Abstract
Technique Video
A curved oblique skin incision is made from the posteromedial corner of the proximal tibia to the insertion site of the pes anserine tendon. An incision is made in the sartorius fascia. The affected knee is placed in a slightly flexed position to relax the gracilis and semitendinosus tendons. These 2 tendons are then identified and scooped with a Kelly clamp and wet gauze. When the 2 tendons are separated, we can see the shallow layer of the medial collateral ligament (MCL) and the joint capsule. The distal attachments of the 2 tendons are left connected to the proximal tibia, and the boundary between the MCL and the joint capsule is marked with an electrocautery scalpel. A rasp is used at the border between the shallow layer of the MCL and the articular capsule to peel away the matter between the bone and the periosteum, which creates room for expansion. The dissection proceeds toward the posterior surface of the tibia and follows the bone so as not to involve the nerves or blood vessels when the retractor is inserted. At the posterior surface of the tibia, a bent-tip elevators can be used. A retractor is inserted between the MCL and the proximal tibia to protect the neurovascular bundles. At this point, the tip of the first Kirschner wire is inserted between the 2 tendons 4 to 4.5 cm below the medial joint line. The second Kirschner wire is then inserted parallel to the first under fluoroscopy. An anterior ascending osteotomy is then performed at an angle of 110° to the horizontal saw cut, ending behind the patellar tendon insertion. An osteotomy is made toward the fibular head, leaving a hinge. With the spreader inserted into the osteotomy site, the Mikulicz line is checked using a long alignment rod to determine the correction angle. Axial pressure is then applied to the calcaneus to reproduce loading conditions. A β-tricalcium phosphate (β-TCP) block is cut into a trapezoidal shape and inserted considering the amount of correction required at the osteotomy site. Soft-tissue repair is performed before the plate is applied. With a Kocher, the MCL is pulled into its correct anatomical position and sutured to the surrounding tissue. Then, the ST tendon and G tendon are also returned to their usual anatomical positions, ensuring that they cover the MCL. The excised joint tendons and then the sartorius fascia are sutured to completely cover the osteotomy. A TOMOFIX anatomical medial high tibial plate is applied to the medial side of the proximal tibia. (G, gracilis; ST, semitendinosus.)
Surgical Technique (With Video Illustration)









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Postoperative Rehabilitation
Discussion
Supplementary Data
- ICMJE author disclosure forms
- Video 1
A curved oblique skin incision is made from the posteromedial corner of the proximal tibia to the insertion site of the pes anserine tendon. An incision is made in the sartorius fascia. The affected knee is placed in a slightly flexed position to relax the gracilis and semitendinosus tendons. These 2 tendons are then identified and scooped with a Kelly clamp and wet gauze. When the 2 tendons are separated, we can see the shallow layer of the medial collateral ligament (MCL) and the joint capsule. The distal attachments of the 2 tendons are left connected to the proximal tibia, and the boundary between the MCL and the joint capsule is marked with an electrocautery scalpel. A rasp is used at the border between the shallow layer of the MCL and the articular capsule to peel away the matter between the bone and the periosteum, which creates room for expansion. The dissection proceeds toward the posterior surface of the tibia and follows the bone so as not to involve the nerves or blood vessels when the retractor is inserted. At the posterior surface of the tibia, a bent-tip elevators can be used. A retractor is inserted between the MCL and the proximal tibia to protect the neurovascular bundles. At this point, the tip of the first Kirschner wire is inserted between the 2 tendons 4 to 4.5 cm below the medial joint line. The second Kirschner wire is then inserted parallel to the first under fluoroscopy. An anterior ascending osteotomy is then performed at an angle of 110° to the horizontal saw cut, ending behind the patellar tendon insertion. An osteotomy is made toward the fibular head, leaving a hinge. With the spreader inserted into the osteotomy site, the Mikulicz line is checked using a long alignment rod to determine the correction angle. Axial pressure is then applied to the calcaneus to reproduce loading conditions. A β-tricalcium phosphate (β-TCP) block is cut into a trapezoidal shape and inserted considering the amount of correction required at the osteotomy site. Soft-tissue repair is performed before the plate is applied. With a Kocher, the MCL is pulled into its correct anatomical position and sutured to the surrounding tissue. Then, the ST tendon and G tendon are also returned to their usual anatomical positions, ensuring that they cover the MCL. The excised joint tendons and then the sartorius fascia are sutured to completely cover the osteotomy. A TOMOFIX anatomical medial high tibial plate is applied to the medial side of the proximal tibia. (G, gracilis; ST, semitendinosus.)
References
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The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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