Charmando. Okay, how far we have come. It's not long ago that there may have been a token Canadian talking at the end of a session about why we should do osteotomy at all. And here we are sitting in a room with a whole session dedicated to osteotomy, which is fantastic, and debating the nuances of anterior closing wedge proximal tibial osteotomy. And yeah, I'm not sure why it's much of a debate, to be honest, because clearly there's only one way to do it. But anyway, we'll get on with it. So disclosures. So why supertubicle? I could probably finish with this one slide. This is my one infratubicle osteotomy that I'm still waiting for it to unite. So yeah, so sagittal alignment. Well, we know the issues, okay? So I don't think you really need to labor the point. Increase in posterior tibial slope, increasing risk of ACL injury. 12 degrees has been identified. Let's look at the literature. So one of the first papers that was published 2014 from Leon, Bertrand Sonemi-Cotte. This is a TTO with a supertubicle osteotomy. Patient's doing very well. Small numbers of patients. Next publication. So David Dejours in the audience. David, one of the largest series, nine patients. Supertubicle, this is leaving the tubicle in place. Okay, so no TTO. Again, patient's doing well. Reduced posterior tibial slope, improvements in anterior translation. Then we've got, this is actually one of the first series from North America. And so we actually have a combined series of supertubicle plus minus tibial tubicle osteotomy. And patient's doing okay in terms of reducing their posterior tibial slope. IKDC score is not so special. But you can see, my old buddy Volker. What's going on, man? You've left, you've deserted us. So apparently he's now going in for tubicles. It'll be interesting to see why he's done that. Note this was only actually published in 2023. So not sure what's going on there. But maybe it's just that he wants to feel a little bit closer to his homeland. And so certainly infratubicle osteotomy has been popularized by the Germans. And for sure, note this is a study that was published by Andreas Weiler. No loss in correction, no delayed union. But you certainly need a more stable fixation. So this is the large internal-external, or internal fixator plate. This is a case that was supplied to me by Tim Spalding. He was actually one of my mentors in the UK. And unfortunately, you can see that the osteotomy's already starting to pull apart. So biomechanically, unfortunately, the extensor mechanism, when you go infratubicle, it's wanting to pull the defect apart. Whereas if you go supratubicle, it's actually wanting to compress it. But thankfully, there are some Germans doing it the right way. And here's a great series, large series of 23 patients with supratubicle with a TTO with excellent results. And notice they're doing this mostly in the first revision, so much more aggressive approach, but getting very good results. So it's definitely food for thought. So supratubicle plus TTO. So my indications for an anterior closing wedge, proximal tibial osteotomy. It's a failed ACL reconstruction with increased posterior tibial slope greater than 12 degrees. That's measured on a short film, because essentially the 12 degrees has been isolated on short films, not long films. We also look for anterior subluxation of greater than 10 millimeters in the lateral weight-bearing view. Patients that have got a fixed flexion deformity, that's also a win, because you can try and improve their extension. But you should be cautious with patients with hyperextension. And certainly in the primary ACLs, think about doing a lateral extraticular. This is essentially a bit of a flow diagram in terms of what I think about. So if I've got a normal coronal plane, and I'm doing a small correction, we can do an ACL reconstruction revision. We can do that supratubicle with no TTO. If I'm doing a much larger correction, I'll take the tubicle off. It's much easier. And then when you start thinking about coronal plane malalignment, if you want to do an asymmetric closing wedge, so in the varus knee, you can probably get about four to five degrees of coronal plane correction with an asymmetric correction. So again, take the tubicle off. Much easier on the proximal side doing that. If you want to do a bigger correction, greater than five degrees in the coronal plane, do an anterolateral closing wedge, proximal tibial osteotomy. And then in the valgus knee, you actually might need to go double and do a femur plus the anterior closing wedge and the proximal tibia. So this is the technique. So essentially, retractors medially and laterally. We're then gonna isolate the tubicle. Don't take it off. We just put in four pins. So there are four pins that are placed parallel on the lateral view on the fluoroscopy. We do a back cut. And you can see here, there's a cut coming more proximally on the tubicle. And that allows basically greater real estate for your ACL reconstruction. But you do have to take a little wedge of bone out of here. Otherwise, the metastasis buttresses against this and you won't be able to close it down. And that's simply fixated with two staples. So this is an example of a patient, 27-year-old male, two failed ACL reconstructions, increased slope, 13 degrees, increased anterior translation, essentially a symmetrical coronal plane. So we did a first stage of an anterior closing wedge, HTO, sorry Mike, then bone grafts of the tunnels. And then the second stage, revision ACL, medial meniscus transplant, lateral tenodesis. So in summary, it's metastasial bone, less risk of delayed nonunion. The extensor mechanism compresses the osteotomy site. That's much easier to perform an asymmetric closing wedge simultaneously to address the coronal plane. And in that case, use a TTO. Thank you very much. And just a simple plug, if you wanna learn more about these techniques, please come to the osteotomy course in October.

osteotomy techniques

proximal tibial osteotomy

coronal plane malalignment

posterior tibial slope

ACL reconstruction