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Opening Wedge High Tibial Osteotomy

- Discussion:
    - surgical descision making:
             - Limb Alignment After Open-wedge High Tibial Osteotomy and Its Effect on the Clinical Outcome
             - Opening wedge high tibial osteotomy for symptomatic hyperextension-varus thrust.
             - The effect of a proximal tibial medial opening wedge osteotomy on posterolateral knee instability: a biomechanical study.

- Osteotomy Options:
    - exposure:
          - sartorius fascia is incised and the pes anserinus retracted distally with a blunt retractor, exposing the superficial MCL; 
     - release of MCL: 
          - long fibers of MCL are mobilized and partially released distally to allow a blunt Hohmann retractor to be placed behind the  
                   posteromedial aspect of the tibia to protect the neurovascular bundle;
                 - release of distal fibers also prevents excessive medial compartment loading as the tibia is hinged into valgus;
     - protection of N/V bundle:
           - blunt retractor is passed deep to the MCL to protect the posterior neurovascular structures;
          - ref: The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study
    - standard osteotomy:
          - two 2.5-mm threaded Kirschner wires mark the oblique osteotomy 5 cm distal to the joint line, starting proximal to the pes
                  anserinus and extending to the  level of the tip of the fibula at the lateral cortex
          - saggital plane (lateral view on flouro)
                  - osteotomy is performed parallel to the posterior tibial slope
          - 2.5-mm K wire marks oblique osteotomy 5 cm distal to joint line, starting proximal to pes anserinus and extending to level
                  of tip of fibula at lateral cortex;
          - starting point for opening the osteotomy is posterior to the superficial medial collateral ligament
                  - start at anteromedial tibia at the level of the superior border of the tibial tubercle (approximately 4 cm distal from the joint
                             line) and aiming the tip of the fibular head (approximately 1 cm below the lateral articular surface)
          - medial border of the patellar tendon was identified, retracted, and protected throughout the whole procedure.
          - latearl cortex: careful not to disrupt the lateral cortex;
                      - mobility of the osteotomy is checked by gentle manipulation of the leg with valgus force.
                      - references:
                             - The effect of lateral cortex disruption and repair on the stability of the medial opening wedge high tibial osteotomy. 
                             - Open-wedge high tibial osteotomy: a technical trick to avoid loss of reduction of the opposite cortex
                             - The prevention of a lateral hinge fracture as a complication of a medial opening wedge high tibial osteotomy

    - V shaped osteotomy:
             - oblique osteotomy is performed in the posterior two-thirds of the medial aspect of the tibia distal to the Kirschner wires and
                      parallel to tibial slope extending to the tip of the fibula, leaving a 10-mm lateral bone bridge intact;
                      - second osteotomy starts in the anterior one-third of the tibia at an angle of 135°, leaving the tibial tuberosity intact
    - References:
             - Distal tuberosity osteotomy in open wedge high tibial osteotomy can prevent patella infera: a new technique 
             - Patellar height relevance in opening-wedge high tibial osteotomy.
             - Modified Retro-Tubercle Opening-Wedge Versus Conventional High Tibial Osteotomy

- Implants:
        - Opening-Wedge High Tibial Osteotomy with a Locked Low-Profile Plate: Surgical Technique
        - Opening-Wedge High Tibial Osteotomy: Review of 100 Consecutive Cases.
 
- Bone Grafting:
       - Union of medial opening-wedge high tibial osteotomy using a corticocancellous proximal tibial wedge allograft.
       - Medial opening-wedge high tibial osteotomy with use of porous hydroxyapatite to treat medial compartment osteoarthritis of the knee 
       - Adverse Event Rates and Classifications in Medial Opening Wedge High Tibial Osteotomy

- Post Operative Care:
    - Early full weight bearing is safe in open-wedge high tibial osteotomy.
    - Medial Opening Wedge High Tibial Osteotomy With Early Full Weight Bearing


- References:

Osteotomies around the knee: patient selection, stability of fixation and bone healing in high tibial osteotomies.
Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function.