JOT - 2026-03-17 - Journal Article
A Tibial Osteotomy of the Medial Collateral Ligament Insertion to Improve Visualization of the Medial Tibial Plateau: A Cadaveric Study.
Barth KA, Tijerina RR, Amin A, Novak AA, Mayer EN, Ismaily SK, Munz JW, Choo AM, Achor TS, Warner SJ, Eastman JG, Kellam PJ
Topics
Key Takeaway
Tibial osteotomy of the MCL insertion achieved 539.0 mm² of medial tibial plateau visualization—585% more than MCL split—and was equivalent to femoral epicondyle osteotomy (614.7 mm², p=0.44) while preserving proximal meniscal attachments.
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Summary
This cadaveric study compared medial tibial plateau visualization across three approaches—MCL split, femoral epicondyle osteotomy, and tibial MCL insertion osteotomy—using a 3D digitizer to quantify exposed articular surface area. Tibial osteotomy yielded 539.0 ± 81.9 mm² versus 87.2 ± 28.4 mm² for MCL split (p<0.001) and was statistically equivalent to femoral epicondyle osteotomy at 614.7 ± 217.6 mm² (p=0.44). The tibial osteotomy preserved the meniscofemoral deep MCL, posterior oblique ligament, and proximal meniscocapsular attachments, which the femoral osteotomy disrupts proximally.
Key Limitation
Cadaveric study with no fracture model—visualization data obtained in intact joints with standardized distraction does not replicate the hematoma, comminution, and soft tissue swelling that limit intraoperative exposure in actual medial plateau fractures.
Original Abstract
OBJECTIVES
To compare visualization of the medial tibial plateau articular surface using three surgical approaches: medial collateral ligament (MCL) split, femoral epicondyle osteotomy of the MCL origin, and tibial osteotomy of the MCL insertion.
METHODS
Seven matched pairs of fresh-frozen adult cadaveric lower extremity specimens (14 knee specimens total) with no evidence of previous surgery were utilized. Through a medial approach to the proximal tibia, the MCL split technique was performed followed by a sub-meniscal arthrotomy. Standardized distraction of the joint was applied using a universal distractor. A three-dimensional digitizer probe was utilized to map the visible articular surface. These steps were repeated for the femoral osteotomy on the same extremity as the MCL split and the tibial osteotomy on the contralateral matched pair extremity. The tibial osteotomy preserved the meniscofemoral portion of the deep MCL, posterior oblique ligament, and proximal meniscocapsular attachments. Visible articular surface area (mm2) for each of the three techniques was calculated from the mapped data points and compared among techniques.
RESULTS
The mean age of the specimens was 77.1 ± 7.2 years. MCL split technique visualized 87.2 ± 28.4 mm2 of articular surface. The medial femoral epicondyle osteotomy provided 614.7 ± 217.6 mm2 of visualization (677% more than MCL split, p < 0.001), while tibial osteotomy achieved 539.0 ± 81.9 mm2 (585% more than MCL split, p < 0.001). No significant difference in visualization was observed between the femoral and tibial osteotomy techniques (614.7 ± 217.6 mm2 vs. 539.0 ± 81.9 mm2, p = 0.44).
CONCLUSIONS
Tibial osteotomy of the MCL insertion provided significantly improved visualization of the medial tibial plateau compared to MCL split technique and achieves similar exposure to femoral epicondyle osteotomy, while preserving the soft tissue structures proximal to the meniscus.
LEVEL OF EVIDENCE
Level IV.