And so, this is a little bit of a debate. First, I always start with my disclosures. My disclosures is I'm a Ranawatt that doesn't do arthroplasty, but I'm gonna tell you that the most important part of this lecture is actually about arthroplasty. And we'll get to that. Second, my second disclosure is that I interviewed Rachel Frank, and when I interviewed her, I realized she's much smarter than I am. So, that's gonna be my second disclosure because even though we just heard a great paper, but Dr. Lyle's basically saying that the debate's over, I won, tibia's better, so I can just leave. She'll still beat me somehow because she's that smart. So, I'm not that smart. I make outlines, I make everything simple. Osteotomy scares people, it confuses people. I'm gonna give you a couple points why I think the tibia's better. From deformity analysis to don't oblique the joint line, to the tibia, it heals better. Versatility, biomechanics, and then conclusion. So, basically, this is bread and butter osteotomy, right? You do your deformity analysis and recognize not all the deformity in the valgus knee is from the femur. It was just what we were taught back in the day, and it can be from the tibia. And this is a good paper that shows that 41% actually is from the tibia, and only 25% or 24% is from the femur. And actually, if you do, then, an analysis and do osteotomy, then an ideal parallel joint line, not oblique in the joint line, will be an ideal osteotomy, 55% in the tibia, and only 19% on the femur. You know, this is a basic principle of osteotomy. It's a basic principle of knee replacement, right? You want your tibial cut 90 degrees. You want your medial prostate tibial angle parallel to the floor. That's osteotomy 101. And we know when we change it a lot, when we oblique the joint line, it's in fear for outcomes for DJD and kinematics. Now, the truth is, we don't really know about joint line obliquity for the valgus knee. This is all based off the varus knee. And a lot of it based from the mail from Dr. Coventry years ago, who says, you know, gave us some big numbers of where you could do some joint line obliquity. And we've slowly dialed that back and saying, really, maybe it's four degrees. Maybe it's five after five who show the increased tibial stress. But again, we always do too much saying, well, if it's good for the varus knee, it's probably good for the valgus knee. And I would agree with the same way with joint line obliquity. Why do I like the tibia? Well, the proximal tibia is rich with Cancel's bone. It's gonna be used for both opening and closing wedge for the valgus knee. And its compressive nature of osteotomy promotes stability and easier weight bearing and quicker healing. And for small deformities, the fibula is protective. Why is the tibial heel better? Well, the DFO has higher non-union rates. In Switzerland, they pretty much abandoned lateral opening wedge DFO because of their high non-union rates. Why? There's a lever arm effect of the knee and of the tibia, and it's always opening up the osteotomy site. So most DFOs now in Europe are closing, medial closing wedge, which is a very good operation. Versatility, right? You have three different ways to work the tibia. You can do opening wedge, closing wedge, and if you have big deformities, you can use nails. Nails with blocking screws are a very effective way to correct large deformity in the tibia. So it's a very versatile osteotomy. And as we heard, you know, the biomechanics, a DFO is an extension osteotomy. A lateral opening wedge is very good, right, at extension, and Bob Arcio taught us that, and now Dr. Lyles taught us that, that with higher flexion, a DFO doesn't really offload as well. But what is lateral disease, right? Valgus knee is posterior lateral disease. So we're offloading the area that doesn't need to be offloaded more extension, and we're not really getting the more posterior aspect of the tibia. Doesn't make a whole lot of sense. And it goes back to basic total knee biomechanics, right? When you wanna have a balanced flexion extension gap, you cut the tibia. A DFO is just a distal femoral cut. So your flexion gap is not balanced. It's total knee 101. And every osteotomy lecture, I always bash my dad, but my dad's right about this lecture too. It's kind of annoying. So in conclusion, I think the role of osteotomies, there's certainly roles for all osteotomy. You do your deformity analysis, you figure out where the deformity is, but realize not all valgus is from the femur. Tibial-based osteotomies have a great healing rates. They're versatile, they're biomechanically sound. As I said, my dad always says, the eye sees what the mind knows. Thank you very much. Thanks. Thanks. Thank you.

tibia-based osteotomies

valgus knee deformities

healing rates

biomechanically sound

deformity analysis