Reverse dome osteotomy for valgus knee from tibial plateau malunion in a young adult: a case report

Abstract

Background:

Malunion of tibial plateau fractures with valgus deformity can cause chronic pain and functional instability, especially in young, active patients. Anatomical correction of the deformity is essential to restore joint function and prevent progression of osteoarthritis. The corrective approach can be intra-articular or extra-articular osteotomy, depending on the type and location of the deformity.

Case presentation:

A 32-year-old woman presented with pain and instability of the right knee 2 years after trauma. Radiological examination showed a lateral tibial plateau fracture malunion with valgus deviation and articular surface depression. Arthroscopic examination showed intact anterior and posterior ligament integrity. Reverse dome osteotomy and internal fixation using plate and screw were performed by the trauma team, and lateral meniscus debridement was performed arthroscopically by the sports team.

Results:

Alignment correction and plateau elevation were successfully performed without ligament surgery. The patient showed significant improvement in pain, stability, and joint function, with ROM reaching 130° and good clinical function scores at 3-month postoperative evaluation.

Conclusion:

Reverse dome osteotomy is an effective technique for the correction of multiplanar deformity in tibial plateau malunion. Arthroscopic evaluation is important to assess joint stability and avoid unnecessary interventions.

Introduction

Tibial plateau fractures, comprising ~1% of all fractures, often result from high-energy trauma in young adults and low-energy trauma in the elderly[1]. Inadequate management may lead to malunion, causing axial deformity, articular depression, and joint instability[2]. This disrupts load distribution and increases the risk of post-traumatic osteoarthritis[3]. Corrective osteotomy is indicated in symptomatic cases with >5° malalignment or >3 mm depression[4].

Valgus malunion of the lateral tibial plateau can mimic ligamentous insufficiency, resulting in pseudo-instability often mistaken for anterior cruciate ligament (ACL) injury, despite intact ligaments^[1,3^]. In cases with focal articular depression, intra-articular osteotomy allows precise correction under direct visualization, improving joint congruence and alignment with good-to-excellent outcomes in over 70% of cases[3]. This technique also minimizes bone graft use and reduces stress on the posterolateral fragment[5]. However, it is technically demanding and carries a higher risk of cartilage injury – particularly in weight-bearing zones – and may lead to step-off if articular congruence is not accurately restored[5].

HIGHLIGHTS

• Reverse dome osteotomy corrects valgus deformity in tibial plateau malunion.

• Arthroscopy confirms ligament integrity before corrective osteotomy.

• Joint alignment and function restored without ligament reconstruction.

• Combined osteotomy and arthroscopy improve outcomes in young patients.

Conversely, reverse dome osteotomy enables multiplanar correction without disrupting the joint surface, preserves tibial length, and offers stable fixation – making it preferable for young, active patients with intact cartilage and long-term joint preservation goals.

Corrective osteotomy is the preferred treatment for tibial plateau malunion in young, active patients to restore joint congruence and delay the need for arthroplasty[1]. Technique selection depends on the malunion’s location, severity, and cartilage integrity. Reverse dome osteotomy enables multiplanar correction, preserves tibial length, and facilitates elevation of depressed fragments[4]. When combined with arthroscopy, it allows evaluation and management of intra-articular pathology while confirming joint stability and minimizing soft tissue trauma[1]. This case demonstrates successful correction of lateral tibial plateau valgus malunion using reverse dome osteotomy with arthroscopy, achieving biomechanical improvement without ligament reconstruction. This case report has been reported in line with the SCARE Criteria[6].

Case presentation

A 32-year-old female presented with chronic right knee pain and a subjective sense of instability during standing and ambulation. The symptoms developed progressively following a right knee injury sustained 2 years prior in a fall, which was managed conservatively with bracing and without surgical intervention. Over the past year, the patient reported worsening pain localized to the medial and lateral aspects of the knee, along with difficulty bearing weight on the affected limb.

Physical examination revealed a valgus deformity of the right lower extremity and localized tenderness over the lateral tibial plateau. Active knee flexion was limited to 90°, with full extension preserved. Distal neurovascular status was intact. Ligamentous stability tests, including Lachman and anterior drawer, were inconclusive due to pain. The preoperative visual analog scale (VAS) pain score was 6/10.

Radiographs demonstrated a malunited lateral tibial plateau fracture with alignment and articular surface depression. CT imaging revealed >5 mm of depression on the anterolateral tibial plateau. Tibial and apparent limb lengths were 84 cm and 91 cm, respectively, without leg length discrepancy. However, a full-length scanogram indicated a varus malalignment with a femorotibial angle of 11.8°, a mechanical lateral distal femoral angle of 83°, an anatomical lateral distal femoral angle of 81 degrees, and a mechanical medial proximal tibia angle of 86° (Fig. 1).

Figure 1.

Preoperative clinical and imaging findings. (A and B) Clinical photographs showing valgus deformity of the right knee in standing anterior and lateral views. (C and D) Preoperative lateral and anteroposterior radiographs demonstrating lateral tibial plateau depression and joint incongruity. (E) Full-length scanogram with superimposed mechanical and anatomical axes, indicating mechanical valgus alignment of the right lower limb. (F and G) CT scan (lateral and AP views) showing intra-articular depression and surface irregularity of the lateral tibial plateau.

The patient underwent a simultaneous procedure combining intra-articular arthroscopic evaluation (Fig. 2) and reverse dome osteotomy with internal fixation, performed by the sports and trauma orthopedic teams, respectively (Fig. 3).

Figure 2.

Arthroscopic views of the right knee during diagnostic evaluation. (A) Suprapatellar pouch with smooth synovium and no loose bodies. (B) Patellofemoral joint with intact cartilage surfaces. (C) Lateral gutter showing mild hyperemia. (D) Medial gutter with normal appearance. (E) Intercondylar notch revealing intact ACL and PCL. (F) Intact and stable lateral meniscus. (G) Medial meniscus with normal morphology and attachment. (H) Fracture site at the lateral tibial plateau showing subchondral irregularity and articular depression.

Figure 3.

Intraoperative and immediate postoperative images of the surgical procedure. (A) Fibular osteotomy to facilitate proximal tibial realignment. (B) Reverse dome osteotomy performed via an anterolateral approach. (C) Steinmann pin placement to aid in fragment manipulation. (D) Mechanical alignment correction confirmed with intraoperative fluoroscopy. (E) Internal fixation with lateral proximal tibial plate and screws, with final fluoroscopic verification. (F) Wound closure showing multiple incisions from arthroscopy and osteotomy. (G) Postoperative clinical image demonstrating restored mechanical axis along the Mikulicz line.

Under combined spinal-epidural anesthesia, the patient was positioned supine. Standard aseptic preparation was followed by diagnostic arthroscopy via anteromedial and anterolateral portals. Articular cartilage of the patellofemoral and tibiofemoral joints was found to be intact. The ACL appeared structurally intact but mildly lax, while the PCL and both menisci were normal. No loose bodies were identified. Minor debridement was performed on the frayed portion of the ACL. Tibial tunneling at a 45° angle was conducted to assess ACL reconstruction feasibility. However, based on intraoperative findings and the identification of malalignment as the primary cause of instability, ACL reconstruction and graft harvesting were deemed unnecessary.

Subsequently, the trauma team proceeded with the osteotomy. A re-prepped anterolateral approach was used to expose the proximal tibia and fibula. Fibular osteotomy was performed to facilitate correction. A reverse dome osteotomy was then executed on the proximal tibia. Osteotomy depth and direction were confirmed using an image intensifier. The fragments were anatomically reduced, and the mechanical alignment of the lower extremity was restored to the physiological axis.

Fixation was performed using a four-hole proximal tibia lateral plate (PLT), with four screws proximally and three screws distally, confirmed by fluoroscopy. A stable and anatomical bone and implant position was obtained. The wound was washed using a 0.9% NaCl solution, and a synthetic bone graft was applied to the osteotomy area. The wound was closed layer by layer. The operation took place without intraoperative complications.

Following reverse dome osteotomy, intraoperative fluoroscopy confirmed restoration of the mechanical axis. No additional ligament procedures were required, as joint stability was achieved after osseous realignment.

Postoperatively, the limb was stabilized using a Robert Jones bandage and knee immobilizer (Fig. 4 for comparative radiograph). The patient began gradual non-weight-bearing mobilization with bilateral crutches. Pain was well controlled (VAS 3/10), and a structured rehabilitation program was initiated in the first postoperative week.

Figure 4.

Comparative radiographs of the right knee. (A) Preoperative anteroposterior and lateral views showing lateral tibial plateau malunion with valgus deformity and articular depression. (B) Postoperative radiographs following reverse dome osteotomy and internal fixation with plate and screws, demonstrating restored mechanical and anatomical axes, improved joint alignment, and optimal implant positioning based on fluoroscopic planning lines.

At 6 weeks, the patient achieved 110° of active knee flexion with full extension and reported no further instability. By 3 months, she could ambulate independently with a knee range of motion of 0°–130°, normal axial alignment, and no sensory or wound complications. Radiographs demonstrated satisfactory bone healing and intact fixation.

At 3-month follow-up, the patient reported minimal pain (VAS 1), resumed daily activities without limitation, and exhibited no signs of instability. Functional outcome, assessed using the Clinical Rasmussen Score, was 28/30, indicating good joint recovery. At 12 months, the patient had no limitation in daily activities, reported no pain and postoperative imaging radiological union with minimal arthritic changes (Fig. 5).

Figure 5.

Radiological finding at 1 years showing good stability and minimal arthritic changes in comparison to postoperative imaging.

Discussion

Malunion of tibial plateau fractures, particularly on the lateral side, may lead to valgus deformity, articular depression, and functional instability due to altered load distribution toward the medial compartment, increasing the risk of post-traumatic osteoarthritis^[1,2^]. Patients often present with chronic pain, gait disturbances, and mechanical instability[1].

In this case, although the patient initially presented with clinical signs of ligamentous instability, arthroscopic evaluation confirmed the integrity of both ACL and PCL. This supports the concept of pseudo-instability – instability resulting from osseous malalignment rather than ligamentous disruption[7]. Alignment correction via osteotomy can restore mechanical axis and joint stability without the need for ligament reconstruction[7].

Reverse dome osteotomy was selected due to its ability to address complex, multiplanar deformities – including valgus deviation, depression, and rotation – while preserving tibial length and maintaining metaphyseal bone stock[1]. This technique allows precise repositioning of depressed fragments and provides stable bone contact for fixation^[3,4^]. In this case, the approach also facilitated the option for future ACL reconstruction by offering sufficient access and structural support for tunnel placement.

In contrast, intra-articular osteotomy, while useful for localized articular depression, carries a higher risk of cartilage injury and technical mismatch in patients with intact joint surfaces^[3,5^]. Therefore, reverse dome osteotomy was considered more appropriate for this case to minimize the risk for damage in the intact cartilage. Arthroscopy played a key adjunctive role by confirming joint integrity and identifying meniscal or chondral lesions, while avoiding unnecessary ligament procedures^[8,9^]. It also minimized soft tissue morbidity, which is particularly beneficial in post-traumatic and revision cases.

At 3- and 12-month follow-up, the patient demonstrated improved VAS, ROM, and knee function scores, with no further need for ligament surgery, indicating that structural realignment alone was sufficient to restore joint function.

Conclusion

This case demonstrates that reverse dome osteotomy is a safe and effective option for correcting multiplanar tibial plateau malunion – particularly valgus, depression, and rotation – in young, active patients. The technique enables global realignment without disrupting the joint surface, preserves ligament integrity, and provides stable fixation. Favorable clinical outcomes support its role as a joint-preserving solution, including in cases requiring future ligamentous procedures.

Ethical approval

Ethics approval is not required for case reports or case series deemed not to constitute research at our institution based on the regulation from our ethical committee, Health Research Ethics Committee FKUI-RSCM. In addition, ethical approval was exempt at our institution since all patients’ identity is blinded throughout this manuscript.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this upon request.

Sources of funding

Private funding.

Author contributions

R.M.M.: Conceived the ideas of the study and performed the surgery. F.B.: Writing the manuscript, provided revisions to scientific content of manuscript, and provided grammatical revisions to manuscript. O.Z.S.: Writing the manuscript, data analysis, and interpretation. All authors co-wrote the paper and discussed the results for the manuscript preparation. All authors have read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no competing interests.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Radi Muharris Mulyana.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

Data were available upon requests.