PMC5893005_01
Preoperative weight-bearing X-rays showing narrowing of the joint space in the internal femorotibial compartment.
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fig1
Postoperative X-rays showing fracture of the lateral cortex at the osteotomy site.
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TomoFix  plate (DePuySynthes, USA) and osteoconductive tricalcium phosphate resorbable bone substitute (chronOS , DePuySynthes, USA) in March 2009 (Figure 2). The varus was measured at 5  preoperatively.
June 2009, 3 months after HTO, postoperative X-rays showing a slight pullout of the proximal screws. No fracture of the plate. No translation of the proximal fragment of the HTO.
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fig3
At 3 months postoperatively, the patient complained of light persistent dull pain when walking and X-rays showed a slight pullout of the proximal screws (Figure 3), increasing at 1 year postoperatively (Figure 4).
Early June 2010, 1 year after HTO, postoperative X-rays showing an important pullout of the proximal screws and slight translation of the proximal fragment of the HTO.
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fig4
At 3 months postoperatively, the patient complained of light persistent dull pain when walking and X-rays showed a slight pullout of the proximal screws (Figure 3), increasing at 1 year postoperatively (Figure 4).
June 2010, postoperative X-rays after revision.
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fig5
In June 2010, the patient was diagnosed with painful nonunion of the HTO, treated by hardware removal, implantation of osteoinductive demineralized bone matrix (DBX , DePuySynthes, USA) and osteoconductive allograft (bone chips by Musculoskeletal Transplant Foundation, MTF  DePuySynthes, USA), and fixation with a TomoFix plate (DePuySynthes, USA) (Figure 5).
June 2011, 1-year after revision, postoperative X-rays showing fracture of the plate and translation of the proximal fragment of the HTO.
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fig6
At the 1-year follow-up, X-rays showed persistence of the pseudarthrosis with a broken plate and slight epiphyseal translation (Figure 6).
June 2012, 2 years after revision, postoperative X-rays showing medial gonarthritis.
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fig7
As the patient was asymptomatic, she refused a new operation. 2 years after revision, the X-rays showed a narrowing of the medial femorotibial compartment (Figure 7).
July 2013, 3 years after revision, postoperative X-rays showing increasing signs of osteoarthritis.
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fig8
Standard X-rays showed an early bicompartmental gonarthritis (Figure 8).
September 2013, after multiple debridements and arthroscopic washout and synovectomy, X-ray showing severe gonarthritis.
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fig9
At this stage, X-rays showed an increase of the knee arthritis (Figure 9).
September 2013, X-rays showing postarticular resection and implantation of cement spacer.
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fig10
Firstly, the partially necrotic, infected tibial articular block was resected (as well as the articular part of the distal femur) and then replaced by a nonarticulating, gentamicin/vancomycin-impregnated polymethylmethacrylate (PMMA)-cement spacer (Figure 10).
X-rays showing 3 months postoperatively rotating hinge total knee replacement with metal augment.
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fig11
Due to necrotic tissue on the edge of the wound and prosthesis volume, a gastrocnemius muscle flap to cover the soft tissue was performed (Figure 11).
X-rays showing 2 years postoperatively rotating hinge total knee replacement with metal augment.
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fig12
At the 2-year follow-up, she walked pain-free and had a function of 110-0-0 of the knee (Figure 12).