Biplanar opening-wedge tibial valgus osteotomy for medial knee OA: Review of 20 year’s experience with tips and tricks

Background: Medial compartment gonarthritis associated with varus malalignment remains a significant cause of cartilage degeneration. While lateral closing-wedge techniques were historically preferred, medial open-wedge biplanar tibial valgus osteotomy using locking plate fixation has emerged as a standard joint-preserving intervention. Objective: This article provides a clinical algorithm and technical framework for performing medial open-wedge biplanar tibial valgus osteotomy, focusing on patient selection, preoperative planning, and intraoperative maneuvers to optimize alignment and minimize complications. Key Points: Success depends on precise deformity analysis using the Mikulicz line, medial proximal tibial angle (MPTA), and joint line obliquity. Indications include symptomatic Outerbridge grade 1–3 medial cartilage lesions with varus deformity exceeding 3°. Critical surgical steps involve a subperiosteal release of the superficial medial collateral ligament to prevent increased medial compartment pressure and a multi-chisel technique to create a stable lateral hinge. The biplanar cut protects the tibial tuberosity and allows for sagittal plane adjustments, such as slope reduction to address extension deficits. Locking plate fixation, specifically the Tomofix system, provides primary stability without the necessity for bone grafting in most cases. Long-term data from 92 patients demonstrate high union rates and significant pain reduction, with a mean correction angle of 9.2°. Potential complications include lateral hinge fractures, thromboembolism, and rare neurovascular injuries. Conclusion: Medial open-wedge biplanar osteotomy is an effective, reproducible procedure for medial gonarthritis. Adherence to a structured surgical protocol and precise intraoperative alignment control are essential for achieving durable clinical outcomes and delaying the requirement for arthroplasty.