Revisiting High Tibial Osteotomy

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2010;92:187-195. doi:10.2106/JBJS.I.00771 J Bone Joint Surg Am.A. Poignard, C.H. Flouzat Lachaniette, Julien Amzallag and P. Hernigou

Opening-Wedge TechniqueRevisiting High Tibial Osteotomy: Fifty Years of Experience with the

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Revisiting High Tibial Osteotomy: Fifty Years ofExperience with the Opening-Wedge Technique

By A. Poignard, MD, C.H. Flouzat Lachaniette, MD, Julien Amzallag, MD, and P. Hernigou, MD

Introduction

Since the first description by Debeyre of medial opening-wedge high tibial osteotomy proximal to the tibial tuber-

osity in 1951 and with the publication of our results in theEnglish-language literature in 19871, our orthopaedic depart-ment has performed this osteotomy in 3756 patients over aperiod of more than fifty years. Although the opening-wedgeosteotomy is not new, the advantages of the opening-wedgeas compared with a closing-wedge technique have been dis-cussed only recently, particularly in the English-languageliterature2-9. The aim of the present report is to describe (1)the key steps in the surgical technique, (2) the determinationof the size of the wedge, (3) the improvements in the tech-nique during the past twenty years, (4) the specific problem ofposterior slope and patella baja, and (5) the technique of con-comitant total knee arthroplasty and opening-wedge tibial os-teotomy to avoid the need for soft-tissue release in knees withsevere varus deformity.

Source of FundingNo funds were received in support of this study.

Key Steps in the Surgical TechniqueInitial Exposure

Alongitudinal incision is made from the medial border ofthe patellar tendon distally along the medial aspect of the

tibia for 10 cm. The insertions of the sartorius, gracilis, andsemitendinosus muscles are divided, and the tendons areseparated from bone as described previously1. The pes an-serinus is incised longitudinally, 0.5 cm medial to its attach-ment to the tibia; if only moderate valgus is required, theincision can be incomplete. The distal portion of the super-ficial medial collateral ligament is exposed and is separatedfrom bone proximally as far as the level of the osteotomy,which should be started at least 3.5 cm distal to the medialjoint line and directed laterally and proximally toward the tipof the fibula. The posterior compartment is opened at thelevel of the osteotomy and the posterior surface is cleared,with the periosteal elevator being directed toward the proxi-mal end of the fibula.

The Osteotomy LineThe osteotomy line begins from 3 to 4 cm distal to the medialjoint line, passing above the insertion of the patellar tendon tothe tibial tubercle. A pin is inserted and is directed toward thelateral border of the tibia at the level of the proximal tibiofib-ular joint. In patients with a large varus deformity, the oste-otomy line is placed at the level of the proximal tibiofibularjoint (Fig. 1).

The Osteotomy Is Performed on the Distal Side of a PinThe osteotomy line is slightly oblique from distal to proxi-mal, and the osteotomy is performed with a chisel on thedistal side of the pin to avoid any extension of the osteotomytoward the lateral tibial plateau. The fibula and the tibio-fibular joint need not be disturbed. Maximum attention isgiven to keep the lateral cortex intact to allow hinging at this

Fig. 1

In patients with a large varus deformity at the knee, the osteotomy is

performed at the level of the proximal tibiofibular joint, with the lateral

part of the knee acting as a hinge.

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor amember of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercialentity.

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COPYRIGHT � 2010 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2010;92 Suppl 2:187-95 d doi:10.2106/JBJS.I.00771

location10 (Fig. 1). As the cut is completed with osteotomes,the lateral part of the cortex of the lateral tibial plateau is leftintact.

The Opening Should Be Medial and PosteriorThe bone at the site of the osteotomy is wedged open. Theportion of the tibia distal to the osteotomy is then pushedinto valgus while the large osteotome maintains the proxi-mal end of the tibia in place. The surgeon avoids flexion atthe site of the osteotomy. The opening must be greater at theposterior part of the osteotomy than at the anterior part inorder to avoid increasing the posterior slope and patella baja(Fig. 2).

The Size of the Wedge Can Be TestedThe osteotomy gap is distracted and is evaluated with fluo-roscopy. Next, a single wedge is placed to keep the wedge areaopen (Fig. 3-A). This correction can be checked during surgeryby calculating the angle between the anatomical axis of the tibiaand a line perpendicular to the tibial plateau. The same mea-surement can be done on the lateral radiograph to ensure thatflexion is not present at the osteotomy site. The trial wedge isthen exchanged for the final wedge, which is usually a bonesubstitute (Figs. 3-B and 3-C).

Positioning of the Wedge and Internal Fixation Are ImportantThe wedge is inserted in the opened osteotomy site mediallyand posteriorly to avoid relative shortening of the patellartendon and an increase of the posterior slope of the tibia. Abuttress plate is then applied to the anterior part of the medialaspect of the tibia to hold the proximal end of the tibia and thetibial shaft (Fig. 4). The wound is closed by repairing the ten-dons and the superficial medial collateral ligament.

Determination of the Size of the WedgeThe Hip-Knee-Ankle Angle

Apreoperative standing radiograph showing both lower ex-tremities from the hip to the ankle is used to determine the

size of the wedge of bone substitute that is needed to produce thecorrection. First, the lines that determine the preoperative hip-knee-ankle angle are drawn. Usually, for patients with osteoar-thritis, the postoperative hip-knee-ankle angle should overcorrectpreoperative angular deformity. The size of the wedge varies withthe change of the opening-wedge angle during the osteotomy andthe width of the tibia at the site of the osteotomy.

The Graphic MethodOn the full-length anteroposterior radiograph, a line is drawnat the osteotomy site. Then a new tibial line, representing the

Fig. 2

The proximal tibial osteotomy opening (arrow) should be done medially and posteriorly.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 92-A d SU P P L E M E N T 2 d 2010RE V I S I T I N G HI G H TI B I A L OS T E O T O M Y: F I F T Y Y E A R S O F

EX P E R I E N C E W I T H T H E OP E N I N G -W E D G E TE C H N I Q U E

future mechanical axis of the limb after the osteotomy, isdrawn. The angle between this new tibial line and the preop-erative tibial line defines the amount of correction needed toproduce the desired hip-knee-ankle angle and to restore themechanical axis of the limb. Next, a tracing of the portion of thetibia that lies distal to the site of the osteotomy is made and issuperimposed on the radiograph as previously reported1 so thatthe axis of this tracing lies exactly on the previously drawn newtibial line on the radiograph.

The Table MethodThis method allows the surgeon to modify the angle of cor-rection by determining the size of the wedge11-15. The size of thewedge varies with the change of the angle during the osteotomyand the width of the tibia at the osteotomy site, and this angle(Beta) is the angle of correction. W is the width of the tibia atthe site of the osteotomy and can be determined on the pre-operative radiograph or during surgery. For example, if theplanned correction is 16� and the width of the tibia at the

Fig. 3-A Fig. 3-B

Fig. 3-C

Figs. 3-A, 3-B, and 3-C After the osteotomy gap is distracted under fluo-

roscopy, a trial wedge provided with the specific ancillary instrumentation

is used to determine the wedge size needed. Fig. 3-A The trial wedge

serves as a distractor to keep the osteotomy site open. Fig. 3-B In most

patients, the anteroposterior dimension of the tibia at the site of osteotomy

is large enough to allow implantation of the definitive bone substitute while

the trial device is still implanted (side by side), as shown. Fig. 3-C The

calcium phosphate ceramic DUOWEDGE (Kasios) is designed to be used

as a wedge for tibial osteotomies. DUOWEDGE is a synthetic bone sub-

stitute. It is a macroporous bioceramic, made of hydroxyapatite and beta

tricalcium phosphate. The trial wedge can be removed after implantation of

the bone substitute.

Fig. 4

The wedge is inserted medially and posteriorly, and the plate is anterior to

the wedge.

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osteotomy site is 65 mm, the size of the wedge is 18 mm (Fig.5).

Improvements in the Technique During the PastTwenty YearsReplacing the Iliac Crest Wedge with a Beta-TricalciumPhosphate (b-TCP) Wedge

Autogenous iliac crest has been the gold standard becauseof its structural characteristics, osteoconductive and os-

teoinductive potential, and high rate of osteotomy union,although potential complications and late donor-site painhave been reported16. The use of a bone-substitute wedgeeliminates these problems17. To allow immediate full weight-bearing, we now use the DUOWEDGE porous beta-tricalciumphosphate (b-TCP) wedge (KASIOS, Launaguet, France). Theadvantage of low-porosity b-TCP is its high initial strength, al-lowing for immediate postoperative weight-bearing.

DUOWEDGE is a unique tibial osteotomy wedge fea-turing two portions with different porosities: a solid highlyresistant portion (resistance to compression, 80 MPa) fits intothe cortical area, where the maximum load-bearing zone islocated, while a porous portion improves graft incorporation(Fig. 3-B). This wedge is fabricated from biphasic porous ceramic(60% hydroxyapatite Ca10[PO4]6[OH]2 and 40% tricalciumphosphate Ca3[PO4]2) that is manufactured and controlled byKasios.

Rigid Internal Fixation with Locking Screws and PlateIn our previous long-term (ten to thirteen-year) follow-upstudy1, all patients with a varus deformity who needed a revi-sion still had a varus deformity one year after the initial oste-otomy. This varus deformity was related to a fracture of thelateral cortex. A fracture of the lateral cortex substantially

reduces the stability of the fixation at the site of the opening-wedge osteotomy, and a lateral fixation with a staple is rec-ommended when this fracture occurs. One of the advantages of

Fig. 5

The wedge size is planned before surgery depending on the preoperative

varus deformity. Normal mechanical alignment of the limb is a hip-knee-

ankle angle of 180�. A varus deformity is indicated by a hip-knee-ankle

angle of <180�, and a valgus deformity is indicated by a hip-knee-ankle

angle of >180�. The angle correction during the osteotomy is the dif-

ference between the planned postoperative hip-knee-ankle angle chosen

by the surgeon and the preoperative deformity. Usually, for patients with

osteoarthritis, the postoperative hip-knee-ankle angle should be ‡180�.The wedge size depends on the angle of correction and on tibial width at

the site of the osteotomy. A = angle of correction, and W = width of the

tibia at the osteotomy site.

Fig. 6-A

Figs. 6-A, 6-B, and 6-C Severe proximal tibial varus de-

formity remains a challenging problem during total knee

arthroplasty. Fig. 6-A Anteroposterior standing radiograph

of the lower limbs in a patient with severe varus deformity

(>15�), mostly due to proximal tibial deformity, who was

scheduled for total knee arthroplasty.

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locking screw and plate osteosynthesis is that, when a fractureof the lateral cortex occurs, additional lateral fixation is notnecessary. We use the Block and Break locking plate (LIMMED,Nesles-la-Valee, France) (see Appendix), which is a new ap-proach to locking screw and plate osteosynthesis. The plate,contoured to the anatomical position of the proximal part ofthe tibia, is made of steel and can be contoured during surgeryif necessary. We use cortical screws for both proximal and distalholes. The innovative locking sleeve, constricting ring, andspecial screws in Block and Break locking systems ensure anexceptional resistance to shear stress at the screw-plate junc-tion, ensuring solid fixation regardless of bone quality. TheBlock and Break system will withstand a maximum of 1200 kg

Fig. 6-B

As shown on this standing anteroposterior radiograph, a

technique that combines opening-wedge tibial osteotomy

and total knee arthroplasty in the same operation allows for

the achievement of good realignment without excessive soft-

tissue release.

Fig. 6-C

The articular deformity (angle A) is represented by the angle

between the two tangents to the femoral condyles and the tibial

plateau; the articular deformity will be corrected by the arthro-

plasty. The extra-articular (constitutional or acquired) part of the

deformity is represented by the complementary angle of the

angle enclosed by the tibial mechanical axis and the straight-line

tangent to the tibial plateau (angle B).

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of shear stress at the screw-plate junction and allows immediatefull weight-bearing.

The Specific Problems of Posterior Slope andPatella Baja

Achange in posterior tibial slope may occur when a me-dial opening-wedge osteotomy is performed. Usually,

the surgeon should avoid increasing the posterior slope inknees with osteoarthritis. A possible reason for increasedposterior slope in the opening-wedge technique might be arelatively anterior approach to the proximal part of the tibia.Because of concerns about muscle and vessel injury18, surgeonsoften do not clear the soft tissues well posteriorly and cannotperform a proper osteotomy of the posterolateral cortex.To avoid patella baja, the height of the osteotomy should al-ways be greater at the posteromedial cortex than at the tibialtuberosity15,19-21.

Combined Total Knee Arthroplasty and Opening-WedgeTibial Osteotomy

Total knee arthroplasty in patients with knee osteoarthritisand severe varus deformity (>15�) remains a challenging

procedure (Fig. 6-A). Total knee arthroplasty requires a majorrelease of the medial collateral ligament to achieve good liga-ment balancing. A technique that combines opening-wedgetibial osteotomy and total knee arthroplasty in the same op-eration allows for the achievement of good realignment with-out excessive soft-tissue release (Fig. 6-B). Opening proximaltibial osteotomy is performed first, and the total knee arthro-plasty is then performed, with stem augmentation, to ensurestability of the construct.

Preoperative PlanningStanding anteroposterior radiographs from the hip to the ankleare used to determine the hip-knee-ankle angle. The preoperativedeformity has two parts: (1) the articular part, related to wear ofcartilage and bone, and (2) the extra-articular part (Fig. 6-C). Thearticular deformity is represented by the angles between the twotangents to the femoral condyles and the tibial plateau, and thisarticular deformity will be corrected by total knee arthroplasty.The extra-articular portion of the deformity is the complemen-tary angle of the angle formed by the tibial mechanical axis lineand the straight-line tangent to the tibial plateau. This angle ismeasured on the medial side. The extra-articular deformity mustbe quantitated preoperatively as it determines the amount ofosteotomy correction needed. The first part of the technique isthe osteotomy; the second part of the technique is the arthro-plasty. In the proximal part of the tibia, only the anterior portionof the joint capsule is released and the pes anserinus is elevated.The superficial medial collateral ligament is divided at its distalinsertion, adjacent to the osteotomy site. The insertion of the deepmedial collateral ligament is left intact, and the semimembrano-sus tendon and the posteromedial capsule are preserved. Thebone is cut proximal to the level of the tibial tubercle and as faraway from the lateral joint surface as possible (at least 30 mm)to leave sufficient bone in the proximal part of the tibia to allow

a bone resection of about 10 mm. After the osteotomy, theosteotomy level should be at the level of the proximal portionof the superior tibiofibular joint. The osteotomy site is openedto the required extent and is held open with a bone-substitutewedge. The size of the wedge is determined as previously de-scribed in the text. The wedge is inserted in the opened oste-otomy site medially and posteriorly to decrease the posteriorslope of the tibial plateau. Care must be taken to ensure that thewedge does not protrude into the center of the medullarycavity, where it would interfere with the insertion of the im-plant stem or of the intramedullary aiming rods used for theinsertion of the total knee replacement. Fixation of the oste-otomy site is obtained with a plate and screws. Screws mayinterfere with the insertion of the tibial stem if they protrudeinto the medullary canal and should never be driven fully homeat the initial part of this combined procedure.

The ArthroplastyOnce the angular deformity has been corrected by the medialopening-wedge osteotomy, femoral resection for the total kneearthroplasty may proceed. The femoral component is insertedin the usual fashion. For the tibial component, a cut is madewith use of a guide with a proximal sensor. The proper amountof advancement of the tibial surface due to the opening oste-otomy can be checked while there is a contact point betweenthe tibial surface and the arm of the sensor. A 9-mm resectioncan be done to remove the same amount of bone on both themedial and lateral sides. One must take care not to remove>9 mm from the lateral tibial plateau, so a maximum amountof bone will be left between the osteotomy and the resectionlines. With the angular correction having been achieved withthe osteotomy, there is no need for additional soft-tissue re-leases to balance the total knee arthroplasty. The tibial implantstem will cross the osteotomy site. We use the Ceraver Hermesposterior-stabilized total knee arthroplasty (Ceraver Osteal,Roissy, France)22, but one must carefully prepare the insertionsite of the tibial tray to avoid fracture of the proximal part of thetibia. Trial insertion of the tibial component is done prior tocementing. Once the trial implants have been removed, thedefinitive components are inserted and are cemented in place(Fig. 7). Cement that tends to fill the osteotomy gap is carefullyremoved. The osteotomy defect is filled with bone that wasresected during the total knee replacement part of the proce-dure (Fig. 8).

RehabilitationThe technique that combines opening-wedge tibial osteotomyand total knee arthroplasty in the same operation allows forthe achievement of the desired realignment without excessivesoft-tissue release (Fig. 6-B). The patient is mobilized early,with limitation of knee motion to 90� of flexion, and is al-lowed out of bed on the day after surgery. Weight-bearing isallowed with use of two walking aides for the first six weeks.Subsequently, the patient is allowed to return to full weight-bearing and range of motion and to discontinue the use ofwalking aids.

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Discussion

Successful high tibial osteotomy depends on the interrelation-ships between several variables, with patient selection and sur-

gical technique likely being the most important. Most authorshave agreed that middle-aged patients with isolated medialfemorotibial degenerative disease, reasonable functional expec-tations, and a patellofemoral joint without osteoarthritis canbenefit from high tibial osteotomy. Many authors have reportedthat the results of tibial osteotomy are better when the preoper-ative radiographs do not show changes indicative of advancedosteoarthritis in the medial compartment such as loss of bone,instability because of erosion of bone, laxity of the lateral struc-tures, or subluxation of the tibia. In knees that have ideal cor-rection (a hip-knee-ankle angle ranging from 183� to 186�), thereis no progression of the disease. The increased load on the lateralcompartment of these knees does not seem to damage the ar-ticular cartilage, and the patellofemoral joint usually remainsunchanged. Therefore, proximal tibial osteotomy with ideal cor-rection modifies the natural evolution of knee osteoarthritis forseveral years in patients with severe varus deformity.

Autogenous iliac crest bone graft has been the gold stan-dard for bone-grafting because of its structural characteristics, itsosteoconductive and osteoinductive potential, and its high rateof osseous union. Problems with this bone-grafting procedureare related to later donor site pain and potential complicationswhen the bone graft is obtained. The use of a bone-substitutewedge eliminates these problems yet provides only osteocon-ductive benefit. As this bone-substitute wedge lacks the osteo-inductive properties of autogenous iliac crest bone graft, a longertime to osseous union may occur. The porous portion of thissubstitute acts as an ideal osteoconductive substitute. The well-established bone-healing process of creeping substitution canproceed across the resorbable part. In combination with thelocking plate, full weight-bearing is possible immediately afterthe operation if pain allows. This is an advantage over previoustechniques, for which full load-bearing was possible only aftersix weeks or longer. The osteotomy sites completely consolidatedin all of our cases, and no serious complications occurred.

Finally, the surgeon must be aware of the importance ofmaintaining the integrity of the lateral hinge at the osteotomysite when performing osteotomies with large corrections. Strictattention to technical details during the operation will serve tominimize the occurrence of hinge fracture. Frequent use of theimage intensifier in multiple views during the procedure and ahigh index of suspicion will assist in making the diagnosis oflateral hinge fracture. Care must be taken to identify this in-traoperative complication when it occurs and to act accordinglywith the application of supplemental lateral fixation.

The opening-wedge osteotomy has some immediateadvantages. Specifically, during the osteotomy, no fibular os-teotomy is needed; peroneal nerve palsy is less likely; and thereis no instability of the lateral knee ligaments. The technique ofrigid internal fixation with a plate and screws has the advantageof avoiding pin-track infection, which occurs frequently inassociation with external fixator pins in patients managed withopening-wedge osteotomy with use of the hemicallotasis tech-

Fig. 7

Fixation of the tibial osteotomy site is obtained with a

plate and screws at the posterior part of the tibia to

avoid filling the medullary canal. The stem of the tibial

total knee arthroplasty component crosses the tibial

osteotomy site. Cement that tends to fill the osteot-

omy is removed.

Fig. 8

The tibial osteotomy defect is filled with use of bone

that was resected during the total knee arthroplasty

portion of the procedure, and the final screws are

implanted.

193




nique. However, probably the most important advantage of theopening-wedge technique is the preservation of bone stock,leading to an easier operative procedure later if a total kneereplacement or a repeat osteotomy is done. A closing-wedgeosteotomy reduces the amount of bone stock proximal to thetibial tuberosity; thus, eversion of the patellar mechanism atthe time of total knee replacement is difficult and it is usuallynecessary to perform a lateral retinacular release during theearly part of the procedure in order to facilitate the eversionof the patella23-28. After opening-wedge osteotomy, eversion ofthe patellar mechanism is easier and the lateral retinacularrelease is not required as often. One of the criticisms of hightibial osteotomy is that it is associated with a high risk of patellabaja, resulting in a difficult conversion to a total knee arthro-plasty. With a closing-wedge osteotomy, this may be linked tothe fact that, with removal of a wedge of bone, the distancebetween the tibial tubercle and the joint line is decreased,creating redundancy of the patellar tendon and secondaryscarring in the retropatellar fat. With an opening-wedge oste-otomy, it is important to put the cement block at the posteriorpart of the osteotomy site to avoid increasing the distance be-tween the tubercle and the joint line. Patella baja did not de-velop in any patient in our study.

When total knee arthroplasty is performed following afailed high tibial osteotomy, the postoperative mechanical axisnever intersects the center of the tibial component because of thedeformed proximal part of the tibia, particularly when the tibiahas been resected perpendicular to the tibial shaft axis after aclosing-wedge osteotomy. After a closing-wedge osteotomy, theuse of a prosthesis that has a tibial component with a central pegmay result in impingement of the tip of the peg on the lateralpart of the tibial cortex, even though the component appears tobe centered on the tibial plateau. This difficulty is due to theabrupt change in the flare of the tibial cortex that is caused by theclosing-wedge osteotomy, which also alters the relative positionof the medullary canal. Consequently, it may be necessary toshift the tibial component slightly medially so that this im-pingement will not occur. Sometimes a custom-made compo-nent will be needed to accommodate the altered anatomy of thetibia. Following an opening-wedge osteotomy, this problem doesnot occur because the tibial cut is higher and the risk of im-pingement of the peg on the lateral tibial cortex is decreased.

Another difference between the two techniques is theability to more easily determine the level of the native tibialjoint after an opening-wedge osteotomy. After a closing-wedgeosteotomy, this is not possible because the lateral compartment

has been pushed down by the wedge removal and because themedial compartment has already had bone loss at the time ofthe osteotomy. After an opening-wedge osteotomy, the lateralcompartment is kept at a more anatomical level.

Correct rotational alignment between the proximal part ofthe tibia and the diaphysis is more frequent after the opening-wedge osteotomy. With the opening-wedge osteotomy, there isno fibular osteotomy and a hinge is maintained at the site of thetibial osteotomy. This hinge and the absence of fibular oste-otomy avoids rotational malalignment during the osteotomy.In our experience, this malrotation of the proximal part of thetibia is more frequent after closing-wedge osteotomy. As a re-sult, a malrotation causing patellofemoral complications ismore frequently observed in patients managed with total kneearthroplasty after closing-wedge osteotomy than after opening-wedge osteotomy.

In conclusion, high tibial osteotomy is a re-emergingtechnology for the treatment of the refractory pain and disa-bility caused by medial femorotibial degenerative articulardisease. The outcomes associated with modern-day total kneereplacements are encouraging. However, although they are lessfrequent than they were in the past, complications and mor-bidity can occur and the long-term outcome in young patientsis unknown. Successful high tibial osteotomy is an effectivealternative surgical procedure that makes it possible to delay oravoid a total knee arthroplasty in selected patients. Probably themost important advantage of the opening-wedge technique isthe preservation of bone stock and an easier operative procedurewhen it is later necessary to perform a total knee replacement or arepeat tibial osteotomy in a young patient.

AppendixA figure showing the locking screw plate osteosynthesissystem is available with the electronic version of this ar-

ticle on our web site at jbjs.org (go to the article citation andclick on ‘‘Supporting Data’’). n

A. Poignard, MDC.H. Flouzat Lachaniette, MDJulien Amzallag, MDP. Hernigou, MDChirurgie Orthopedique, Hospital Henri Mondor, University Paris XII,51 Avenue du Marechal de Lattre de Tassigny, Creteil 94000, France.E-mail address for P. Hernigou: [email protected]

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Revisiting High Tibial Osteotomy

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