Patent Publication Number: US-2023157703-A1

Title: Systems and method for forming biplanar osteotomies

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims benefit to Provisional Patent Application No. 62/967,252; filed Jan. 29, 2020; and Provisional Patent Application No. 63/054,561; filed Jul. 21, 2020; and Provisional Patent Application No. 63/108,238; filed Oct. 30, 2020, all titled “SYSTEMS AND METHOD FOR FORMING BIPLANAR OSTEOTOMIES”; herein incorporated by reference in their entirety. 
     This application incorporates by reference commonly owned Patent Application PCT/US20/019094 filed Feb. 20, 2020; and Provisional Patent Application No. 62/808129 file Feb. 20, 2019, both titled “SYSTEM AND METHOD FOR HIGH TIBIAL OSTEOTOMY”. 
    
    
     FIELD OF THE INVENTION 
     This invention is related to surgical apparatus and methods in general, and more particularly to apparatus and methods for forming a biplanar osteotomy, to realign bones. 
     BACKGROUND 
     Osteotomies of the lower limbs are an important technique for modifying the loadbearing geometry of the knee. For example a tibial osteotomy may treat knee osteoarthritis by adjusting the geometry of the knee joint to transfer weight bearing loads from arthritic portions of the joint to relatively unaffected portions of the joint. As another example tibial or femoral osteotomies may address abnormal knee geometries, e.g., due to birth defect, injury, etc. Most lower-limb osteotomies are designed to adjust the manner in which the load is transferred across the knee joint. One method of adjusting the orientation of the tibia, is an open wedge technique, represented in  FIG.  1 B  wherein a cut is made into the upper portion of the tibia, forming two segments of the tibia connected by a boney hinge  81 . The tibia is then manipulated to separate the two segments and open a wedge-like opening in the bone, and then the bone is secured in this position (e.g., by screwing metal plates to the bone or by inserting a wedge-shaped implant into the opening in the bone), thereby reorienting the lower portion of the tibia relative to the tibial plateau and hence adjusting the manner in which load is transferred from the femur to the tibia.  FIG.  1 B  shows an exemplary open-wedge high tibial osteotomy in association with a knee joint  75  between a femur  70  and a tibia  80 .  FIG.  1 B  is an anterior-posterior view. A planar cut  90  at a selected angle β relative to a first reference axis A of the knee joint  75  can be made. This is a partial cut, i.e., not a through cut, and can extend from an external surface boundary  92  at the intersection of the planar cut  90  with the outer surface of the tibia  80  to a second boundary  94  at the selected cutting depth illustrated as distance L in  FIG.  1 B . The second boundary  94  functions as a hinge axis line (also referenced with numeral  94 ) for opening a wedge angle γ between first and second opposing faces  96 ,  98  of the cut  90 , as illustrated by arrows C in  FIG.  1 C . The location of the first and second boundaries  92 ,  94 , the angle β of the planar cut  90  relative to the reference axis A, and the wedge angle γ may be determined during the pre-operative planning stage for correcting a condition of the particular patient. Typically, these are all determined such that the planar cut  90  extends along the coronal plane only, with the second boundary ( 94 ) defining an anterior-posterior line substantially parallel to the sagittal plane. Typically, these are all determined according to a single plane correction, in this case a coronal correction angle. However there may be times when the anterior-posterior slope of the tibial plateau may require tilting in the sagittal plane (reference  FIG.  1 A ) for example to further aid in an ACL or PCL condition. This therefore requires two substantially orthogonal corrections to be superimposed upon each other, hereinafter defined as a biplanar correction, represented in  FIG.  2 A . This may result in a twisting of the remaining boney hinge  81 , which may crack  100  ( FIGS.  2 A and  2 B ). Referring back to  FIG.  1 C  which shows a single correction plane osteotomy similar to the left hand side of  FIG.  2 A , in order to accommodate an additional sagittal plane correction, at least one of the first and second opposing faces  96 ,  98  must now be rotated relative to each other such that opening angle γ varies from anterior to posterior sides. Some attempted solutions have tried adding a stress-relieving hole at the apex or boundary  94  of the cut, to minimize propagation of any cracks, but this has not sufficiently addressed the needs of the procedure and cracking may still occur. Other attempted solutions if a crack is detected, is a more conservative rehab regime. However, this requires additional post-op follow up and care. Therefore, there is a need to provide an improved method and systems for controlling stresses on a boney hinge while correcting alignment of two segments of a bone, accommodating a biplanar correction. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       For a detailed description of example embodiments, reference will now be made to the accompanying drawings in which: 
         FIG.  1 A  shows a body defining planes through the body for reference purposes; 
         FIG.  1 B  shows a tibial osteotomy in the coronal plane only, for reference purposes; 
         FIG.  1 C  shows a tibial osteotomy distracted in the coronal plane only, for reference purposes; 
         1 D shows a femur osteotomy open and closed wedge, in the coronal plane only, for reference purposes; 
         FIG.  2 A  represents a possible result of a biplanar correction with a boney hinge axis or boundary oriented parallel to the sagittal plane, and thereby accommodating a single plane only; 
         FIG.  2 B  shows a boney hinge with a crack formed while twisting the opening to accommodate a second orthogonal correction, for reference purposes; 
         FIGS.  3 A and  3 B  represent X-ray images including an anterior-posterior view (left) and a sagittal view (right) image of a knee joint respectively; 
         FIG.  4 A  represents a model used to calculate an adjusted hinge axis, in accordance with the present disclosure; 
         FIG.  4 B  graphically represents the  varus  angle, AP angle and resultant adjusted hinge axis, in accordance with the present disclosure; 
         FIGS.  4 C and  4 D  schematically represent some example adjusted hinge axis angles of a tibia, in accordance with the present disclosure; 
         FIGS.  5 A and  5 B  schematically represent some example adjustment hinge axis angles of a tibia, in accordance with the present disclosure; 
         FIGS.  6 A- 6 C  schematically represent an example method and system for performing an open wedge biplanar osteotomy on a tibia, in accordance with the present disclosure; 
         FIGS.  7 A- 7 F  schematically represent an example method and system for performing a closed wedge biplanar osteotomy on a femur, in accordance with the present disclosure; 
         FIGS.  8 A- 8 E  illustrate an aimer assembly and components thereof, for placing a hinge pin at a target modified angle through the bone, in accordance with the present disclosure; 
         FIG.  9    illustrates an anterior cut guide in accordance with the present disclosure; 
         FIG.  10 A- 10 F  illustrate various views of a bone spreader, in accordance with the present disclosure; 
         FIG.  11 A- 11 C  illustrate various views of alternative bone spreader embodiments, in accordance with the present disclosure; 
         FIG.  12 A- 12 D  illustrate various views of a bone plate having a complex aperture, in accordance with the present disclosure; 
         FIG.  13 A- 13 C  illustrate torques on a boney hinge having a modified hinge axis angle and a resultant preferable plate location, in accordance with the present disclosure; 
         FIG.  14 A- 14 B  illustrate an alternative embodiment of a bone plate having a complex aperture, configured to be placed at a location to reduce torque on the boney hinge, in accordance with the present disclosure; 
         FIG.  15 A- 15 E  illustrate an alternative embodiment of a bone plate configured to reduce torsional moments on the tibia as a result of modifying the hinge axis angle, in accordance with the present disclosure; 
         FIG.  16 A- 16 D  illustrate a system for adjusting compression on a boney hinge in accordance with the present disclosure; 
         FIG.  17 A- 17 C  illustrate a method of compressing a boney hinge using an external compression tool; and 
         FIG.  18 A- 18 C  illustrate a plate and method of ACL repair or reconstruction, concomitant with an open wedge osteotomy of a tibia. 
     
    
    
     SUMMARY 
     Various terms are used to refer to particular system components. Different companies may refer to a component by different names—this document does not intend to distinguish between components that differ in name but not function. In the following discussion and in the claims, the terms “including” and “comprising” are used an open-ended fashion, and thus should be interpreted to mean “including, but not limited to . . . .” Also, the term “couple” or “couples” is intended to mean either an indirect or direct connection. Thus, if a first device couples to a second device, that connection may be through a direct connection or through an indirect connection via other devices and connections. 
     Generally, this disclosure is directed to a realignment of a bone, which may include forming a wedge in the bone that may be an open wedge, tibial osteotomy of the knee, and is intended to provide a cut having a predetermined or calculated apex. This predetermined apex or boundary defines an axis of rotation while opening the osteotomy, the axis determined to incorporate both coronal and sagittal corrections. While existing methods include forming an osteotomy  90  accounting for a single plane correction only, as discussed with reference to  FIG.  1 B- 1 D , this disclosure modifies the boney hinge boundary or axis to include a rotation angle θ about a longitudinal axis of the bone, A-A that may be calculated or determined to accommodate for the two orthogonal planes of correction superimposed on each other, hereinafter termed “biplanar correction” or “biplanar osteotomy”. The two orthogonal planes include non-zero corrections in both the sagittal and coronal planes. This rotation angle θ may define a resultant hinge axis angle or orientation; hereinafter termed “modified hinge axis” angle. Compared to a method wherein an osteotomy is formed accounting for a single plane correction only such as the coronal plane only, and then the osteotomy is twisted to accommodate the second plane correction, this method avoids or reduces the need for twisting of the bony hinge. This may mitigate weakening, creating concentrated stresses on, or cracking the bone hinge. A biplanar correction may include forming a single plane osteotomy, the single plane oriented at an angle that accommodates two orthogonal planar corrections. The present invention may also be directed towards a closed wedge tibial osteotomy, utilizing similar principals. For example, in  FIG.  1 D , the present invention may be implemented for an osteotomy of a femur  70 . The present invention may be implemented for a closed wedge osteotomy of any bone. Shown in  FIG.  1 D , the bone may be removed as a wedge between boundary  94 ,  95  and  96  and the bone rotated (see arrows) to a closed or abutting position. The present invention determines an improved orientation of the boundary. The present invention may be implemented for any osteotomy on any bone where two superimposed substantially orthogonal correction angles that are non-zero are desired. 
     Various embodiments are directed to a surgical method of attachment of a first bony segment in relation with a second bony segment, both segments belonging to a same bone. The method may include cutting the bone partially, to separate it in two bony segments linked together by a bony hinge and distracting or rotating both bony segments around the bony hinge, wherein the bony hinge is configured to rotate both bony segments around a single degree of freedom of the bony hinge and accommodate two substantially orthogonal correction planes. Twisting the bony hinge as shown in  FIG.  2 A  distracts or rotates the bony segments in at least two degrees of freedom. In some embodiments, the method may include preoperative steps of determining the relative three-dimensional positions of both bony segments to obtain the final desired alignment of the two bony segments, the relative three-dimensional position including the two substantially orthogonal correction planes and determining the orientation and position of the bony hinge. In some embodiments the two substantially orthogonal planes include the sagittal plane and the coronal plane. In some embodiments determining the orientation and position of the hinge, comprises using a look-up table. In some embodiments determining the orientation and position of the hinge, comprises using a computer program. In other embodiments determining the orientation and position of the hinge, comprises using a mechanical computer, wherein two angles may be input into a mechanical construct that mechanically resolves the rotation and wedge angle via cams and linkages. In some embodiments after determining the orientation and position of the bony hinge, the method may include drilling a hole through the bone to form a hinge axis at the determined orientation and position. In some embodiments, determining the orientation and position of the bony hinge comprises determining a rotation angle ( 0 ) of the hinge axis relative to a vertical plane, or sagittal plane of the bone, about a longitudinal axis of the bone. The method may include the preoperative steps of determining the relative three-dimensional positions of both bony segments to obtain the final desired alignment of the two bony segments, the relative three-dimensional position including the two substantially orthogonal correction planes and determining a final wedge opening angle. The method may include determining the final wedge-opening angle using either a look-up table or a computer program. The method may include rotating the two bony segments to the final wedge-opening angle. 
     An alternative surgical method is disclosed for attaching a first bony segment in relation with a second bony segment, both segments belonging to a same bone. The method includes cutting partially into the bone, cutting being implemented until obtaining a partial cut, which separates partially the bone into two bony segments linked together by a bony hinge, the bony hinge defining a hinge axis that is oriented at a non-zero angle relative to a sagittal plane through the bone. The method also includes rotating the first bony segment with respect to the second bony segment about said bony hinge about a single degree of freedom until obtaining a desired three-dimensional alignment of the two bony segments, including a biplanar correction as defined herein, and reaching a position in which facing sides of said bony segments are separated from each other by a predetermined opening angle. In some embodiments, the method may also include determining a hinge rotation angle relative to the sagittal plane using a targeted  varus  correction angle input and a targeted anterior-posterior slope correction angle input, thus defining a hinge axis angle that provides rotation of the first bony segment with respect to the second bony segment around the single degree of freedom. In some embodiments, the method may include determining the hinge rotation angle (θ) using physical charts. In some embodiments, the method may include determining the hinge rotation angle (θ) using a computer program. In some embodiments, the method may include drilling a hole and thus creating a boney hinge axis. In some embodiments, the method may include drilling the hole using preplanning navigation. In some embodiments, the hole may be drilled using a computer piloted robot whose working head is able to be moved according to at least three degrees of freedom. In some embodiments, the method may include cutting the bone, implemented by using a computer piloted robot whose working head is able to be moved according to at least three degrees of freedom, the working head supporting a cutting tool. In some embodiments, the method may include using a cutting guide to guide the orientation of the cutting tool. 
     A further method is disclosed of controlling a computer piloted robot having a working head that moveable according to at least three degrees of freedom, in order to implement a surgical method of attachment of a first bony segment in relation with a second bony segment, both segments belonging to a same bone. When a cutting tool is coupled to the working head, this method includes causing the cutting tool to cut partially the bone until obtaining a partial cut, which separates partially the bone in two bony segments linked together by a bony hinge, the bony hinge defining a single hinge axis. The method also includes rotating the two bony segments about a single degree of freedom to reorient the first bony segment relative to the second bony segment to a desired orientation including non-zero corrections in two substantially orthogonal planes. In some methods, the two substantially orthogonal planes may include the coronal and sagittal correction. In some methods the computer controlled robot may be in communication with a computer, the computer configured to preoperatively or intra-operatively determine the position and direction of the partial cut, calculating its depth, calculating an opening angle and the relative position of the first bony segment with respect to said second bony segment necessary to obtain the final desired alignment of the two bony segments, the final desired alignment including a biplanar correction. 
     A non-transitory computer-readable medium is also disclosed that stores a program that, when executed by a processor is configured to cause the processor to receive a value indicative of a first correction angle of a bone and receive a value indicative of a second correction angle of a bone, substantially orthogonal to the first correction angle. This processor is configured to determine a value indicative of a modified bony hinge axis angle including both the first and second correction angle. This processor may also be configured to determine a value indicative of a final wedge opening angle of a first bony segment of the bone relative to a second bony segment of the bone accommodating both the first and second correction angle. In some embodiments the processor may be communicably coupled to a computer piloted robot having a working head that is moveable according to at least three degrees of freedom, and wherein the program, when executed by the processor is configured to cause the computer piloted robot to orient the working head to the determined modified bony hinge angle, determined by the processor. In some embodiments, the computer piloted robot may be in communication with navigation sensors, configured to aid in orienting the working head at the determined modified bony hinge angle. In some embodiments when a cutting tool is coupled to the working head, the processor may be configured to cause the computer piloted robot to cut partially into the bone with the cutting tool until obtaining a partial cut which separates partially the bone into the two bony segments linked together by a bony hinge, the bony hinge oriented at the modified bony hinge axis. In some embodiments when a drilling tool is coupled to the working head, the processor may be configured to cause the computer piloted robot to drill into the bone along the modified bony hinge axis. In some embodiments when a wedge-opening tool is coupled to the working head, the processor may be configured to cause the computer piloted robot to distract the two bony segments to the final wedge opening angle by rotating the first bony segment relative to the second bony segment about a single degree of freedom. In some embodiments when a cutting guide is coupled to the working head, the processor may be configured to cause the computer piloted robot to orient the cutting guide in a desired orientation according to the determined modified boney hinge axis. 
     In addition, an example surgical method of attachment of a first bony segment in relation with a second bony segment, both segments belonging to a same bone, is disclosed herein including the step of: determining a modified hinge axis angle of a boney hinge that provides a single degree of freedom rotation of the first bony segment relative to the second bony segment, the modified hinge axis angle accounting for a final desired alignment of the two bony segments including two substantially orthogonal plane corrections. An aimer assembly is then placed around the bone. The method may include orienting a guide tube of the aimer assembly in a first orientation and then moving the guide tube along an aimer arm of the aimer assembly to orient an axis of guide tube along the determined modified hinge axis angle. A drill may then be inserted through the guide tube to form a hole through the bone, the axis of the hole defining the modified hinge axis of the bony hinge. In some example methods, moving the guide tube includes sliding the guide tube along the aimer arm. Moving the guide tube may include moving the guide tube up to a target numerical value indicated on the aimer assembly correlating to the modified hinge axis angle. Placing the aimer assembly may include first placing a posterior retractor around a posterior portion of the bone and coupling the aimer arm within a slot of the posterior retractor to place the aimer arm around a medial and anterior portion of the bone. Orienting the guide tube in a first orientation may include manipulating a handle extending from the posterior retractor. The first orientation may be defined as an orientation accounting for only one of the two substantially orthogonal plane corrections. The example method may also include removing the drill from the guide tube; and inserting a hinge pin through the guide tube. The example method may include inserting the hinge pin through the drilled hole to positively-engage a portion of a posterior retractor. The example method may include removing the aimer assembly from the posterior retractor, leaving the hinge pin within the hole and coupled to the posterior retractor; and coupling an osteotomy cutting guide to the posterior retractor and hinge pin. 
     An example embodiments of an aimer assembly is disclosed herein for forming a hole through a bone at a predetermined modified hinge axis angle. The example assembly includes an aimer arm that links to a retractor and extends around an outer portion of the bone. The assembly also includes a guide tube coupled to the aimer arm configured to move along the aimer arm and thereby around the bone and alter the guide tube orientation relative to the bone. The guide tube is configured to receive a means of forming a bone hole therethrough. The guide tube and aimer arm each include indicating markers that cooperate with each other to indicate a value correlating to the guide tube orientation relative to the modified hinge axis angle. In some example embodiments, the guide tube is slidingly coupled to the aimer arm. In some example embodiments, the guide tube is also configured to receive a hinge pin therethough, to place the hinge pin through the bone. In some embodiments, the guide tube aims the hinge pin towards an engagement mechanism of the retractor. The indicating markers may include numerical values on the aimer arm that correlate to the modified hinge axis angle. The numerical values may provide for a modified hinge axis angle up to 31 degrees relative to a reference angle. The reference angle may define an angle accounting for a single correction plane to the bone, the modified hinge angle accounting for a biplanar correction. The guide tube and aimer arm are configured to disconnect from the hinge pin and retractor, leaving the hinge pin and retractor coupled with each other and the hinge pin remaining through the bone hole. 
     Example embodiments of a laminar spreader are also disclosed herein, for separating two opposing sides on an osteotomy. An example laminar spreader may include a base having a distal end tapered to slip between the two sides of the osteotomy. The laminar spreader may also include a lifter having a proximal free end and pivotally coupled to the base adjacent the base distal end, that rotate relative to the base defining a cavity between the base and lifter. The laminar spreader may also include a wedge construct operably coupled to the base and configured to axially move a wedge of the wedge construct along the cavity to rotate the lifter and define an angle of separation of the two sides of the osteotomy. In some example embodiments, the wedge construct includes a lead screw orientated parallel to a base longitudinal axis and operable coupled to the wedge. Rotation of the lead screw axially moves the wedge along the cavity. The wedge may engage the lifter at a discrete portion of a top surface of the wedge. The wedge top surface may be disposed within the cavity and may be spaced away from the lifter. The wedge may engage the lifter at a location configured to indicate a separation value of the two sides of the osteotomy. 
     An example method of attaching a first bony segment in relation to a second bony segment, both segments belonging to a same bone is disclosed, including cutting partially into the bone, the cutting being implemented until obtaining a partial cut, which separates partially said bone in two bony segments linked together by a bony hinge. The bony hinge may define a modified hinge axis angle that is oriented to account for a biplanar correction. The method also includes rotating the first bony segment with respect to said second bony segment around the bony hinge about a single degree of freedom until obtaining a desired three-dimensional alignment of the two bony segments, in which facing sides of said bony segments are separated from each other by a predetermined opening angle. The method also includes fixing the desired three dimension alignment of the two boney segments with a bone plate, the bone plate including a bone engaging surface and holes therethrough, the engaging surface contour and the at least one of the holes&#39; orientation at least partially configured to account for the modified hinge axis angle. In some embodiments, the bone plate bone-engaging surface is contoured to match a contour of the preferred location of the first and second segment of the bone that is approximately parallel with the modified hinge axis. In some embodiments, the bone plate bone-engaging surface is contoured to position the plate at a location approximately facing the modified hinge axis. In some example embodiments, at least one of the holes through the plate defines a complex aperture including two overlapping threaded holes that are oriented at an angle to each other. The angle between the two overlapping threaded holes may be at least partially defined by the modified hinge axis. For a larger predetermined modified hinge axis relative to a hinge axis for a single correction plane only, the angle difference between the two overlapping holes axes is reduced. In some example methods, the bone is a bone of the knee and the method may also include forming a tunnel through the bone for reconstructing an ACL and wherein the two overlapping threaded holes are configured to place at least one fixation member therethrough in a direction that avoids the tunnel through the bone. In some example methods, the holes through the plate defines an inferior plurality of holes configured to orient a fixation member extending therethough at a first angle and a superior plurality of holes configured to orient a fixation member extending therethough at a different angle to the first angle, defining an offset angle configured to account for torsion along the bone that results from the modified hinge axis. The larger the modified hinge axis relative to a hinge axis for a single correction plane only, the larger the offset angle. 
     Another example plate is disclosed herein for fixing a first boney segment relative to a second segment of the same bone, after the two segments have been distracted around a bony hinge. The bony hinge may be configured to rotate about a single degree of freedom and may be oriented at a modified hinge angle axis to obtain a desired three-dimensional alignment of the two bony segments accounting for two orthogonal correction planes, in which facing sides of said bony segments are separated from each other by a predetermined opening angle. The plate may include a bone-engaging surface configured to match a surface of the plate at a preferred location accounting for the modified hinge angle axis. In some examples, the bone is a bone of the knee and a tunnel may be formed for reconstructing or repairing an ACL. The plate may include an aperture through a superior portion of the plate configured to aim a fixation member to accommodate a concomitant ACL repair or reconstruction. The fixation member may extend through the aperture and adjacent to, but not intersect the tunnel formed therethrough. In some example embodiments, the aperture defines a complex aperture including two overlapping threaded holes that are oriented at an angle to each other and wherein the angle is at least partially defined by the modified hinge axis angle. For a larger predetermined hinge axis angle relative to a hinge axis for a single correction plane only, the smaller the angle is between the two overlapping holes. The two overlapping threaded holes are configured to place at least one fixation member therethrough in a direction that avoids the tunnel for reconstructing the ACL. In some example embodiments, the plate bone-engaging surface is contoured to match surface contours of the bone at the preferred location, which is traverse the distraction and approximately faces the modified hinge axis angle. The plate may include a plurality of apertures through the plate defining an inferior plurality of apertures configured to orient a fixation member extending therethough at a first angle and a superior plurality of apertures to orient a fixation member extending therethough at an offset angle to the first angle, configured to account for torsion along the bone due to the modified hinge axis angle, and wherein the larger the modified hinge axis angle relative to a hinge axis angle for a single correction plane only, the larger the offset angle. 
     In addition a bone plate flexing system for compression of a bony lateral hinge of an open wedge osteotomy is disclosed, the flexing system for use with a bone plate and fasteners. The bone plate defines a plurality of threaded holes for receiving a plurality of the fasteners therethrough in engagement with the threaded holes. The bone plate includes a bone contacting first surface, an opposing second outer surface, and a thickness extending in a dimension between said the first and second surfaces. The system includes a first shaft having a handle end and a threaded end for threadingly engaging with a first threaded hole of the plurality of the threaded holes. The system also includes a second shaft having a handle end and a threaded end for threadingly engaging with a second threaded hole of the plurality of the threaded holes. The first and second shafts each define a longitudinal axis. The system also includes an apparatus having a distal end configured to engage both shaft handle ends. The apparatus also includes actuation means for moving the first and second shaft handle ends relative to each other while engaged with the bone plate, and thereby elastically flexing the bone plate. 
     In some example embodiments, the apparatus includes a means of maintaining the bone plate in an elastically flexed configuration. The first and second shafts may both define drill guides. The first and second shaft threaded ends may define a length longer than the plate thickness such that the threaded ends extend beyond the first surface of the plate and form a local standoff between the first surface and bone. The first and second shaft ends may be independently engageable with the bone plate and may by engaged and disengaged by hand. The first and second shaft ends may both engage holes of the bone plate that are disposed either side of a third hole of the plurality of holes. The first and second shaft ends may both engage holes of the bone plate that are disposed at opposing ends of the plate, such as the inferior end and superior end. The first and second shaft ends may both engage holes of the bone plate that are one each side of the osteotomy distraction. 
     A method of elastically flexing a bone plate and thereby compressing a bony hinge of an open wedge osteotomy is also disclosed herein. The bone plate stabilizes the open wedge osteotomy and includes a superior portion for fixing with a superior side of the osteotomy and an inferior portion for fixing with an inferior side of the osteotomy. The method includes placing a bone plate adjacent an osteotomy of a bone, the bone plate having a first plurality of threaded holes disposed through the plate superior portion and a second plurality of threaded holes disposed though the plate inferior portion. The superior portion of the plate is fixed to the bone. A first elongate body is engaged with one of the holes of the first plurality of holes, and a second elongate body is engaged with one of the second plurality of holes. A plate-flexing tool is then engaged with the first and second elongate bodies. Using the plate-flexing tool, a force is applied via the first and second elongate bodies, to elastically-flex the plate along the plate longitudinal axis. While applying the force, the bone plate is further fixed to the bone, at a location spaced between the first and second elongate bodies, and thereby compressing the bony hinge. In some example methods, applying the force to elastically-flex the plate moves the inferior portion of the plate further away from the bone. The method may include releasing the plate-flexing tool from the first and second elongate bodies after fixing the portion of the bone plate to bone at the location spaced between the first and second bodies, and thereby relaxing the inferior portion of the plate towards the bone. 
     DETAILED DESCRIPTION 
     The following discussion is directed to various embodiments of the invention. Although one or more of these embodiments may be preferred, the embodiments disclosed should not be interpreted, or otherwise used, as limiting the scope of the disclosure, including the claims. In addition, one skilled in the art will understand that the following description has broad application, and the discussion of any embodiment is meant only to be exemplary of that embodiment, and not intended to intimate that the scope of the disclosure, including the claims, is limited to that embodiment. 
     The disclosure may generally include improved methods and systems to determine, form and fixate a bone alignment adjustment that includes an osteotomy and accommodates a bone alignment with correction in two substantially orthogonal planes. This disclosure may include improved systems and methods of ACL repair or reconstruction that includes a concomitant bone alignment adjustment. These methods and systems may determine a modified open or closed wedge angle and boney hinge axis that accommodates a targeted bone alignment including two substantially orthogonal planes. These two substantially orthogonal planes may be the sagittal and coronal planes of the body. This disclosure may also include methods including calculating or determining an improved hinge-opening angle and hinge axis to accommodate a targeted bone alignment around two substantially orthogonal planes. This hinge-opening angle and hinge axis are configured to rotate the osteotomy about a single degree of freedom only, and thereby require no twisting of the boney hinge to accommodate the biplanar alignment. This disclosure also includes systems for forming and maintaining this improved osteotomy cut angle and/hinge line and hinge opening angle, accommodating for changing forces and torsions on the bone. The osteotomy may be part of a high tibial osteotomy, or a lower (or distal) femur osteotomy. The osteotomy may be part of shoulder-elbow-wrist (SEW) realignment. The osteotomy may be part of a procedure including an open-wedge osteotomy or closed wedge osteotomy. In a closed wedge osteotomy, a wedge of bone is removed and the two segments rotated towards each other. This disclosure may therefore also include determining parameters associated with the size, angle and location of the wedge of bone to be removed, such that upon removal, rotation of the two segments rotates them around a single degree of freedom and accommodates a biplanar correction. 
     The desired correction angle including the two substantially orthogonal planes may be determined during a pre-operative planning stage of the procedure. For example using a series of several preoperative medical images and data (x-rays echography, MRIs or CAT scans for example), the surgeon knows for example the pathologic angle HKA (Hip-Knee-Ankle) or alternatively SEW (Shoulder, Elbow, Wrist) of his patient. For example, represented in  FIGS.  3 A and  3 B  represent two views of the tibia commonly taken by X-ray.  FIG.  3 A  shows an anterior-posterior view, used to determine the  varus  correction, otherwise defined as a correction in the coronal plane.  FIG.  3 B  shows a sagittal view, used to determine the AP correction otherwise defined as a correction in the sagittal plane. Based on these desired angles, a computer may be configured to determine the desired target alignment of the two bony segments. The computer may include a series of mathematical equations, or a look up table. The computer may include a 3D modelling program that may automatically model the current anatomy orientation based on the medical image data and determine the targeted orientation of the hinge axis. Alternatively or additionally the computer may determine at least one of the starting position ( 92 ) on the bone surface, the orientation relative to the sagittal and coronal planes, the depth of the future partial cut, the opening wedge angle of the hinge after distraction or rotation of the bony segments and the relative three dimensional positions of the first bony segment with respect to said second bony segment. The computer may include a 3D modelling program that may interactively model the current anatomy orientation based on medical image data and allow the surgeon to modify a targeted bone alignment and determine at least one of the position, the direction and the depth of the future partial cut, the opening angle of the hinge after rotating of the bony segments and the relative three dimensional positions of the first bony segment with respect to said second bony segment. The computer may be in the form of a tablet, including an “APP” and provide information to the surgeon or surgical technician. The computer may be in communication (directly or wirelessly) with a robot and/or surgical navigation system or 3D localizer configured to place a cutting tool, guide and/or drill in the desired location and orientation, after registering the anatomy with the virtual model. 
     The computer may also address combined surgeries such as Anterior Cruciate Ligament (ACL) reconstruction with the High Tibial Osteotomies (HTO). In this example, the ACL reconstruction tunnels and osteotomy cut with plating screws could inadvertently intersect, creating negative surgical outcomes. With 3D computer navigation, this issue could be eliminated. Alternatively, rather than using a computer, on the basis of these medical images a chart or look-up table may be referenced directly by the surgeon to determine at least one of the position, the orientation and the depth of the future partial cut, the angle of the hinge axis relative to the sagittal plane and the relative three dimensional positions of the first bony segment with respect to the second bony segment. In other embodiments, a mechanical computer may be used, wherein two angles based on the medical images may be input into a mechanical computer construct that mechanically resolves the rotation and wedge angle via cams and linkages. 
     For example for desired  Varus  and AP slope corrections angles, using for example the two images in  FIGS.  3 A and  3 B , a modified hinge axis orientation may be determined. For a  varus  correction angle only, the hinge axis typically extends substantially parallel to the sagittal plane and is hereinafter defined as the reference plane.  FIG.  4 A  represents a model of the tibia with the varying input angles. This may be used as a means of calculating the modified hinge axis angle relative to the reference plane that may be incorporated into a computer, or used to form a look up table, as described earlier. Shown in  FIG.  4 A  is an example  varus  correction angle    400 , determined using the Anterior-posterior image ( FIG.  3 A ) for example. Shown in  FIG.  4 A  is an example AP slope correction angle  ,  410  determined using the sagittal image ( FIG.  3 B ) for example. For reference purposes, the anterior, posterior, lateral and medial sides are represented and correspond to anterior, posterior and lateral and medial sides of the tibia. For point of reference the true AP Axis may be boundary line  94  in  FIGS.  1 B and  1 C , corresponding to a single plane correction that is parallel to sagittal plane is shown. The equation that may determine the modified hinge axis  450 , modified by a rotation angle (θ) relative to the AP axis or relative to the sagittal plane, with known AP≥  410  and  Varus      400  using  FIG.  4 B  as reference may look as follows. 
     
       
         
           
             Solving 
             ⁢ 
                 
             for 
             ⁢ 
             
                 
                  
             
             ⁢ 
             X 
             : 
           
         
       
       
         
           
             
               tan 
               ⁡ 
               ( 
               
                 AP 
                 ⁢ 
                 ∢ 
               
               ) 
             
             = 
             
               X 
               / 
               L 
             
           
         
       
       
         
           
             X 
             = 
             
               
                 tan 
                 ⁡ 
                 ( 
                 
                   AP 
                   ⁢ 
                   ∢ 
                 
                 ) 
               
               × 
               L 
               ⁢ 
                      
               
                 ( 
                 
                   
                     where 
                     ⁢ 
                         
                     L 
                   
                   = 
                   1 
                 
                 ) 
               
             
           
         
       
       
         
           
             X 
             = 
             
               tan 
               ⁡ 
               ( 
               
                 AP 
                 ⁢ 
                 ∢ 
               
               ) 
             
           
         
       
       
         
           
             Solving 
             ⁢ 
                 
             for 
             ⁢ 
                 
             Y 
             : 
           
         
       
       
         
           
             
               tan 
               ⁡ 
               ( 
               
                 Varus 
                 ⁢ 
                 ∢ 
               
               ) 
             
             = 
             
               X 
               / 
               Y 
             
           
         
       
       
         
           
             Y 
             = 
             
               X 
               
                 tan 
                 ⁡ 
                 ( 
                 
                   Varus 
                   ⁢ 
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                 ) 
               
             
           
         
       
       
         
           
             Solving 
             ⁢ 
                 
             for 
             ⁢ 
                 
             Hinge 
             ⁢ 
                 
             Angle 
             : 
           
         
       
       
         
           
             
               Hinge 
               ⁢ 
                   
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             = 
             
               
                 arctan 
                 ⁡ 
                 ( 
                 
                   Y 
                   L 
                 
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               = 
               
                 arctan 
                 ⁡ 
                 ( 
                 Y 
                 ) 
               
             
           
         
       
       
         
           
             
               Hinge 
               ⁢ 
                   
               ∢ 
             
             = 
             
               arctan 
               ⁡ 
               ( 
               
                 X 
                 
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                   ⁡ 
                   ( 
                   
                     Varus 
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             Substituting 
             ⁢ 
                 
             
               tan 
               ⁡ 
               ( 
               
                 AP 
                 ⁢ 
                 ∢ 
               
               ) 
             
             ⁢ 
                 
             for 
             ⁢ 
                 
             x 
             : 
           
         
       
       
         
           
             
               Hinge 
               ⁢ 
               
                   
                    
               
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               ∢ 
             
             = 
             
               arctan 
               ⁢ 
               
                 ( 
                 
                   
                     tan 
                     ⁡ 
                     ( 
                     
                       AP 
                       ⁢ 
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                     ) 
                   
                   
                     tan 
                     ⁡ 
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                       Varus 
                       ⁢ 
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     Similar calculations may be made for other bones, using similar references. For example, the modified axis may be rotated about a longitudinal axis of a bone and with reference to any plane along the bone that is appropriate, anatomically. For example, the rotation angle θ could be calculated relative to either a sagittal or coronal plane through the bone. 
     In addition, a new distraction angle γ′ may be determined, and is a resultant angle taking into account the two substantially orthogonal angles; the  Varus  correction angle    400 , and the AP slope correction angle    410 . This new distraction angle γ′ or single combined “Total Angle” in combination with the modified hinge axis angle is configured to orient the first bony segment relative to the second boney segment, with rotation about a single degree of freedom, (without twisting of the two bony segments relative to each other) accounting for at least two substantially orthogonal creation planes. 
     The equation that may determine the resultant wedge angle γ′ with known AP  and  Varus     look as follows. 
     
       
         
           
             
               Wedge 
               ⁢ 
                  
               ∢ 
             
             = 
             
               
                 
                   AP∢ 
                   2 
                 
                 + 
                 
                   Varus 
                   ⁢ 
                      
                   
                     ∢ 
                     2 
                   
                 
               
             
           
         
       
     
     An example look up table, using the above equations is shown below. V/V represents the  Varus  correction angle    400 , A/P represents the AP slope correction angle    410 . “Total Angle” is the resultant Wedge opening   (γ′), or described above. “Rotation Angle” in the chart below is the “Hinge  4 ” per the equation above, and is the modification in angular degrees)(° to the hinge line axis, indicated as 0 on  FIGS.  5 A and  5 B . In summary, this algorithm or series of calculations use a plane that is described by angles (lines) in two correction planes:  Varus  Angle (Coronal Plane) and AP Angle (Sagittal Plane), and resolves that into a “surgically useful” single plane described using an axis in space (Hinge Axis) and single (total) angle. 
     
       
         
           
               
               
               
               
               
             
               
                   
                   
               
               
                   
                   
                   
                 Total 
                 Rotation 
               
               
                   
                 V/V 
                 A/P 
                 Angle 
                 Angle 
               
               
                   
                   
               
             
            
               
                   
               
            
           
           
               
               
               
               
               
            
               
                   
                 5 
                 0 
                 5.0 
                 0 
               
               
                   
                 5 
                 2 
                 5.4 
                 21.7 
               
               
                   
                 5 
                 4 
                 6.4 
                 38.6 
               
               
                   
                 5 
                 6 
                 7.8 
                 50.1 
               
               
                   
                 10 
                 0 
                 10.0 
                 0 
               
               
                   
                 10 
                 2 
                 10.2 
                 11.2 
               
               
                   
                 10 
                 4 
                 10.8 
                 21.6 
               
               
                   
                 10 
                 6 
                 11.6 
                 30.7 
               
               
                   
                 15 
                 0 
                 15.0 
                 0 
               
               
                   
                 15 
                 2 
                 15.1 
                 7.4 
               
               
                   
                 15 
                 4 
                 15.5 
                 14.6 
               
               
                   
                 15 
                 6 
                 16.1 
                 21.3 
               
               
                   
                   
               
            
           
         
       
     
       FIG.  4 C  schematically represents an exemplary series of hinge axis angle orientations for a 15 degree  Varus  correction for a series of AP corrections about the coronal plane in a first direction that reduces the anterior/posterior slope of the tibial plateau.  FIG.  4 D  schematically represents an exemplary series of hinge axis angle orientations for a 15-degree  Varus  correction for a series of AP corrections about the coronal plane in a second direction that increases the anterior/posterior slope of the tibial plateau. There will be situations where the patient requires an increase in AP slope and instances where the patient needs a decrease in AP slope to optimize a biplanar correction. Improper AP slope can lead to increased risk of ACL rupture. In some cases, ACL reconstruction is completed concurrent with a HTO procedure. 
     AP slope correction may include increase or decrease the AP Slope for the tibial plateau. The osteotomy will open opposite the boney hinge location. If the hinge is rotated anteriorly (or clockwise) as shown in  FIG.  4 C  the osteotomy will open posteriorly, decreasing the tibial plateau AP slope. If the hinge is rotated posteriorly ( FIG.  4 D ), the osteotomy will open anteriorly increasing the AP slope. In summary, rotating the hinge axis posteriorly will have a positive increase in AP slope. Rotating hinge anteriorly will decrease the AP slope.  FIG.  5 A  shows a view representing three variations of the rotation angle θ of the hinge axis about a longitudinal axis such as axis A-A. In this example, the angle θ is provided relative to the sagittal plane. The left hand image represents rotating the hinge anteriorly, while the right two images represent rotating the hinge axis posteriorly.  FIG.  5 B  shows a top view of a tibia parallel with the transverse plane with an example rotation angle θ (rotation angle). Reference line R-R indicates a typical cut made for a coronal correction only as shown and described in  FIGS.  1 B and  1 C . 
       FIG.  6 A- 6 C  represent portions of a system and method that may be used to form a biplanar osteotomy through the bone  80  as disclosed herein. The example system and method may include determining the modified hinge axis angle (θ) and location. This may be achieved using a computer program or a look-up table for example. A hinge pin  600  may then be located through the bone at this modified hinge axis location and orientation. A mechanical guide may be used to aid the surgeon in placing this pin  600  along the modified hinge axis angle. For example, a guide construct may include a series of openings or tubes aligned at a series of angles to each other, corresponding with a plurality of discrete modified hinge angles, the openings configured to receive at least one of a guide wire, drill, trephine or pin therethrough. As another example, a guide construct may include a marker or opening slideable between a series of positions, the positions corresponding with a plurality of modified hinge angles, the opening also configured to receive at least one of a guide wire, drill, trephine or pin therethrough. 
     An example aimer assembly  800  is disclosed in at least  FIG.  8 A- 8 D . In this embodiment, a drill bit may first be inserted through the opening  810 , once the aimer assembly  800  has been aligned, opening  810  aligned with the predetermined modified hinge axis orientation. Drill may be inserted through the bone to create a tunnel corresponding with the hinge line axis at the modified angle θ. Drill may then be removed and a pin  600  put in its stead. Alternatively the drill bit may also double as a hinge pin, and remain in place. A cutting guide  610  may be operationally coupled to the hinge pin  600  to place a cutting tool  620  at a desired location relative to the hinge pin  600 . The guide  610  and hinge pin  600  may then be removed and the two bony portions distracted about a single degree of freedom defined by the modified hinge axis angle and thereby achieve the biplanar alignment. This may produce an opening accounting for both the coronal and sagittal correction, with no twisting of the bony hinge, and thereby is a distraction limited to a single degree of freedom. 
     In alternative systems and methods, a hinge pin  600  may be eliminated and a cutting guide  610  may be configured to place the cutting tool  620  at a desired orientation to form a cut that is adjusted and oriented at an angle to the sagittal plane according a determined modified angle. The terminal end of the cut therefore defines the modified hinge axis  450  or boundary that defines a modified hinge axis, the modified angle (θ) that is non-parallel to the sagittal plane. Alternatively, an aimer assembly  800  may be avoided and a drill bit may be coupled to a working end of a robot operable to orient the drill bit at the desired orientation and location, to orient the hinge pin  600  in the determined orientation and place it into the bone. Alternatively, an aimer assembly  800  may be avoided and a cutting tool may be coupled to a working end of a robot operable to orient the cutting tool at the desired orientation and location, to orient the osteotomy  600  in the determined orientation to form an osteotomy partially through the bone that terminates at a boundary that aligns with the predetermined modified hinge axis. 
     An alternative system and method may include forming a patient specific cutting guide and/or hinge pin orientation construct. This may be used to place a hinge pin through the bone  80  and/or corresponding cutting plane, accounting for the two substantially orthogonal correction planes. Similar to the previous example disclosed, this example system and method may include determining the modified hinge axis angle and location or a cutting plane orientation and location. This example system and method may include determining a cutting guide surface morphology that conforms to external surfaces contours of the tibia. The guide surface contours may be configured to place the guide in the target location and orientation that forms the predetermined osteotomy. More specifically the guide contours may position the guide and may orient a hinge pin and/or cutting saw  620  through the tibia at the determined location and orientation that realigns the bone with a rotation about a single degree of freedom and accommodates a biplanar correction. The guide morphology may be determined using images (CT or X-ray for example), and 3D images. Determining the 3D surface morphology may include using a computer program. A mechanical guide may be formed or modified according the determined morphology, specific to the patient, based on these images received. For example an inner surface of the guide may be formed or modified to have an inner surface morphology configured to engage and match a determined location of a medial side of the tibial external surface, specific to the patient. Matching is preferably configured to place a saw  620  at the determined starting location and orientation to form the determined osteotomy trajectory. The guide  610  may also include a construct that aligns the hinge pin  600  at the determined angle. The hinge pin alignment construct may include a patient matched reference surface specifically configured to align the hinge pin through the tibia at the determined modified axis angle. The hinge pin patient matched reference surface may cooperate with a surface of the guide or with external surface of the patient bone. 
       FIG.  6 C  shows means of forming the determined wedge distraction angle γ′ that accounts for the two substantially orthogonal correction planes. A first means may include includes a wedge  650  with a scale  660 . The scale  660  may include values indicative of a wedge opening angle such as angle γ′. Wedge  600  is tapered for gradual insertion and distraction and may be tapped or pushed in up until the determined wedge angle, the scale  660  indicating a distraction angle γ′. To account for both substantially orthogonal correction planes, the wedge may be used to rotate the two bony segments up to the modified distraction angle γ′. Wedge  650  may be selectively coupled to a handle that includes a surface configured to be tapped or hammered on to gradually distract the two boney segments. 
       FIG.  7 A- 7 F  illustrate an example method of forming a closed wedge biplanar correction on a femur  70 . Similar to the previously disclosed method, the example method may begin by determining the modified hinge axis angle and location. This method may also determine a wedge size, and thereby the orientation of two cuts into the bone, as a closed wedge osteotomy removes a wedge portion of bone and the two remaining surfaces rotated towards each other. Predetermining the modified hinge axis and wedge size may be achieved using a computer program, app, or a look-up table for example. An aimer assembly similar to assembly  800  may first engage the femur  70  and the opening  810  may be moved along arm  820  to the determined angle ( FIG.  7 A ). A drill may be inserted through opening  810  to form a hole that aligns with the predetermined modified hinge axis through the femur. Drill may remain in place, to act as the pin or be removed and replaced by a hinge pin  600 . The aimer assembly  800  may then be removed, leaving the pin  600  in place and a cutting guide  610  may be operationally coupled to the hinge pin  600  to guide a first cut  701  through the femur  70  up to the hinge pin  600  ( FIG.  7 B ). The cutting guide  610  may then be moved to a second location, while remaining engaged with the hinge pin  600  ( FIG.  7 C ). The cutting guide  610  may be rotated a predetermined amount, to form the predetermined wedge size. A wedge size indicator  755  may be operably coupled to the cutting guide  610  with markings to indicate a wedge size. Indicator  755  may include a first lip  756  that may be inserted through a saw guide slot  612  of the cutting guide  610 , and a second lip  757  that may be inserted into the first cut  701 . The cutting guide  610  may then be rotated about pin  600  up until the predetermined wedge size as indicated on the indicator  755 . The indicator  755  may then be removed and a second cut  702  formed, up to the pin  600 . The guide  610  and hinge pin  600  may then be removed and the resultant boney wedge removed to form an opening γ′ having an axis of rotation that accommodated a biplanar correction ( FIG.  7 E ). The two boney portions may then be rotated towards each other about a single degree of freedom defined by the modified hinge axis angle and thereby achieve the biplanar alignment. The two segments may then be fixed in place with a plate  780 . 
       FIG.  8 A- 8 C  illustrates details of aimer assembly  800  for placing a hinge pin  600  and thereby orienting a boney hinge axis at the modified hinge axis θ. The assembly  800  as shown may allow up to a thirty degree hinge angle rotation in either direction from reference angle R-R ( FIG.  5 B ). Shown in  FIG.  8 A , the angle is at zero, and the aimer assembly  800  oriented along reference angle R-R. In use, the surgeon may first place a posterior retractor  850  around a posterior portion of tibia  80 , and then link aimer assembly  800  with retractor  850 . Aimer  800  may then be adjusted initially to align a guide tube  810  for the  varus  correction angle only (at zero), and therefore substantially parallel to the sagittal plane, herein defined along the reference angle R-R. Using information from a look up table, computer program or app together with pre-procedure images and planning, the guide tube  810  may then be adjusted by sliding a portion of the aimer  800  around the aimer arm  820  to the determined modified axis angle θ. Guide tube  810  may be configured to receive a drill therethrough and aim the drill through the tibia  80  at the predetermined modified hinge axis angle θ. A hinge pin  600  (as disclosed in  FIGS.  6 A and  6 B ) may optionally then be placed within drilled hole at this pre-planned axis angle. 
       FIG.  8 B  illustrates an exploded view of the aimer  800 . Aimer arm  820  is configured to link to a posterior retractor  850 , seen in  FIG.  8 E , and that may be used to later couple to a construct that guides the osteotomy, as disclosed herein. Aimer arm  820  defines a linking end  812 , which may include a ball plunger  814 . This may include a biasing member to help maintain the aimer arm  820  within posterior retractor slot. Aimer arm  820  is configured to extend around an outer surface of a patient knee. Aimer arm  820  defines markings such as laser marks, to indicate an angle corresponding to the “Rotation Angle” or modified hinge line axis θ, disclosed herein. Aimer guide  825  may be slidingly coupled to the aimer arm  820 . Aimer guide  825  may also include a cannulation for receiving guide tube  810  therethrough such that guide tube  810  may be removed from aimer guide  825 . Sliding the guide  825  along the arm  820  and thereby around the bone  80 , moves the guide tube  810  around the bone also. Moving the aimer arm  820  to align the marks to a value indicative of a rotation angle θ, is configured to align the guide tube at the determined modified hinge axis angle. Aimer guide  825  may also include means to selectively lock the guide  825  in a target location relative to arm  820 . A threaded plunger  830  may extend through arm  825  and may selectively engage a portion of arm  820  to lock the guide  825  at the target modified angle. Knob  832  may operate plunger  830  to selectively lock guide  825 . A series of holes or an elongate slot  824  may receive an end of plunger  830 , selectively inserted using knob  832 . Aimer  800  may also include a construct  860  for retaining tube  810  in position. Construct  860  may include a ratchet plunger, locking cap and spring that may cooperate with ridges  811  on tube  810  to axially fix tube  810  in position within the guide  825 . 
       FIG.  8 C  shows a cross section through aimer  800  and retractor  850 . Ball plunger  814  together with a tapered linking end  812  may insert into a slot  855  of retractor  850 . This aligns the aimer arm  820  to the retractor  850 , so that the hinge pin  600  will accurately align with retractor  850 . Retractor  850  may also be configured to positively engage an end of hinge pin  600 . For example, retractor  850  may include an opening  852  with a retaining BalSeal or spring like O-ring  854  to secure the hinge pin  600  to the posterior retractor  850 . Opening  850  may include a tapered opening  853 , opening towards bone engaging surface of the retractor  850  to guide receipt and alignment of pin  600  with opening  852 . The aimer  800  may then be removed leaving the retractor  850  and pin  600  in place and a cut guide may be assembled to the hinge pin  600  and retractor  850 . An example cut guide  610  is shown in  FIG.  6 B  that references the hinge pin  600 . Cutting guide may be similar in part, with cutting guide disclosed in commonly owned patent application No. 62/808,129 filed Feb. 20, 2019, titled “SYSTEM AND METHOD FOR HIGH TIBIAL OSTEOTOMY”; herein incorporated by reference in its entirety. 
     The hinge pin  600  may locate the cut guide  610  in the target position and orientation to produce the preferable osteotomy plane angle relative to the modified hinge axis angle θ. The cutting guide  610  may connect to the posterior retractor  850 . The hinge pin  600  also provides a barrier or border to the osteotomy, thereby limiting travel of a saw (such as tool  620 ) creating a high precision osteotomy cut. Cutting guide  610  and pin  600  may then be removed and an anterior cut guide  900  placed adjacent the tibia  80  to orient a transverse cut to relieve the patella tendon. An example anterior cut guide  900  is shown with a lip that may fit between the two boney segments, formed by the osteotomy. Anterior cut guides are disclosed in at least commonly owned patent application No. 62/808,129 filed Feb. 20, 2019, titled “SYSTEM AND METHOD FOR HIGH TIBIAL OSTEOTOMY”; herein incorporated by reference in its entirety. This anterior cut allows the osteotomy opening to occur. 
     During preplanning, the surgeon may use a series of charts provided, examples of which have been disclosed herein. For example, for a determined  Varus  correction (degrees) and a determined AP slope Correction (degrees) a modified hinge axis angle orientation (degrees) may be determined and the aimer  800  may orient a guide tube and thereby the hinge pin  600  at this determined axis angle. In addition, with the same two input corrections, a chart may also provide an overall opening angle (Hinge  ). Alternatively, a wedge opening distance (in mm for example) may be provided in lieu of or in addition to an opening angle γ. In alternative embodiments a computer program or app may convert the two input correction angles and provide the surgeon with the modified hinge angle axis and wedge opening dimension. 
       FIG.  10 A  illustrates a further embodiment laminar spreader that may distract the two bony segments. Laminar spreader  1000  is configured to distract the two boney segments at a controlled rate. Laminar spreader  1000  may also include a means to indicate the opening angle and control the opening to the target opening angle (γ′ or Hinge  4 ) that is previously determined using charts. Spreader  1000  may also include a means to maintain that opening once attained. The opening distance is planned prior to the procedure, and requires accuracy in order to improve patient outcome. The osteotomy must be opened slowly, carefully, and accurately to the appropriate opening size to mitigate cracking of the boney hinge  81 . The spreader  1000  also includes a means to provide feedback as to an opening dimension. The spreader  1000  is preferably multi-use and therefore configured to be disassembled and sterilized. The spreader  1000  is preferably small, less than ½ inch wide and 4 inches long, to be placed between the two boney segments of the osteotomy while still not obscuring the target site. 
     Seen in  FIG.  1013    shows a spreader  1000  placed between the two boney segments formed by an osteotomy of tibia  80 . The instant opening angle may be 15 degrees ( FIG.  10 C ), illustrated by numerical values on the wedge portion that align with a mark on a lifter, disclosed in more detail later. The spreader  1000  may include a base  1010  having a tip  1020  that slides into the osteotomy. Tip  1020  therefore defines a tapered end. Spreader  1000  may be hammered to initially insert tip  1020 . Tip may be inserted up to the end of osteotomy initially, while in a low profile configuration. Spreader  1000  includes a lifter  1030  that may be controllably opened to engage one of the boney segments and distract the bony segments from each other. A plurality of embodiments are disclosed to control a lifter  1030 . Key features of this spreader assembly  1000  include a means to control the elevation rate of the lifter  1030  at a slow rate; indication means of the opening value, or means to limit the opening value to a target value; and a hinge means that is low profile. 
     For example, shown in  FIGS.  10 A- 10 F  is a first embodiment including a lead screw wedge mechanism. The mechanism includes a lead screw knob  1050  coupled to a lead screw  1055  that moves the wedge  1060  axially towards tip  1020  and causes the lifter  1030  to distract the osteotomy to the desired dimension. Lifter  1030  may include a free end  1032 . Lifter  1030  may be pivotally coupled and may rotate relative to the base  1010 , defining an adjustable cavity  1015  between the base  1010  and lifter  1030 . Wedge  1060  may axially move in and out of cavity  1015  to define orientation of lifter  1030  and thereby opening dimension between the two boney segments. Wedge  1060  may engage lifter  1030  coincident with an indicator or numerical marking indicating an opening size of wedge. Shown here, the opening dimension is indicated using laser mark lines with numerical values; which correspond to osteotomy opening angles or opening gap sizes. For example the indicator on lifter  1030  lines up with the number “15” on the wedge  1060  as shown in  FIGS.  10 C , which may correlate to an osteotomy opening of 15 mm. Alternatively, the threaded wedge can be switched out for a patient-specific wedge that, when linearly moved forward in the assembly to a defined laser-line, for example, may open the osteotomy to the targeted opening size that the surgeon defined in pre-op. The portion of wedge  1060  disposed within cavity  1015  may be spaced away from lifter  1030 . The lifter may solely engage the wedge at a discrete location coincident with the opening size indicator. Lead screw  1055  defines an axis parallel with the base longitudinal axis and may operate to move wedge linearly along the base  1010 . In order to reduce the overall height of the tip  1020  of assembly  1000 , the pivot defines a hardware-less and thereby low profile coupling. Illustrated in  FIG.  10 D-F , the lifter may be removed from the base  1010  by rotating lifter  1030  until a flat surface  1033  is parallel to the base flat surface  1012 . 
     An alternate embodiment is illustrated in  FIGS.  11 A and  11 B  including a means of controlling the opening using a ratcheted lifter  1100 . Actuation of a handle may rotate the ratcheted lifter  1100  to distract the osteotomy. The base  1120  may include a stationary ratchet mechanism  1125  that is operatively coupled to the lifter  1100  to rotate the lifter  1110 . Each ratchet step as the lifter arm  1100  is rotated open may equate to 1 mm of wedge opening, for example, so the user may count the opening distance from audible ratchets. When it is required to be closed, tabs at the top of the ratchets can be pushed and the lifter arm is free to rotate back down into place. 
       FIG.  11 C  illustrates an alternative embodiment spreader  1150 , including a linear actuator coupled to a lead screw wheel  1105  via a lead screw  1108 , that, when turned, drives a linear actuator  1110  forward. This linear actuator  1110  is directly coupled to a coupling arm  1115 , which is coupled to the lifter  1180 ; and thereby opening the osteotomy. In other alternative embodiments, a patient specific set of wedges may be provided or formed, based on the preplanning images. These wedges may include a plurality of shimmed segments that may interlock. These segments may be placed adjacent each other, to progressively increase the opening, up to a preplanned final wedge opening γ′, as determined during preplanning. 
     The disclosure now turns to fixation plate embodiments configured to provide fixation and optional compression to a bony hinge that may accommodate a biplanar alignment that avoids twisting of the boney hinge, as described herein. Generally, the inventors have found that modifications to the osteotomy orientation and axis of rotation leads to changes in torsional forces along the bone and torques on the bony hinge. Therefore a plurality of improved plate embodiments to account for these changes are disclosed. Firstly plate fixation may preferably be disposed directly opposite the modified hinge axis, where anatomy allows. In addition should a concomitant ACL reconstruction procedure add a tunnel to the tibia, the plate may include apertures than direct fixation members such as locking or compression screws around or away from this tunnel. The configuration of these apertures may depend on the modified hinge axis and thereby plate location. A series of plates is therefore envisioned depending on the modified hinge axis. Some plate embodiments may include contours that match anatomy of the preferred location on the bone that may be directly opposite a series of hinge axis angles, given other anatomy considerations such as the MCL. This series of plates may also include apertures specifically configured to accommodate an ACL tunnel, given the preferred location of that plate. The plate may also include an offset axis between a proximal head and distal tail of the plate, to account for torsional forces on the tibia and local anatomy considerations. 
       FIG.  12 A  shows a first example embodiment plate  1200  placed on a tibia  80  having been distracted. The plate  1200  includes a plurality of single axis holes  1210  therethough for receiving a fixation member therethrough. Plate  1200  may be “T” shaped. Holes  1210  are generally configured to receive a series of fixation members  1210  such as non-locking/locking screws for attaching plate  1200  to a portion of bone tibia  80  including over a distracted osteotomy. Plate  1200  defines a first surface  1240  shaped to engage the bone and an opposing outer surface  1245  defining a plate thickness therebetween. Plate  1200  includes at least one complex aperture  1220  having two immediately adjacent overlapping holes that extends through the plate thickness. This provides the surgeon a choice between placing a fixation member  1212  in one of two orientations. For example, a first fixation orientation  1221   a  allows for an orthogonal insertion where the fixation member  1212  follows that of the surrounding nearby fixation members. A second fixation orientation  1221   b  may be more parallel to the posterior tibial  82  surface. This second orientation  1221   b  may avoid a tibial ACL graft tunnel formed during combination HTO/ACL surgery or increase the distance between the nearby screws to cover a larger area in the tibial metaphysis. Therefore the two overlapping holes includes a first hole that extends along a first axis that places a fixation member in the first fixation orientation, and a second hole that extends along a second axis that places a fixation member at a second fixation orientation, that is different to the first orientation. The angle between the first and second axis may be defined at least partially given the plate location around the tibia, that may be at least defined by the modified hinge axis angle and also be configured based on a location of an ACL tunnel through the tibia. Complex aperture  1220  is configured to engage with a single fixation member only, so either orientation  1221   a  or  1221   b  may be selected, and not both, simultaneously. 
     Illustrated in  FIGS.  12 C and  12 D  the complex aperture  1220  extends through the plate thickness and comprises of at least two overlapping holes, having offset centers from each other. Complex aperture  1220  may include a chamfer  1222  extending from the plate surface  1245  to ease placement of a fixation member therethrough. Each of the two overlapping holes define a threaded portion to engage with threads on the fixation member  1212 . The complex aperture  1220  may define a figure-of-eight shape. Complex aperture chamfer  1222  extends from a figure-of-eight shaped opening on the second (outer) surface  1245  and may intersect with the threaded portions. 
     Complex aperture  1220  is preferably placed on a superior portion of plate  1200  and through a portion of the plate  1200  configured to be closest to an anterior side of the tibia. The anterior portion during ACL reconstructive surgery may have a tunnel formed through the tibia and a graft placed therealong. Depending on the tunnel location, the second axis orientation  1221   b  may preferably place a fixation screw in a location that will not interfere with an ACL reconstruction tunnel or meniscal root repair tunnel.  FIG.  12 B  shows placement of a plate  1200  in a preferable location on the tibia for a hinge axis (R-R) with no rotation due to an A/P correction; rotation angle θ is zero. Plate  1200  may preferably have a contoured surface configured to generally match the shape of the tibia in that medial-anterior location as shown, reducing irritation between the adjacent soft tissues and the plate. The complex aperture  1220  may define a first axis that is orthogonal to the plate  1200  and a second angle orientated at an angle (F) relative to the first axis, between 10-30 degrees, and may preferable be about 15 degrees from the first axis. The second angle orientation preferably avoids any ACL tunnel ( 87  in  FIGS.  18 B and  18 C ) that may be formed through the tibia and places. 
     The disclosure now turns to a discussion of the changes in forces on the tibia  80  when the hinge axis angle is rotated.  FIG.  13 A  illustrates torques τ1 and τ2 on a plate  1200  placed and centered around location N, similar to the location shown in  FIG.  12 B , for an unmodified plate hinge axis. Excess force is balanced out by the F hinge resistance . Torque acts directly on the hinge  81 .  FIG.  13 B  represents an example case wherein a 15 degree rotation of the hinge axis may be recommended to accommodate a coronal plane correction. In this example case, the torque on the bony hinge, if the plate were centered around the same location, indicated by N, would be larger, as d 2  is larger. Therefore it would be preferable to move point N to a more medial-posterior location; for example towards point B. This reduces the dimension d 2  and thereby reduces torque on the bony hinge. Plate placement directly opposite the modified axis is not however always reasonable at the extremes, as the plate may interfere with the MCL and some neurovascular structures towards the posterior portion  82  of the tibia. The plate is preferably placed directly opposite the modified hinge axis, thereby reducing dimension d 2 , limited by anatomical restrictions. 
     Therefore a plurality of plates may be provided, not only to accommodate the left or right patient leg, or different tibia sizes but also to accommodate an adjusted placement of a plate to reduce torque on the bony hinge  81 , for a modified hinge axis angle θ. For example, for a biplanar correction for a decreased A/P correction as shown in  FIG.  4 C , an example plate  1200 ′ may preferably be contoured to be placed more medially and posteriorly relative to plate  1200 , to more directly face the modified hinge axis. Plate  1200  and plate  1200 ′ are shown with their relative example positions in  FIG.  13 C . This plate  1200 ′ may be configured to reduce a torque on the boney hinge  81 , by being preferably contoured to match a more medial outer surface of the tibia  80 . Plate  1200 ′ may include a bi-directional complex aperture  1220 ′ having a first axis orientated orthogonally to the plate, and a second axis oriented at a second orientation, different than the first axis orientation. This second orientation may be between 0-30 degrees relative to the first axis. A plate  1200 ′ that is configured to be placed more medially and posteriorly may have a reduced angular offset between the first and second axis of these overlapping holes compared with plate  1200 . For example plate  1200 ′ may have almost parallel axes or an axes difference of 0-5 angular degrees, while plate  1200  may have a 15 angular degree angle between the first and second axis. 
     A plurality of plates may be provided to accommodate a series of modified hinge axis angles. The plate may include a contour to match a preferred location based on the modified hinge axis angle. The plate may include a complex aperture as disclosed herein, the complex aperture having at least two axis orientations that may be different from each other. The two axes may be angularly offset by a value defined by the modified hinge axis angle or modified osteotomy orientation as disclosed herein. The two axes may be angularly offset to provide a plurality of placement angles of a fixation device while avoiding the ACL tunnel or MCL relative to that preferred location. For example, a first plate of the plurality of plates may include a first custom contoured shape that matches a first portion of the tibia outer surface and may also include a first complex aperture having a pair of axes angularly offset from each other to provide a means to avoid and ACL tunnel. The plurality of plates may also include a second plate including a second custom contoured shape that matches a second portion of the tibia outer surface, different than the first portion due to a modified hinge axis angle. The second plate may also include a second complex aperture having a pair of axes oriented at a second angular offset different than the first angular offset of the first plate, configured to provide a means to avoid and ACL tunnel. 
       FIGS.  14 A and  14 B  illustrate an alternative plate embodiment, configured to be placed in a more medial location around the tibia  80 , similar to plate  1200 ′. This may accommodate the changes in torque to the boney hinge  81 , as a result of rotating the hinge axis angle θ, as disclosed herein. Plate may be an “L” shape, with at least one complex aperture  1410 , disposed at an end of the plate  1400  that is configured to be paced in the most anterior location of the tibia. Complex aperture  1410  is configured to receive a first fixation member  1415   a  or second fixation member  1415   b  but not both simultaneously. Complex aperture  1410  is configured to define an orientation of the first and second fixation member  1415   a  and  1415   b , each orientation different from each other and configured to provide a choice of orientations to the surgeon, given the tibia anatomy and ACL tunnel placement, as disclosed herein. 
       FIG.  15 A- 15 E  illustrate an alternative plate embodiment  1500 , configured to be placed in a medial location around the tibia. This may accommodate the changes in torque to the bony hinge  81  as a result of rotating the hinge axis angle θ, as disclosed herein. In addition, the superior portion of this plate  1500  may be configured to be placed in a location that is spaced away from the ACL tunnel sufficiently that a complex geometry opening may not be required. This example plate  1500  includes an inferior plurality of holes  1510  and a superior plurality of holes  1515 . Inferior plurality of holes  1510  may orient fixation members  1530  at a different angle to the superior plurality of holes  1515 . This may account for torsional moments on the tibia  80  caused by modifying the hinge axis angle and location.  FIGS.  15 B and  15 C  illustrate the first orientation of the superior fixation members  1530   a  relative to the inferior most fixation members  1530   b . Angle Z may increase as the plate accommodates larger modifications to the hinge axis angle. For example for an A/P correction of 4 degrees, per the chart shown in  FIG.  4 C , the modified angle would be approximately 14.6 degrees (correlating to the 14 degrees shown on tibia model). A plate configured for this modified angle may therefore preferably include contours matching a location around the medial portion of the tibia to reduce torque on the bony hinge, and may include a superior plurality of through-holes  1510  for orientating a plurality of fixation members at a first angle, and an inferior plurality of through-holes  1510  for orienting at least one fixation member  1530   b  at a second, different angle relative to the first angle. The plurality of plates may all include a superior plurality of through-holes for orientating a plurality of fixation members at a first angle, and a second inferior plurality of through-holes orienting at least one fixation member at a second, different angle relative to the first angle. Each of the plurality of plates may have a different angular offset Z between the superior plurality of through-holes and the inferior plurality, tailored for the differing torsions moments along the tibia, depending on the modified hinge axis angle value. In general the larger the modified hinge axis angle, the larger the angular offset Z. 
     In addition, plate inferior surface portion  1520  may be oriented at angle X to the longitudinal axis L 1  of superior portion  1525 . This allows for improved apposition with the bone surfaces in this medial location. In addition, inferior portion  1520  may define a longitudinal axis L 3  extending through at least two central axes of holes  1210 , L 3  offset (W) from a longitudinal axis L 2  of plate. This places the superior portion  1525  more medially on the tibia superior portion and more anteriorly on the tibia inferior side of the osteotomy, to center the inferior stem  1520  along the tibia and resist torsional moments on the tibia as a result of the modified hinge axis angle. A plate that accommodate a larger modified hinge axis angle, may have larger values of W and X relative to a plate that accommodates a smaller modified hinge axis angle. 
     The disclosure now turns to a system  1600  for adjusting and increasing compression to a lateral bony hinge of an HTO. This system may be applicable for both the more traditional single plane open-wedge high tibial osteotomy as well as the biplanar HTO as disclosed herein. Increased compression on the bony hinge  81  may improve the patient outcome in a variety of ways. It may facilitate faster bone healing during an HTO procedure; it may decrease a chance of non-union should the bony lateral hinge crack during the procedure; and it may allow for earlier weight bearing on the osteotomy as it preloads the osteotomy, which decreases the chance of a loss of correction during the healing process. Generally this system includes a means of engaging a fixation plate, such as fixation plate  1200  for example and a means of adjustably elastically bending or flexing the plate  1200 . Once a portion of the plate in this flexed state is fixed to the bone, the bony hinge  81  may be fixed in this compressed state. 
       FIG.  16 A  shows an example fixation plate, that may be similar to plate  1200  disclosed herein with a plurality of holes  1210  therethough. Holes  1210  are generally configured to receive a series of fixation means therethough, such as non-locking/locking screws, for attaching plate  1200  to a portion of bone  80  including over a distracted portion of bone. Holes  1210  may be threaded. Plate  1200  is an exemplary shape and the number of holes  1210  and location may differ. System  1600  includes a means of engaging the plate  1200  at spaced apart locations, preferably at two locations, one towards a superior end and one towards an inferior end of the plate  1200 . In this embodiment, a first shaft  1610   a  may threadingly couple to hole  1210   a  located at a superior end of plate. First shaft  1610   a  may be a first drill guide  1610   a . Hole  1210   a  is disposed on a superior side of the osteotomy, and may be disposed between the osteotomy and other more superiorly located fixation holes  1210   d . A second shaft that may be a second drill guide  1610   b  may threadingly engage a hole  1210   b  through the plate  1200 , hole  1210   b  being disposed towards an inferior end of the plate  1200 , on an inferior side of osteotomy. Hole  1210   b  may be the inferior-most hole on the plate  1200 . There is preferably at least one fixation hole, such as holes  1210   c  between hole  1210   a  and  1210   b , so that a fixation means may extend through hole  1210   c  and fix the plate  1200  while in the flexed or stressed configuration. It is preferable that flexing is primarily along a longitudinal axis of the plate. Drill guides  1610   a ,  1610   b  may both allow a drill tip therethrough and therefore may be cannulated to direct an orientation of a drill tip into the bone  80 . Drill guides  1610   a  and  1610   b  may include tips that threadingly engage a corresponding threaded hole  1210 . These threaded tips may extend through and beyond the associated hole  1210 , providing a standoff between a bone facing surface  1240  of the plate  1200  and the bone  80 . A standoff distance may be between 1 mm and 5 mm.  FIG.  16 B  illustrates the drill guides  1610   a  and  1610   b  extending through and beyond the fixation holes  1210 . With only the drill guides forming standoff of up to 5 mm, some limited compression may be achieved while fixing the plate though hole  1210   c . However, additional compression on the bone may be beneficial. 
     Turning now to  FIG.  16 C , system  1600  also includes a tool  1650  that imparts additional flex to the plate  1200 . An external compression tool  1650  may engage the shafts  1610   a  and  1610   b  and flex the plate  1200 . External compression tool  1650  may be disposed externally to the patient during use, with the two shafts  1610   a  and  1610   b  extending through skin incisions. Generally, compression tool  1650  is configured to engage the two shafts  1610   a  and  1610   b  and move the axis of each shaft so as to flex the plate  1200 . There are a plurality of ways of achieving this. For example, external compression tool  1650  may be a pivoting clamp or pliers style tool that extends transversely away from longitudinal axes of the shafts  1610 . Tool  1650  engages drill guides  1610   a  and  1610   b , and rotates the longitudinal axis of each shaft to impart stress on the plate and elastically flex plate  1200 . In this example system  1600 , tool distal end  1652  at least partially encircles each drill guide  1601   a  and  1610   b . Squeezing handle end  1655  rotates the two drill guides longitudinal axes relative to each other and imparts a longitudinal flexing on plate  1200 . Handle end  1655  may include a means to maintain the flexed state. Ratcheting means  1657  are illustrated. Each successive ratchet tooth increases the stress on the plate  1200  and thereby compression on the bony hinge  81 . In other embodiments, a threaded member may be operatively coupled to and between the handle end  1655 , such that actuation of the threaded member may adjust the distance between the handles, to move the shaft longitudinal axes relative to each other and imparts a longitudinal flexing on plate  1200 . In some embodiments, the longitudinal axes of each shaft  1610  may rotate from being approximately parallel with each other to non-parallel. Other example embodiments of a tool  1650  may be inserted into each of the cannulated end of the drill guide  1610 . Tool  1650  may extend longitudinally from shafts  1610   a  and  1610   b . Tool  1650  may include a ratchet mechanism that extends directly between the two shafts  1610   a  and  1610   b , and the user may squeeze the two shaft handle ends towards each other to engage a successive set of teeth on the ratchet. Alternatively a threaded member may extend between the two shafts  1610   a  and  1610   b , and actuating the threaded member may alter the distance between the two shafts  1610   a  and  1610   b .  FIG.  16 D  illustrates a plate  1200  on bone  80 , with the system  1600  engaged and elastically flexing the plate  1200 . Plate  1200  may align with line pin the relaxed state, and upon flexing the plate via tool  1650  and via drill guides  1610   a  and  1610   b , plate  1200  may elastically flex to align with line Q. Placing fixation means through holes  1210   c  while the plate is flexed in this shape imparts higher compression on the bony hinge  81  than with the plate less flexed or in a relaxed state. 
     A method of adjustably compressing a bony hinge  81  therefore is illustrated in  FIG.  17 A- 17 C . Fixation plate  1200  may be placed on the target bone  80 , either side of the distraction. A superior portion of the plate may be fixed with the bone  80  using guides  1690  and locking screws. Shafts, which may be drill guides  1610   a  and  1610   b  may be coupled to plate  1200  and may extend through and beyond the bone-facing surface  1240  of the plate  1200  to space the plate  1200  away from the bone outer surface. Drill guides each define a longitudinal axis and have a length defining a handle end, such that each drill guide  1610  may be engaged with the plate by hand, and at least one of the drill guides may be used to handle and place the plate  1200  on the bone  80 . A superior drill guide  1610   a  may extend through an incision formed in the patent to place the plate. A second minimal incision may be formed more inferiorly to allow access for the second drill guide  1610   b  to the plate  1200 . Two discrete connecting locations between the drill guide  1610  and plate  1200  may be preferable to reduce incision sizes through the patient skin. First drill guide  1610   a  may be coupled through a hole  1210   a  that is disposed between the superior-most holes and the distracted bone. Second drill guide  1610   b  may be coupled to a hole  1210   b  that is an inferior-most hole of the plate  1200 . External compression tool  1650  may then engage the drill guides  1610   a  and  1610   b  and operated to elastically flex the plate  1200  before fixation means are placed through holes  1210   c , so as to compress lateral hinge  82  of bone  80 . Tool  1650  may have a series of settings to adjustably flex the plate  1200  and thereby adjustable compression on the hinge  81 . After fixation via holes  1210   c , tool  1650  may then be released ( FIG.  17 C ). Drill guides  1610   a  and  1610   b  may then be used to guide a drill along a targeted trajectory. Drill guides  1610   a  and  1610   b  may then be removed and plate  1200  further fixed to the bone via holes  1210  and  1210  (not shown). Stressing the plate  1200  can be carefully planned and made precise and accurate to what is needed clinically. 
       FIG.  18 A  shows a further example embodiment plate  1800  placed on a tibia having been distracted, with a plurality of single axis holes  1810  therethough for receiving a fixation member therethrough. Plate  1800  may be an asymmetrical “T” shape. Holes  1810  are generally configured to receive a series of fixation members  1805  therethrough such as non-locking/locking screws for attaching plate  1800  to a portion of bone tibia  80  that may include over a distracted osteotomy. Plate  1800  defines a first surface  1840  shaped to engage the bone and an opposing outer surface  1845  defining a plate thickness therebetween. Unlike plate  1200 , plate  1800  may not include a complex aperture  1220 , but instead may include two separate holes  1810   a  and  1810   b , that are directly adjacent each other on a superior end of plate  1800 . The two holes  1810   a  and  1810   b  may have axes parallel to each other or, as shown may be angularly offset from each other. In this example embodiment, hole  1810   a  may have an axis that is orthogonal to the plate  1800  and may be parallel to other holes directly adjacent to it. Hole  1810   b  may define a central axis that is angularly offset by about 15 angular degrees)(° from a central axis of hole  1810   a . These two holes  1810   a ,  1810   b  are configured to provide at least one hole,  1810   a  or  1810   b  that allows a fixation member  1205  a path through the tibia that avoids an ACL tunnel  87  or  87 ′. However, unlike a complex aperture, fixation members  1205  may also extend through both holes ( 1810   a ,  1810   b ) simultaneously, should the anatomy allow, hence increasing plate fixation overall.  FIG.  18 B  shows a plate  1800  placed in a more anterior position on the tibia  80 , wherein a fixation member  1205  is preferably placed through hole  1810   b  and not hole  1810   a , to avoid the ACL tunnel  87  or  87 ′. Explained earlier, a fixation plate is preferably placed directly opposite a hinge axis, for torque considerations, and therefore a plate may be placed more anteriorly for a hinge axis rotation in a direction that increases the tibial plateau slope, as shown in  FIG.  4 D . No fixation member  1205  is placed though hole  1810   a . Alternatively,  FIG.  18 C  shows plate  1800  placed in a more medial position on the tibia  80 , wherein a fixation member  1205  is preferably placed through hole  1810   a  and not hole  1810   d , to avoid the ACL tunnel  87  or  87 ′. This may correlate to a biplanar correction that decreases the tibial plateau slop, as shown in  FIG.  4 C . No fixation member  1205  is placed though hole  1810   b . Turning back to  FIG.  18 A , depending on the concomitant surgeries and location of the ACL, both holes  1810   a  and  1810   b  may receiving a fixation member  1205  therethrough, to increase fixation with the tibia  80 . Therefore the two holes ( 1810   a ,  1810   b ) includes a first hole that extends along a first axis that places a fixation member in the first fixation orientation, and a second separate hole that extends along a second axis that places a fixation member  1205  at a second fixation orientation, that is different to the first orientation. The angle between the first and second axis may be defined at least partially given the plate location around the tibia, that may be at least defined by the modified hinge axis angle and also be configured based on a location of an ACL tunnel through the tibia. 
     The above discussion is meant to be illustrative of the principles and various embodiments of the present invention. Numerous variations and modifications will become apparent to those skilled in the art once the above disclosure is fully appreciated. It is intended that the following claims be interpreted to embrace all such variations and modifications.