This is a brief video of a proximal opening wedge at tibial osteotomy. Preoperative planning is essential, and in general, we aim for the lateral tibial spine for the correction of the mechanical axis. In this case, an incision was previously there, and we're carrying this down towards the osteotomy site. In general, the incision is halfway between the anterior crest and the posteromedial tibia. Incision is carried down through skin, subcutaneous tissue, down to the periosteal layer. The insertion of the patellar tendon is the first landmark, as exposed here. A curved retractor is used to protect the patellar tendon. An intramedial aspect of the tendon insertion is released. Incision is carried down to the periosteum and elevated. You can see here subperiosteally, medially, and posteromedially. This is an important step to allow opening of the osteotomy. The osteotomy is carried out from the insertion of the patellar tendon to the posteromedial aspect of the tibia. A guide wire or parallel guide wires are inserted, as you can see here, to outline the osteotomy line. The guide wire is two centimeters distal to the joint and ends up laterally at the tibiofibular joint. This will give ample protection to the joint and avoid the risk of intraarticular fracture. A microsagittal saw is used to cut the medial and posteromedial cortex. Then the rest of the osteotomy is completed using an osteotome, as you can see here, always with the guide wire or guide wires in place to protect you from going proximally towards the joint. Again, this is a safe way to perform the osteotomy, protects you, and avoids any bone loss or deviating from the osteotomy line. As you can see here, the osteotome is parallel to the guide wire. And again, the osteotome is gradually penetrated towards the lateral cortex, and we usually go about a centimeter short of the lateral cortex. This avoids any intraarticular fracture. Again, once the osteotomy is completed far enough, you can see it opens up slightly, as you can see there. And at this point, it's ready for opening. This is an eye-balance technique, and this is an eye-balance guide. The lug holes are drilled. You can see here, this is the shape of the implant. The bone is preserved that's reamed from these lug holes. At this point, we're ready to open up the osteotomy site. Again, you see how it's able to open. And so this is the wedge opener. You can use one of these lug holes to make sure that the wedge opener is in the right location and doesn't interfere with the implant placement. Once it's open to the desired amount, you can check it with the ruler to make sure you're in the appropriate location, fluoroscopy, and make sure there's no complications. So the implant can be inserted at this point, or you can put in bone graft. Here we've got two triangular calcium phosphate wedges, and I think it's nice to use this technique, or put the wedges in, and it keeps the osteotomy open, so then you can insert your implant without difficulty. Here the implant is inserted and tapped in, and you can see it's flush with the tibia. Check the alignment. You can check fluoroscopy, make sure everything's fine, and then insert the screws to the appropriate depth for fixation. One of the advantages of this technique is that there's no prominent hardware, and you can close the periosteum, close the soft tissues, and again, this allows good physical therapy, no irritation of the soft tissues or hamstrings, and no need for removal of hardware. Thank you for your attention. www.ottobock.com

proximal opening wedge

tibial osteotomy

incision

osteotomy

wedge opener