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High tibial osteotomy for proximal tibial osteonecrosis with medial tibial plateau fracture in a patient with prior knee arthroscopy: a case report

Year: 2026

Type: article

Abstract: Background High tibial osteotomy (HTO) is a well-established joint-preserving procedure for unloading the medial compartment of the knee and is widely used for medial compartment osteoarthritis. It has also been applied in selected cases of spontaneous osteonecrosis or subchondral insufficiency fracture of the knee. However, the coexistence of proximal tibial osteonecrosis, medial tibial plateau fracture, femoral condylar bone infarction, and subchondral bone cyst after knee arthroscopy is extremely rare, and the role of HTO as a joint-preserving strategy in this setting has rarely been described. Case presentation A 50-year-old man presented with a 2-year history of right knee pain and limitation of motion. He had undergone arthroscopic surgery at another hospital in 2022, but the pain recurred and progressively worsened. Preoperative imaging demonstrated varus malalignment of the right lower limb, a fracture of the medial tibial plateau, proximal tibial osteonecrosis, bone infarction of the lateral femoral condyle, and a bone cyst in the medial femoral condyle. Clinical examination showed medial joint line tenderness, a range of motion of 0–90°, a visual analogue scale (VAS) pain score of 6, and a Lysholm score of 67. Given the patient’s age, activity demands, preserved lateral compartment, and desire to avoid arthroplasty, arthroscopic assessment combined with medial opening-wedge HTO was performed. Intervention and outcome Arthroscopy confirmed intact cartilage in the lateral compartment, whereas the weight-bearing area of the medial femoral condyle showed grade III–IV cartilage damage. The articular surface at the tibial plateau fracture site remained relatively congruent. Histopathology of the resected bone from the osteotomy site confirmed focal osteonecrosis. The osteotomy gap was opened to 15 mm and filled with allogeneic cancellous and cortical bone grafts. At 1 year, the patient was pain-free, had returned to normal daily activities and work, and could stand on the operated leg without pain. The VAS score improved from 6 to 0, the Lysholm score improved from 67 to 97, and postoperative radiographs showed satisfactory correction, with the mechanical axis passing through the lateral intercondylar eminence region of the tibial plateau (approximately 58% of the tibial width). Conclusion In this rare case of complex post-arthroscopic medial compartment knee pathology, arthroscopic assessment combined with HTO achieved favorable short-term clinical and radiographic outcomes. HTO may be a valuable joint-preserving option for selected middle-aged and active patients with complex medial compartment lesions associated with malalignment, particularly when the lateral compartment remains preserved and joint replacement can reasonably be deferred.

Source: BMC Surgery

DOI: 10.1186/s12893-026-04203-5