A 7 cm longitudinal incision is made along the anteromedial aspect of the distal tibia. Two Kirschner wires are inserted about 5 cm above the ankle mortise, just proximal to the tibiofibular syndesmosis, under fluoroscopic image intensifier in order to guide the osteotomy. Then, a periosteal incision of less than 1 cm is made along the site to perform the osteotomy, in an effort to maintain as many soft tissue attached to the distal bone fragment as possible. The osteotomy is performed parallel to the ankle mortise, and the lateral cortex at the apex of the distal part of the tibia must be preserved so that it can be used as a hinge. After completing the osteotomy, the distal osteotomized fragment is shifted inferiorly by introducing an osteotome through the medial aspect of the osteotomized site. Intraoperative visualization and fluoroscopy are used to evaluate the adequacy of the correction angle and lower limb alignment. Then, the osteotomy is fixed with 7-hole dynamic compression plate, in order to place three holes proximal and three holes distal to the osteotomy site. The gap is filled with autologous or allogenic bone graft.

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