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Tibial osteotomies have commonly been used to treat varus malalignment with associated medial compartment degeneration. Initially, lateral closing wedge osteotomies were commonly used. However, with the advent of improved plate osteosynthesis techniques, medial opening wedge osteotomies have become the mainstay of treatment. Presently, there are several available fixation devices, with no clear consensus on which represents the superior option. This article will serve to review the technological evolution of tibial osteotomy fixation devices, highlighting the comparative biomechanical evidence of available constructs.