External Tibial Plateau Reconstruction with Patient-Specific Guides: Surgical Planning and Controlled Osteotomy

Intraoperative view during external tibial plateau reconstruction showing the osteotomy step guided

Intraoperative preparation of the allograft used for external tibial plateau reconstruction.

In this case of external tibial plateau reconstruction, performed by Dr Bonnevie, the planning was not intended to rigidly dictate the surgical gesture, but rather to define a precise framework while allowing controlled intraoperative adaptation.

From the earliest discussions, several key constraints guided the strategy : the complexity of the proximal tibia, the need to protect the posterior cruciate ligament (PCL) insertion and the Anterior Tibial Tuberosity (TTA) but also the limitations due to the exposure must be taken into account.

These elements directly influenced the orientation and the extent of the osteotomy planes, particularly in the proximal and posterior regions.

The patient-specific cutting guide was designed to materialize the critical cutting trajectories.

K-wires were positioned at the intersection of the cutting planes to define the true cutting axes, providing direct references to safely initiate the osteotomy and control its direction, while limiting invasiveness to the surrounding soft and bone tissues.

Given the anatomical constraints, the proximal cutting plane was intentionally kept short.

This choice led to a mixed strategy: an initial guided cut to engage the osteotomy along the planned trajectory, followed by a partial freehand continuation, supported by the guidance provided at the entry of the cut.

The use of a narrow sagittal saw and the possibility to work with the knee flexed were both integrated into the planning phase.

After resection, reconstruction using an allograft required a separate line of decision-making.

The allograft guide, positioned on the resected surface, was designed with an extended proximal cutting plane to facilitate graft shaping in a less constrained environment than the patient’s surgical site.

Altogether, this case illustrates a collaborative planning approach between engineering and surgery, in which patient-specific guides act as decision-support tools securing critical steps while respecting the realities of the surgical gesture.

Many thanks to Dr Bonnevie and the surgical team for their trust in this collaborative work.