therapeutic options in case of vicious callus of the proximal tibia, to discuss the physical examination of an unstable knee, and to propose an innovative technique. Stay tuned for Part 2!

Vincent Marot

Hospital Nostra Senyora de Meritxell - ANDORRA

Orthopaedic surgeon

Part one

Clinical presentation

32-year-old female
Occasional skier
Knee trauma skiing 3 years ago operated on with an anteromedial proximal tibial plate
Her main complaints are pain and subjective knee instability.

Pre-op Xrays

Pre-op MRI

Part two

Quiz results

In view of the lateral radiography, which test(s) do you expect to be positive in your physical examination?

✔️ Reverse pivot shift test
✔️ Posterior sag sign

The lateral X-ray shows a posterior displacement of the tibia due to a PCL torn. In those cases, you should find a positive reverse pivot shift test and a posterior sag sign

^{Nielsen S, Helmig P. Posterior instability of the knee joint. An experimental study. Arch Orthop Trauma Surg (1978). 1986;105(2):121-5. doi: 10.1007/BF00455846. PMID: 3718189.}

Which type of surgery should be proposed to the patient?

✔️ Shiba osteotomy

A conservative treatment should be proposed for this very young patient even if a TKA may be a legitimate treatment according to other surgeons. No UKA should be proposed because of the PCL lesion.

^{Mody BS, Mody K. Arthroplasty in young adults: options, techniques, trends, and results. Curr Rev Musculoskelet Med. 2014 Jun;7(2):131-5. doi: 10.1007/s12178-014-9213-3. PMID: 24677185; PMCID: PMC4092200}

^{Kwon HM, Kang KT, Kim JH, Park KK. Medial unicompartmental knee arthroplasty to patients with a ligamentous deficiency can cause biomechanically poor outcomes. Knee Surg Sports Traumatol Arthrosc. 2020 Sep;28(9):2846-2853. doi: 10.1007/s00167-019-05636-7. Epub 2019 Jul 25. PMID: 31346669.}

Final strategy decision

In this case, our choice was to perform a shiba osteotomy (intra-articular osteotomy) thanks to a custom-made cutting guide (NEWCLIP), and a PCL reconstruction thanks to a posterior tibial tendon allograft.