All right, thanks Armando, Rachel, for moderating this session. We'll talk about some of the outcomes of DFO and HTO in a rather higher level patient cohort. So our disclosures can be found on the AOS site. Myself and Armando have some relevant disclosures, but not relevant to this particular talk. I'd like to thank the co-authors on this project, which are a combination of the Stedman Clinic as well as our institution at NYU. So literature has really investigated the outcomes of return to sport in lots of different procedures. However, with high tibial osteotomy, distal femoral osteotomy, something that's gaining a lot more traction, we have to ask the question, is a high-level athlete still a high-level athlete if they're gonna have some sort of osteotomy procedure, whether it be a coronal plane alignment procedure or a sagittal plane alignment procedure? We don't know yet if those athletes are able to return to full functionality after we try and get them there. So the purpose of this talk is to evaluate the outcomes in high-level athletes defined as tegner greater than or equal to five, and this has been in conjunction with other literature that's been reported in the Journal of ESCA, following HTL or DFO procedures. We did a few sub-analyses to see whether the more elite athletes, as tegner over seven sex or concomitant procedures has any impact on the outcome. Our hypothesis was that we were gonna find an acceptable rate of return to sport and satisfaction after these particular procedures. So looking at our study design, this is retrospective, obviously. Inclusion criteria included unilateral primary high tibial or distal femoral osteotomies at a single academic institution, NYU. We had more than two years of follow-up, greater than 18 years of age, and tegner scores prior to symptom onset had to be greater than or equal to five. So what was their activity before they started developing symptoms? Exclusion, tegner below five prior to symptom onset, and the patients who had an ipsilateral total knee arthroplasty were included in the cohort, but really not included with the PROs because there was a little bit of a subset of a category. We also excluded inflammatory arthritis disease as well. Patients' subjective scores, return to sport, complications were assessed, and again, the tegner at three different time points here are really the most critical thing. Number one, the peak tegner score before the onset of their pathology. Number two, the tegner score at the time of their surgery, and number three, their current tegner scores. So looking at this, we had 80 patients that met criteria. 11 patients were excluded because they had an ipsilateral total knee arthroplasty at the last follow-up time. We had 60 high tibial osteotomy patients, 20 distal femoral osteotomy patients with an average age of about 38. Tegner score was 6.6 prior to the symptomatic onset, so these athletes were relatively high level, and our follow-up was pretty good, almost six years of follow-up on this cohort. Concomitant procedures, always important to talk about. We did find about 30 to 40% of patients had concomitant procedures that were relevant, including ACL reconstruction, osteochondral allograft transplantation, or meniscus transplant, which obviously is gonna be the lowest rate of all of those. Looking at our results, we found significant improvements in the Tegner score from the time of the patient's procedure to their current score, which is about a 1.5 point improvement on the Tegner. Almost 60% of patients reported quote-unquote complete symptom resolution. 75% of these higher level athletes would do the procedure again, and we found almost a 50% return to sport, of which 63% of those returned to their peak athletic activity. When we broke this down into the elite athlete, we had identified 28 patients in the cohort, and again, as you would expect, we found significant improvements in the Tegner score from 3.5 to 5.3, with 64% having complete symptom resolution. 75% of the patients were pretty satisfied, they would do it again, and again, in conjunction, similar to the last slide, about 50% of those patients returned to sport, 40% of which returning to their peak. Additional analysis showed that patients that had joint preservation procedures like ACL reconstruction, meniscus transplants, they did pretty much exactly the same as patients treated in isolation alone for osteoarthritis. Males versus females demonstrated no difference. We found an overall complication rate in this cohort of 11%, including patients with mostly infection or stiffness, with one patient having that dreaded complication of compartment syndrome. So we found ultimately that high patient satisfaction increases in Tegner scores do exist in high level athletes after these procedures. The return to sport of 50% may appear low, but it does represent an important and a clinically meaningful change in activity, but the return to the highest level of activity is really, in my opinion, poor. 20 to 40% at best when you look at everybody here. So patient counseling is really, really key. Osteotomies are great procedures for quality of life, and this is like a lifestyle procedure. As Armando and I were talking about before, this is a lifestyle surgery. Return to sport, if you can get it, it's amazing. You might not be able to achieve it in everybody. We have to be thinking about it, and our next step is to see who's really failing these surgeries. Who can we not get back to sport? So we're gonna look at our corrections, our joint line obliquities, as well as patient demographics, and that's gonna really be our next topic moving forward. So thanks very much for your attention. Thank you, Mike. Thank you, Mike. Our next paper will be Leg Length Changes Following DFO Validation of a Predictive Tool in Comparison of Lateral Opening Wedge and Medial Closing Wedge Techniques by Dr. Adam Yanke. Thank you, Rachel. When I went into orthopedics, I was told there would be no math, but this will prove otherwise. My name's Adam Yanke. Thanks for allowing me to present on this. As discussed, this is change in leg length after opening versus closing wedge distal femoral osteotomy. Basically, there's two techniques that we know for distal femoral osteotomy to correct valgus, lateral opening or medial closing. We know that the clinical outcomes are equivalent based on the studies exist in literature between these two techniques, so there's no difference in patient-reported outcomes. The question is, is there a difference between leg length when you correct with one form versus the other? There was only one study that ever looked at this for lateral opening, and they actually showed it was no different, and there's no prior studies that have looked at the leg length changes for medial closing wedge osteotomy. And so the goal of this study was simple, to try to make a model that could predict leg length changes based on your planned surgical correction, and then do a comparison between patients that had this done and validate our model to some extent. And so that's what we set out to do. In our hypothesis, that was lateral opening wedge, you're making a gap and straightening a leg, so that should lengthen it, whereas closing wedge is those two are racing together to lengthen and shorten the leg at the same time, and that's probably more variable. So to do this, we tried to do a validation with 10 patients that had lateral opening and 10 patients that had medial closing. We had two independent graders, and we tried to predict the change that should be there from the calculation and measure the actual change and compared these for each patient. We also did a separate calculation for each patient for a five, 10, or 15 degree change, so that if you don't wanna do the calculation, you get a sense of how much change you have based on what you're planning to do. So here comes the math. We'll try to make this as interesting as possible, I guess. But this is the equation that we basically came up with. It is just trigonometry, and what we're looking at is for the hinge point for a lateral opening wedge osteotomy, so this is where you would have your medial hinge. You have one leg of the triangle is the distance from there to the hip. The other leg of the triangle is the distance from there to the ankle. And basically, there's what we called in this setting the angle alpha, which is the correction angle, so that is what you would take to get to neutral. And then if you have those three pieces of information, you can calculate the calculated leg length that they should have based on that triangle, which ends up being the hypotenuse. When you do medial opening wedge osteotomy, that hinge is now on the lateral side, and obviously, we need the same two lines, and we still need to calculate that hypotenuse. But again, one of these is adding space. The other one's removing space, but both are straightening the leg, and so what is the race of those to lengthen or shorten the leg based on how things go? And this is an exaggeration, but you can see how if you use those triangles, and that would be like a 20-degree correction, there's gonna be a large leg length difference between those two situations. And so that's what we set out to do and to evaluate using that information. This was in partnership with Erin Critch at Mayo and with our patients to see if that, we take the predicted change in alpha angle, and then we also look at the change that was actually occurred in surgery. So we had patients pre- and post-op x-rays. We looked at how much correction was actually obtained, and we applied that same calculation to the preoperative one to see how close our predictions got, essentially. I wanna show two examples of how this changes over time. So this would be a continuous change, and when we look at this patient, when we correct them, they would need a nine-degree correction to get to neutral. When you look at nine degrees, the opening wedge would lengthen the leg eight millimeters, and the closing wedge would shorten the, I'm sorry, would shorten the leg 1.5 millimeters. So it's almost a one-centimeter difference between the two. And in this patient, with the closing wedge, you're either staying the same or shortening, but opening is always lengthening. And if we compare this to a different patient that starts at a different amount of deformity, the closing wedge will actually lengthen for a while and then eventually shorten, whereas lateral opening wedge will just always lengthen throughout its entire course, which again, hypothetically, is what we expected, because you're adding space and straightening a leg. So for our results, when we looked at the predicted leg length changes for opening versus closing, we predicted on average five millimeters of lengthening with opening, and 2.6 millimeters of shortening with closing. And when we looked at the actual changes that we saw, these were essentially statistically the same. So the math checked out to what was planned. So trigonometry wins again, I guess, and just shows that you can actually predict this with a high degree of accuracy, and that in this setting, opening always lengthened, and closing, for us, did always shorten. And that's also because most of us that are gonna do a closing wedge osteotomy probably aren't gonna do it for five degrees or less, and that's where it really stays the same. And once you get beyond that, that's when things start to shorten. So our findings were different than the prior studies that looked at opening wedge in the past, and the ability to correct the mechanical axis in real-world patients were the same between the two. So again, the overall accuracy of the surgeries are the same, and the average correction was seven to six degrees. This is a overall gestalt. If you don't wanna use the calculation, if you're gonna correct five degrees, it's about 3.7 millimeters of lengthening. You can see I won't read all of these, but we produce these as a quick and dirty way to figure out what you would end up with, because leg length changes for patients can create a lot of dissatisfaction. If you can avoid it with all else being equal, then it's probably worth considering. And then this is, again, a gestalt. It shortens about half a millimeter per degree for medial closing wedge, and lengthens about 0.8 millimeters per degree for opening wedge. So these are kind of the two big take-homes from our paper. I think that this can easily be included in some of the web-based calculations that we have for risks, for re-dislocation, things like that, so that all you have to do is put in the three numbers, and you don't have to worry about the rest of the variables that are in here. Or you can just use a chart like this to try to estimate it. And again, with the previous literature, they showed only a change of about one millimeter, and ours was definitely different than that, and matched up with the math. So those were our overall findings, and leg length is altered by both of these, and can be predicted, and so you can pick the right option for your patient. Thank you very much. Thank you. Thank you, Adam, that was great. I encourage everybody standing in the back. There's plenty of room up here in the front, and some seats out here if you wanna sit. Next, I wanted to welcome Richie Amendola from the University of Nebraska, and he's gonna talk about CT analysis of the variation in the medial and lateral posterior tibial slope in patients undergoing osteotomy of the knee. All right, thank you. How do you, there we go. All right, I don't have any disclosures. My co-authors can be, their disclosures are on the web. Thanks to my co-authors for their help with this. So tibial slope, or sagittal slope of the proximal tibia is a contributor in primary ACL rupture, as well as failure of ACL reconstructions. Medial and lateral tibial slope can be different within the same knee. The consequences of this are unknown, and because of the medial and lateral plateau morphology, the biomechanics could be different, and the clinical significance needs to be better understood. So at this point, there's many studies which look at tibial slope, and there's a handful of studies which look at medial and lateral slopes separately. There are a few clinical studies which claim a higher lateral tibial slope leads to a higher velocity pivot shift, and is a negative prognostic factor in ACL injuries. All these studies are limited in the type of images used for data analysis. No studies have explored the variability of medial and lateral tibial slope in the same knee with use of full tibia CT. The purpose of this study is to describe the differences in the medial and lateral tibial slopes within the same knee as measured from a semi-automated osteotomy planning software using full CTs of the tibia. So we included 97 consecutive patients that underwent osteotomy about the knee. These included both distal femoral and proximal tibial osteotomies as well as sagittal, coronal, or biplanar corrections. So we defined sagittal correction as a change in more than two degrees, and a coronal correction as a change in more than 5% of the weight-bearing line as a ratio of the tibial width. Osteotomies were planned using a semi-automated system. A line from the center of the tibial plafond to the center of the tibial plateau is created. Best fit planes are created for the medial and lateral tibial plateaus separately. The angle between these planes and the axis of the tibia is used to find the posterior tibial slope of each plateau. And typically, the surgeon's not involved in this process. So our results show that the average medial and lateral slope in all our patients is about the same. Looking at our results by type of osteotomy, there were 68 osteotomies performed for a coronal correction, 10 for a sagittal, and 17 for a biplanar. And 100% of the sagittal correction osteotomies were associated with an ACL reconstruction. 82% of the biplanar ones were also associated with an ACL reconstruction. And only three patients with a coronal correction were associated with an ACL reconstruction. As expected, the patients with a sagittal or a biplanar correction, and most of them having ACL reconstruction, have a higher or a steeper slope. They had both a higher medial and a lateral slope. Only two of the nine patients with a sagittal correction had a steeper lateral slope, meaning seven had a steeper medial slope. The absolute difference in medial and lateral slope was pretty similar between osteotomy types. And then the coronal correction group had the patients with the highest absolute difference between medial and lateral slope. So looking at the group as a whole here, the data on the left is represented as a histogram on the right. So the lateral tibial slope was greater than the medial tibial slope about half the time, meaning like even split as to which one was steeper. And this didn't matter if you're looking at the whole group or males or females or left or right. The mean absolute difference of about 2.5 to 3 degrees, no matter which group you're looking at. Sixty percent of the patients had a difference between their medial and lateral slope of less than 2.5 degrees. Interestingly though, 39 out of 97 patients have an absolute difference greater than 2.5 degrees. 18 of those were greater than 5, and 5 of those greater than 7.5. Two of them were even a difference of 10. So the limitations of this is that all the patients were ready to undergo an osteotomy about the knee. And this semi-automated commercial software has not been validated by an independent control. So differences in the medial and lateral tibial slope are common. These differences are difficult to recognize. Anecdotally, this picture here shows a knee where on x-ray it measures about 13 degrees and it would be difficult to appreciate the difference between medial and lateral slope. But with the planning software, it produced numbers of 8 and 16. Sixteen of the 97 patients have a difference between 5 and 10 degrees, and two patients had a difference greater than 10. Compared to the literature out there, our slope measurements are similar to other studies using full tibia CTs. But in contrast to some clinical data, the patients in our series which were ACL deficient did not trend towards having a steeper lateral slope. Thank you. Okay, as Armando is pulling up the last talk, our last paper is from Dr. Nick Kennedy. And it will be Supratubercle Anterior Closing Wedge Osteotomy, No Change in Patellar Height Compared to Decreased Height for Medial Opening Wedge Proximal Tibial Osteotomy and Significant Decreases in Anterior Tibial Translation at Six Months Postoperatively. I think I just summarized everything. A lot of words. Thanks, Frank. So, yeah, thank you very much for the honor today. I'd like to take a quick thank you to all my co-authors, specifically Dr. Leprod, whose patients these obviously are, and then soon-to-be Dr. Luke Tolson for his work on this talk. My disclosures can be found online. So, as a background, obviously, to hit on this last talk, revision ACL reconstruction continues to gain more prevalence and popularity in the recent literature. I think most of us are aware that posterior tibial slope plays a role in increased risk factors for failure, both in the primary and revision setting. You know, mechanically, we understand this to be because increased slope leads to increased force through the native ACL as well as the graft. So, in a revision setting, where you also have concomitant increased posterior tibial slope, you may consider an anterior closing wedge osteotomy. Again, mechanically, we know this decreases the forces through the graft, and also it leads to decreased anterior tibial translation, and we do have some more recent clinical studies showing decreased failure rates. A more hotly debated topic that is not yet accepted is where to do this osteotomy, whether it be supratubercle, transtubercle, or infratubercle. The concern from a supratubercle standpoint is that you induce a metrogenic patella alta. Therefore, the purpose of our study was to assess a cohort undergoing anterior closing wedge osteotomy from a suprapatellar standpoint and to assess the following parameters, height, anterior tibial translation, as well as posterior tibial slope. This was a retrospective radiographic analysis. Our study cohort was all patients undergoing revision, or oftentimes multiple, revised ACL reconstruction in a two-stage fashion, the first stage being the anterior closing wedge osteotomy. We also had a comparison cohort of patients undergoing a medial opening wedge osteotomy for varus mechanical malalignment. We assessed these patients at the pre-op time point, post-op day one, post-op three-month and six-month, and this was the same surgeon with the same technique for all patients involved. The demographics are listed there. So in terms of how we measured height, we went with Katanda-Shomps Index, the way it is historically defined. Anterior tibial translation was a little unique. We used a long-leg, single-leg standing lateral x-ray with the patient's knee flexed at about 15 to 20 degrees of flexion to hopefully induce some extra anterior tibial translation. We looked at a couple different measurements, but the one we found to be most reliable was a perpendicular line from the posterior aspect of the lateral femoral condyle to the posterior aspect of the lateral tibial plateau. Using those same lateral x-rays, we also assessed anatomic posterior tibial slope. From a result standpoint, the closing wedge did do its job in terms of reducing posterior tibial slope to normal ranges and significantly compared to pre-op. What we did see is a transient increased patellar height, and that is at post-op day one, there was slight increase in patellar height compared to pre-operative values, but interestingly, there was a linear decrease over the next three to six months, and both at the three-month and six-month time point, there was no statistically significant increased patellar height compared to the pre-operative values. Now, if you look at our comparison cohort, this is quite similar. We saw a decrease in patellar height with time, or likely with patellar scarring in, and you had a statistically significant patella decreased height at six months compared to pre-op. In terms of anterior tibial translation, we found substantial differences in translation at the six-month time point with an average of nine millimeters. So limitations, obviously, this is a relatively small cohort as a lot of our closing wedge cohorts are. We have short follow-up, but long-term follow-up is needed, and we're looking at reassessing these patients now at the greater than 15-month time point. We have no comparison cohort that was a closing wedge cohort, i.e. an infratubrical versus the transtubrical technique, and future studies should look at that as well. So in conclusion, our cohort found no significant differences in patellar height after anterior closing wedge osteotomy from a super patellar standpoint, and we did see significant decreases in anterior tibial translation as well as posterior tibial slope. Thank you very much. Well, thank you to all of our papers. Just looking at the room, the incredible interest in osteotomy is just so inspiring, honestly. Does anyone in the audience have questions? If you do, come to the podiums, or come to the mics. We have two mics. We have two minutes for questions. Otherwise, I have a question to get us started for the doctor to my left, Dr. Alea. Okay, 50% return to sport rate, 20%-ish at a good level. So you have a patient coming in who's an NHL player. He's coming to see you in New York for a second opinion, and he has three years left on his contract, and he needs an osteotomy. He currently cannot play. He physically cannot function, but his ADLs are fine. Osteotomy or no, and what do you tell him? Is he a Ranger or an Islander? Because that influence his decision. See, this is one that I would just send up the street to Anil to have that difficult conversation with that New York Rangers player. If a player can't return to sport, they can't return to sport. They don't have a career if they can't get back out there. At this point, they've tried everything under the sun. If they've tried the injections, they've tried arthroscopic debridement, minisectomy, et cetera, everything under the bus. I don't see a problem with trying, particularly for hockey. Hockey is a sport where various needs are probably not as important as something like soccer, where they kind of need that. For hockey, it might be a little bit different. Patient counseling is everything, as you just alluded to. Patient counseling is literally everything under the sun. Now, thankfully, I don't have a lot of NHL players walking through my door, but you've got to give them a chance, and you've got to give them a chance, because this is their livelihood. All right, Adam, I have a question for you, a lot of math and way over my head, but what I took home is that even with corrections up to 10 degrees or so, you're going to change leg length by less than a centimeter, give or take. If I calculated your calculations correctly in my head. With a leg length difference of less than a centimeter, what are you going to counsel patients? Are you going to even bring this up to patients and introduce the possibility that your osteotomy may change their leg length and open up that whole can of worms with respect to discussion pre-surgically, or are you ignoring that discussion? Currently, I never have that discussion with patients. Yeah. Where I actually found it very, very helpful is I've had some patients with 14 degrees of valgus and no leg length difference between them whatsoever, and my typical approach for them would have been a lateral opening wedge osteotomy, which based on this information is going to lengthen them 12 millimeters. So now I took somebody with no leg length complaint and gave them something that's over a centimeter off, and to me, that's where this conversation started. So like you're saying, when it's smaller corrections, it's irrelevant, but bigger corrections where people start out in neutral, people will always find anything that's different than how they were before as a complaint, and you're just always better off heading off at the pass or avoiding it, and that's where actually my amount of medial closing wedge osteotomies has increased quite a bit for that reason. Great. I want to thank our speakers for the excellent talks, and we're going to go ahead. Is there a question? Oh, sorry. Dr. Amendola. Oh, thanks. Sorry. I wanted to ask Dr. Amendola a question. That is allowed. We will go over time for this. Okay. I thought that was an interesting study, and I think we're getting much more accurate with osteotomies with the 3D preoperative planning. So in the cases that were really a high difference in the medial and lateral tibial plateau, was there a change in the operative procedure versus the standard operative procedures that was carried out? I wasn't involved with any of them, but I believe the algorithm that Dr. Vidal uses typically is to try to get... If you're doing a slope reducing osteotomy to get the highest one below 10, am I remembering that right? Yes. Okay. So he would look at which one's higher to bring that down. He's not like taking the average, I guess, if that's the question, how the numbers influence it. Yeah. It's really hard to make that decision, right? Like which slope is most important? Does our CT measurement correlate with that 12 degree number that we all use? So in general, I want to get the highest of the two slopes if feasible below 10. Sometimes we had a big enough differential where that would actually push the other slope negative. So it's a challenge. No, I think it's interesting. I think the next step is to see if there's any differences in outcome in these variable ones versus the non-variable plateaus. Absolutely. Thank you again to our speakers. Really great session. All right. We're going to have a little fun. We're going to see some surgery. We're going to invite Dr. Alfred Mansour up and he's going to show us his technique, which is really excellent for infratubrical closing wedge osteotomy for slope reduction. How do I pause it? It's already starting. Yeah. There we go. Perfect. All right. First, thanks. Thanks, Armando. Thanks, Rachel, for having me. Thanks, Walt, for pushing me along in this journey. And thanks for giving me a timed talk. This is actually going to be a voiceover, so it's like I'm narrating a movie. So I'm going to try to stay with it, but please forgive me if it gets off a little bit. But I'm going to present our... Is it showing up? It's coming up on your screen. Yeah, I can see it. I can't see it. Let's try this again. All right. All right. Bingo. Still not up. While Armando is working through the technical difficulties of the audience, who does slope correction osteotomies? Who does supratubercle for most of them? Who goes infratubercle for most of them? Interesting. And who takes the tubercle off? OK. I could think of other questions to ask. Who uses a plate for fixation for any of their slope correction osteotomies? Who uses just staples? Who uses a combination of staples and plate? OK. Interesting. I'm going to keep this going. If you're doing a state or a concurrent revision ACL reconstruction, while there's nuances with respect to bone tunnels and size, who's often doing a concurrent revision ACL reconstruction at the same time as their slope correction osteotomy versus bone grafting? So doing the revision ACL at the same time. OK. That's wrong. How about bone grafting? OK. We're making progress. Who thinks that doing a slope correction osteotomy with BTB AutoGraft is one of the most difficult procedures in the world? Just me? Just me? OK. Anil, what's your graft of choice for a concurrent ACL reconstruction, if you had your choice with slope correction? For those in the back, Anil selects hamstrings. Is that what the majority of people would pick if they're available? Who would pick quad? And if BTB was available, who would pick BTB? OK. Contralateral BTB. You're going to torture that patient with two knee surgeries. OK. All right. Agree, yeah. For those who can't hear because we're not at a mic with our audience, contralateral BTBs do do well. I'm joking. I love doing that procedure if I need to for that right athlete. Patients tolerate that harvest site quite well. Who's doing osteotomies in general about the knee outpatient almost exclusively? Who's doing inpatient almost exclusively? How about overnight observation, 23-hour ops? All right. Dr. Lowe, you do a lot of osteotomies in for tubercle. Oh, we're up. Never mind. Too late. Too late. You get to talk later. Okay. Okay. We're going to switch the order, it seems. Yeah. But thank you all for participating in the Q&A. It's a really good surgical technique. You guys missed it. It was awesome. I'm going to invite Anil up to give a talk on the meat-opening wedge using PSI while we figure out Alfred's son. Thank you. It's an honor. It's amazing to see this room. This has really changed a lot in the last 15 years of AOSSM, see osteotomies like this. So I'm definitely excited about this. I will say that there's one professional athlete that returned back after an opening wedge osteotomy, and he went back to hockey, and you can tell him he's a very famous hockey player who played in Detroit, but I can't tell you his name. So that's the answer to that, is slides are not advancing. So if the PowerPoint doesn't play, Dr. Mack has volunteered his knee. He's had a little bit of tequila, and we can get going, a live demo. I think it's just the mask. Okay, so I have some disclosures that are a little relevant, but nothing that relevant. I've worked with every PSI company out there. So let's talk about why do we think we're doing this? What about preoperative planning? That's the fundamental principle of osteotomy, but especially with PSI, give you a case and a technique and some conclusions. So I was just giving this lecture at West Point, and I saw all of our greatest military leaders, and they were, and I said, did you guys ever go on a night trip, and you attack the bad guys, and you guys use night vision? And they're like, yeah. I'm like, that's really cool technology. That really works. It makes you see at nighttime. And then we did an osteotomy together, and they used a bogey cord. That doesn't make any sense to me. We want to find enabling technology, not disruptive technology. Enabling technology makes an operation more accurate, safer, more efficient, and more versatile. So what this PSI software planning does, it takes a 3D CT, but what it does, it overlaps it on a long-leg cassette. There are a lot of robotic technologies that you've seen when you were residents or fellows that are taking you over arthroplasty that just use CT. This is an overlap of CT and X-ray, so it gives you a semblance of soft tissue balancing and really overlaps the two concepts, because this is more than just a bony operation. It's also a soft tissue operation, and I think that's the future of osteotomy. Then you do your virtual osteotomy. Even if you don't believe in PSI, I would say you have to believe in digital templating, because from here, I can adjust where I want to make my cut, and I can adjust my hinge axis. Understanding the hinge axis is understanding opening wedge osteotomy. Do I want to go in A to P, slope-neutral hinge axis? Do I want to do a decrease in slope, an anterolateral hinge axis, or do I actually want to increase slope for a PCL-deficient knee? This is a powerful tool to do this. It's also a powerful tool that you can play around and say, wow, when we first started doing this, me and Armando and a lot of guys in the front, we would never do double-level osteotomy. That was a crazy concept. But here, you can easily plan a double-level osteotomy. We used to do big corrections, break hinges, and I was scared. I thought a double-level osteotomy was way too much surgery on one patient. It's actually much less surgery on a patient, because a knee will accommodate smaller corrections from a soft tissue perspective much better than one large correction. So here's a case. It's a 35-year-old female, very active, upper side, New York City, kind of crazy, much better shape than I am. She had an ACL with a BTB about 10 years ago and had a meniscectomy. She now has menial knee pain, and she's failed all conservative management. She's not going to the NHL. So this is the power of this PSI planning. It gives you all of your numbers. It gives you the coronoplane and the sagittal plane. As we saw on the bottom, it gives you both medial and lateral slope. For this patient, slope wasn't really the issue, because her ACL was stable. It also gives you all your coronal axis. It gives you the mechanical axis deforming. It gives you your tibiofemoral axis. It gives you the MPTA and the LDFA. So you can really figure out what you want to do, and then it gives you your delta. So you played with your virtual thing, and this is where you want to go. So it really gives you the roadmap. It is your ways to get home. You still have to drive the car, but it gives you the ways. And then you get this templating system. The reason why I love this system, it's an opening wedge system. Opening wedge kills bone. And the best way to decrease thermal necrosis is using drill bit technology. Using drill bit technology, I can precisely put my hinge anywhere I want. For this scenario, my hinge axis is exactly neutral. It's a slope neutral osteotomy. I also can do a pre-templating of my screws, so I don't want to hit her ACL tunnel, because her ACL was still functional, and it was good. And once you position this PSI guide, and the PSI guide has a lot of personality to fit the proximal tibia, why PSI failed in arthroplasty, all their PSI guides didn't have enough personality. So you could put it any way you want, and an experienced arthroplasty surgeon could just do it totally much quicker than fitting this guide on. These guides have gotten much better. So here's a technique. First, you know, she also had an OCL graft for that menocondrial lesion, so that's why it's such a big incision. But how you manage the MCL is really this operation. We can talk about dedo. This is an older case I did where I do a complete peel of the MCL. You can do an L flap of the LCL. I like to call that the Armando flap. You can also do the double windows. That's more the European Olivier kind of construct in Christian clay. Or you can just do the Fowler technique where you cut right through the superficial MCL. So how you manage the MCL is a critical part of your learning experience of this operation. But here you now see the MCL is totally exposed. We're about the back of the tibia, and then I expose the tubercle so we're protected in all places. Once you fit the guide on, it's press fit. You screw it into place, and I call this the Rachel Frank shot, where I take one shot to prove where I'm going to adjust my... ..where my hinge axis is going to go, and do I like my osteotomy cut. And then you place the drill bits on top of that, and you start drilling your drill bits. Once this point is on, the operation is pretty much done. And then once you finish drilling, you then finish it off with osteotomes, and you have your plane, and it's really a quite simple operation. All your osteotomes are calibrated. It tells you how deep to go. Then you remove part of the PSI guide, and then you can finish the rest of the osteotomy off with osteotomes, with the PSI guide off, except these two little pieces that are still on the bone, and they will be your lever points or your lever box to help open the osteotomy in a controlled fashion. And that's once we put the anchor box in there and we open it up, and you gradually open the osteotomy. And as we heard from Rachel, this is a very gradual process, or hoop stress, hoop stress in the Mayo Clinic. And once you're finally done, you put a pre-templated guide, which all your screws are pre-templated. You just drill, drill, drill. You have a wedge that's actually tapered to the wedge of the implant. You also have an anterior and posterior wedge height control, so you have a trapezoidal box in terms of your opening wedge, so you don't have... You increase your slope, and then you just put your plate on, and you put your screws in, some pegs, and it's pretty standard. And after this, I use bone marrow aspirate with Cotton & Evans wedges. You don't have to do this, but I like to find an X-ray where I fill all the bone. These are your X-rays. They're very reproducible. You can see it's slope neutral, and we got it out of Varis. So I think osteotomies are biomechanically sound. They maintain high function. They preserve the bone. They're very versatile. PSI really is, to me, the future. We need more enabling technologies to do an operation that relies itself on bony cuts, so let's have better technology. I don't believe always that technology is the cure for everything, but when you have enabling technology, and you're still the surgeon that drives that technology and controls that technology, that's enabling technology. As my dad would always say, the eye see what the mind knows. Thank you very much. APPLAUSE Next up will be Travis, taking us through the distal femoral osteotomy journey on both the lateral and medial side. Or excuse me, on the lateral side. Excellent. Thank you both to Armando and Rachel for having me, and Adam for setting me up with his research to give me justification for my anecdotal decision-making. Disclosures are on the website. My overall thoughts, alignment trumps all. I think that's why many of you are here. Bony alignment trumps all soft tissue procedures. If you're on the fence for an osteotomy, most certainly do it. My question here was, should I do an opening or closing wedge and how to do it? Really, it depends. Limb length, discrepancy, size of the wedge, osteotomy, healing, nicotine, patient factors, BMI, compliance, concomitant surgery. All of these are things to think about, and as Dr. Yankee taught us, limb length discrepancy might be something to really consider, and I've always thought that to be the case, although the research hasn't shown it up until now. This is not advancing. There we go. Maybe? Okay. Quick overview, obviously, calculate your angles. You guys have heard a lot about that here. No need to belabor it. Medial proximal tibial angle, lateral distal femoral angle, and your joint line congruence angle. Make sure you calculate these things and know where you're going. Briefly, I prefer case-based stuff. It helps me wrap my mind around things. So, this is a 29-year-old male, lateral joint line pain, injured in high school, activity modifications, nothing's working for him, and these are his alignment views. So, you can see asymmetric valgus for him. When you calculate it, his proximal tibial angle's 93, distal femoral angle's 80, joint line congruence angle, not too bad, and valgus at 13. He has a limb length discrepancy, Dr. Yankee, of 0.9 centimeters. So, we're thinking here, where do you do, where do you want to do it, and how do you do it? So, in this case, he doesn't have a significant limb length discrepancy. This looks to me femoral-based. Here is pictures that we briefly saw, and now what to do. So, from my perspective, in this case, I preferred a medial closing wedge. This is a big osteotomy. It's a big change. This is a prophylactic pin that I placed laterally. I found this to be very useful. If you're going to close a long distance, you can fracture out. While, yes, this is theoretically a green stick fracture, it can become a non-green stick fracture, and in this case, it was planned that it was going to break, and sure enough, it did, but the pin was placed first. So, that's one little quick tip that can help you so you don't get translation, and then the plate's placed on. And, ultimately, his post-op films look like he has good alignment, and there's some decent science behind this to demonstrate that medial closing wedge osteotomies do fairly well, and they're fairly straightforward. This, for me, is a go-to. You saw Dr. Yankee give you lots of confusing math that I can't understand. For me, I use the Hoonigoo chart. This works really, really well. It works for HTOs. It works for DFOs. You shoot your pins. You measure them. You get anterior and posterior, and then just use this chart, and it tells you how much you're going to close, and it works really well. So, now, how to do this. I was really scared about medial closing wedge osteotomies when I first started in practice, and so this turned into a very simple procedure for me. The initial dissection, this is my go-to for almost all DFOs at this point. It dissects off very easily. VMO peels off with your finger. Then, retractors are placed posterior and anterior, and this is just a simple dissection. I use four pins. They go proximal and distal. You can recess the impale fell slightly, and those pins effectively are now my cutting guide. You can use a caliper, or you can use a wedge. At this point, I'll then mark my saw, and this tells me one centimeter less than the distance I want to go, and I effectively stop where the mark is, both anterior and posterior, and the wedge comes out. Again, the pins are the cutting guide, and as you can see there, that goes all the way across, and this is the flexibility you want to see. So, when you see that flexibility, you know you're good. Now, interestingly, medial closing wedge initially was very concerning to me because I thought I'd have a hard time closing it. A few quick tips, going back briefly, to play that one more time. So, what I want you to focus on here is really the distance between the pins, and this took a few years for me to figure out. Initially, with an HTO, you want to cut to the pin, and you want the pins to go all the way in touch. With a medial closing wedge, you don't. You want those pins to have just a little bit of separation, and the bigger the closing wedge, the less separation you need, actually, because there's a distance between your saw and the pin, and if you have those pins coming together and converging perfectly on that lateral side, you won't take out enough bone, especially if you have a small wedge. So, at this point, I go fairly reasonably with the saw and taking that out, and using the saw is a very safe thing to do. I prefer not to use osteotomes, actually, to complete those osteotomies because it propagates fractures, and the saw is very safe. This dissection is very, very clean and easy. So, I'd encourage all of you to consider doing closing wedge and making it, as Dr. Yankee described, lower changes in limb-length discrepancy, and also very, very strong osteotomy, especially in patients who have comorbidities. So, translating now to a 39-year-old male rancher. He had right knee pain. These surgeries were done previously. He had a sub-total lateral mastectomy. Surprisingly, that didn't help. He had continued pain, and these are his alignment views. So, he's a larger gentleman. You can see the positive smile sign at the top of the long limb-length views, and now you see, obviously, a huge correction. So, lateral distal finger angle is 81. He's an 11 degree of valgus, and his limb-length discrepancy is almost 2 centimeters. So, in this case, I actually want to give him some length. So, this is a person I would consider doing a lateral opening wedge osteotomy. These are his scope pictures. I like to scope them to look at the medial side to make sure it's okay, and, again, we're going to open him up. So, he's a big opening wedge. Again, we have that pin, and you can see a propagation of the fracture. I would argue that's my fault, actually, but this began my journey of pinning things before they break, because I've managed to cause problems even when I don't want to. So, this one's pinned and opened, and, again, this is a simple dissection of just going past your IT band. I think everyone knows how to do lateral opening wedge osteotomies, medial being the most concerning and difficult one. So, this was pinned and opened, and, obviously, a plate placed on to open and hold the osteotomy, and I would say the interesting thing here and the reason I picked this, if you see the difference between the picture on the left and the picture in the middle, this osteotomy and the screw can be used to reduce, if you do fracture out, you can reduce the fracture if you displace, and it actually closes down and compresses. So, another pearl there to consider in your operatory. So, post-op films are here, and this is him eight years out, and he wants the other knee done, and I'm trying to convince him not to. So, at this point, my point here, valgus-correcting osteotomies can be performed all over the knee. They should be concerned. You've heard about different things by Dr. Ranawa and others on how to do it. Opening and closing wedges are very, very good techniques to be used. I would encourage everyone to be able to do both of them, and, actually, I do do both of them, and sometimes above and below the knee can be done as well to appropriately reduce your limb-length discrepancy, and most of mine are closing wedge immediately unless there's a limb-length discrepancy at this point. So, what's better? The answer is none of them. They're all fantastic. Just pick the one that works better for you and consider maybe the pearls you hear in this talk to help you out, and the other panelists to help you as well. Thank you. All right, I'm being told that Alfred's talk is going to work now. It's really an awesome talk, so I really want to make sure you guys can all see this. It's so good you shouldn't see it. It's so good. Is that going to be all right? Yeah, except I can't see it. How do we restart it? Otherwise we're going to hit this. On the volume. All right. Can we go back? That's all I'm going to let us do. Pull it back. I'll do it from the beginning. Yeah. Pause it. Sit over there. Okay. And then pull it over. And how do you start after that? I think space bar should do that. Yeah. Okay. All right. So this is my preferred technique, infratubrical closing wedge. Thanks again for the opportunity, and thank you for your patience. It's been well described by a couple of papers. This is not an invented technique by me. I'm just describing the preferred one that we use. So our case is a 19-year-old D1 football player. Tore his ACL in 22. Had a BTB autograft. It re-tore. Came to see us. He had full motion 2B Lachman pivot glide. And standing alignment was fairly neutral. You can see his previous screw fixation from his BTB autograft. His MRI shows an ACL graft tear. And then the meniscus shows a ramp lesion as well. These are his alignment films. I'm a long leg alignment guy. This is 15 degrees posterior tibial slope and neutral. And so we have an ACL tear. We have a medial meniscus ramp tear and then elevated slope. So we chose quad autograft, single stage. This is my planning. So I use the long leg and then zoom in so I can see what the short leg alignment is. Calibrate the x-ray always and measure it every time. It's not 1 degree to 1 millimeter. So that is not going to give you an accurate planning. So this is a large anterior incision. I'm focusing on the osteotomy. We've already performed the ACL, fixed it to the femoral side. And you can see the strands of the graft fixation that are through the tibial tunnel. I'm opening the anterior compartment. And the length of the incision and the exposure of the anterior tibial compartment depends on the type of plate you use. So in this demonstration, we're using an anterolateral plate. And so it's a little bit more dissection of the anterior compartment. It's important to visualize the inferior fibers of the patellar tendon insertion. You can see where I've exposed that. And now what I'm doing is elevating that dense, thick periosteum distal to that. And I'm going to repair that over the osteotomy site. So now I use fluoroscopic imaging. I like a thicker pen here because it doesn't sky this easily because you're doing a fairly oblique pen insertion. So center the tubercle up to the posterior tibial flare. So we'll place that first pen, make sure it's exactly where we want it. And then we'll just use our preoperative templating and measure the gap, similar to the other osteotomies you've seen. And then we'll take that second pen to converge it. But just like previously stated, you don't want to go point to point because you need to account for the width of the saw. And there's always some amount of deflection of the osteotomy saw blade there. Cut these pins at separate lengths because when you collapse it down, it's hard to remove pins that are the same length. Just trust me, I've struggled on that. So cut them separate lengths. And then I use fluoroimaging and a cob elevator to elevate medially and laterally in the direction of the osteotomy site. So it's not a full exposure, particularly medially. It's just enough to make sure I can protect my saw. So I'll place the radiolucent retractors. I prefer those because I can still use fluoroscopic imaging and still have careful retraction. So this is starting our saw blade. The saw that I prefer just cuts at the distal tip, which I think has increased my precision. It's easier to guide, and I think there's less collateral damage with it. So we'll carry that saw blade. You can see I start approximately with this, both medially and laterally. And again, you can see that deflection right there at the end. And then we'll start inferiorly in a similar fashion, working back toward the posterior cortex. It is an incomplete osteotomy, so we leave the posterior cortex intact and just work slowly, medially, and laterally, taking your time, using irrigation. And then obviously this is in fast forward. I don't operate this fast. But you can see a fairly good-sized wedge that you can remove. Now the key and one of the pearls here is the osteotomy site is not flexible at this point. Think of the medial and lateral sides as an I-beam. If you don't go back to the posterior cortex, you won't have enough flexibility. And if you try to collapse it, then you'll fracture the osteotomy site. So you can see I'm working both medially and laterally. And then I'll actually use a curette in those back corners. And what you want to see is right here as I'm using that osteotomy, now the curette, as I'm removing that bone, you can see flexibility of the osteotomy site. If you can see that, it's starting to close like a Pac-Man mouth. That's really important. Don't bother trying to close it down if you don't see that flexibility because you're going to have to force it. And if you do this correctly, then it's going to be pretty straightforward. So I'm working those corners, posterior, medial, and laterally, and then I have that flexibility, and now I'll just hyperextend the leg, and the osteotomy site closes. I hold it with a clamp of your choice. And then I prefer an interfragmentary pin, so I put a tibial tubercle pin in, and that really gives you a fairly immediate stability of your osteotomy site. And now it's a matter of plating. Again, you can plate medially, you can plate laterally. A lot depends on your concomitant procedures. I think one of the advantages of the lateral plating is that it leaves the entire medial articular block open. So if you're going to do a concomitant medial meniscus transplant or you're going to need several medial tunnels, you don't have to worry about fixation interfering with this. So I'm an advocate of locked plating. I think particularly infratubercle probably needs more rigid stability than a supratubercle technique with staples, so I don't have any experience with the staple technique on infratubercle. But I know that rigid fixation allows fairly immediate rehab. The only difference in our rehab protocol is probably more protected weight-bearing than we would if we did a standard ACL. If you have a meniscus that you're protecting, there's not a whole lot more weight-bearing precautions that you would utilize. So the key that I was talking through there was I do put an interfragmentary screw to compress the osteotomy site. I think good compression AO technique can allow pretty rapid healing, so I do protect the tubercle with a screw and then use compression along the plate. So what I'm demonstrating here is our kind of final construct, AP and lateral, with our fixation. You can see what I'm doing here is removing that corner that's always present on the distal fragment, and then I've turned the osteotome 90 degrees and peddling that cortical bone to encourage healing. And then that's that periosteal flap to cover the osteotomy site that really gives you good vascularized coverage. And then we'll put a tibial screw and just tie to the post there for our tibial fixation. Touchdown weight-bearing than partial, full motion. I do use aspirin for DVT prophylaxis and vitamin D on all my patients that have osteotomies. This is a post-op, and you can see kind of pre- and post-op with the osteotomy slope correction. And that technique's very straightforward. I think it's probably easier than supratubercle. We have a small but fair series in very high-level athletes that are making it back after this, so I do think in the select patient you can make it back fairly predictably with a pretty reasonable rate of return. So thank you. All right, we did have a case panel originally scheduled, but we are tight on time, so we have to keep it to our... We have five minutes, so... Oh, we can add five minutes. We have nine minutes now for cases. Okay. Actually, let's go ahead and bring the case panel up then. Thank you, Allison. So thank you to the speakers. Awesome techniques, and we will get this loaded up here. Case panel, come on up. Nine minutes for cases. I'm going to keep Rachel up here. I'm here to keep the time, okay? I know. I may need the AV guys up because I think when they did that, the cursor moved off the screen to pull that. I can't even see it. Welcome to our expert panel. Joining Dr. Vidal moderating this panel will be Dr. Amidola, and we have Drs. Getgood, Lowe, Volker, and Bertrand up here. And this is really a worldwide collaboration here with osteotomy experts. While Armando is pulling up the cases, are we up? Yep. Armando, take it away. I'm actually going to... Ned, this is your case. So Ned and I are co-moderating this section, so I'm going to let Ned present this first case to our panel. I was just following your lead, Armando. So moving forward. All right, this will go quickly. A 19-year-old is one of my patients. He was a freshman on the football team. He had a previous history of his other knee. He had an ACL a couple years before, and he actually was starting to have some symptoms in that knee and having some medial knee pain. So he had an acute pivoting episode at practice, and you can see his X-rays and his MRI here. And, again, just to get through the case, he's got a complete ACL tear. He's got an injury to the posterior root of the lateral meniscus, and he's got a Saigon sign laterally, and he's got a tibial slope of, you can see there, about 15 degrees. Posterior tibial slope of 15 degrees. So the thing with this one is that he was also having some symptoms on the other side. He had a hamstring, autograft, ACL reconstruction. And so even as a 19-year-old, you can see he's having some failure of the previous ACL down on the other side. So the question at this point, with a high slope, past history of a previous ACL that's starting to fail, how would you treat this one, Volker? Well, I'm not concerned about the other side failing because he had the wrong graft anyway. So he would get a patellar tendon ACL. I see the Saigon fracture, and I'm very happy to see it because the soft tissue probably wouldn't heal so well, but the bone heals so beautifully, so I do nothing to it. And, of course, I will discuss with the patient and tell them, you know, 15 degrees is terrible. I hate to see it. But if he's on the team currently playing, I probably delay that slope just like I said yesterday morning, although you cannot unsee it. I admit to you that 10 or 12 years ago, I never looked at that slope. It looked at me, but I didn't look at it. And so now I see it, I measure it, I get a long tibia, I convince myself it's true, I see the contralateral story. Now, if in that conversation he then comes to me and says, okay, doc, wait a minute, I'm a major in mechanics, and I understand the slope so well, why wouldn't you fix it? Well, then I'd go down this path with him and explain to him, yes, we probably do that, but only if he's in it. Alan? Yeah, just what he said, no. I think for me the slope's not the big issue here, it's his anterior tibial translation, that makes me very nervous. And the fact that he's already... But you're saying that he's failed on his left-hand side? Sorry? The ACL's failed on his other side? On the other side, he has some laxity, but it's still intact. So, I mean, he's already saying that he's high risk, and I agree, okay, he had a hamstring, didn't have an LET, but he's at significant risk of having a further injury with this right-hand side. His anterior tibial translation, trying to control that with a soft tissue graft, whatever that would be, even with adding a lateral tenodesis, I would be having a conversation with him about a slope correction, and if he didn't want it, I'd do a BTB-LET. So you'd be that aggressive, thinking of a slope correction, first-time ACL? I would have that conversation with him, for sure. Walt, we just saw your technique. You do a U-T ortho. What would you do? Well, I'd actually kind of follow out. We do have a couple of primaries, a little higher slope than that. In the primaries, they have returned, as you saw the talk yesterday, at a very similar time to just the ACL alone. So when you see that slope, that anterior translation, that lateral side sagon fracture, this is just a really unstable knee, and it needs a big surgery. And I think if you do it, they're going to get well. And I agree with Al. You have the talk, and if Mom and Dad and players say, I don't want the bone cut, then you do the L-E-T, and you do a BTB-ACL, and you say some prayers when you get home that night, for sure. But once you have that talk with people, what I find is they get it, and they buy into it, and they say, if this is what I need to be fixing good, they'll say, let's go for it. All right, let's ask everybody in the audience, who would just fix the ACL and do the lateral repair? How many would do an osteotomy at this stage? I guess we're not strong enough. Armando, we didn't do an osteotomy. I did talk to him and the family about doing an osteotomy. We did an ACL reconstruction with bone tendon and bone, did an open lateral repair of the sagon injury and reinforced that, and did the lateral meniscal root repair. He's done very well on this side, but we'll see what happens in the next few years. I think we have time for one quick little case. This is my case. It's a 31-year-old female ski instructor, left knee pain instability. She had a hybrid hamstring-auto-allo combo, and then a partial meniscectomy a year later. Her primary complaint is medial pain and instability. From an exam standpoint, it's just ACL, no collaterals, and she's got medial joint-line tenderness. She has a slope of 14 on her short leg lateral, and her alignment is a weight-bearing axis of 42%, so she's slightly varus. Lateral compartment looks okay. Some cystic change underneath her lateral meniscus root. ACL is incompetent. Medial meniscus root tear. Tibial cartilage damage. Slight femoral cartilage damage. This is her staging scope. Damage on the femur. Damage on the tibia. Medial meniscus root tear. ACL deficient knee. In summary, she's got medial wear, root tear, varus alignment of 42%, slope of 14. Are you guys going to do an osteotomy? If so, what kind? Let's keep it to that question. Again, failed ACL. Are you going to do an anterior closing? Are you going to do an osteotomy? If so, what kind of osteotomy? I'll start with Bertrand on the far side and work our way down. I do not understand. She's complaining of the medial side? She's complaining of medial-sided knee pain and instability. Okay, so I will do probably a revision, one-stage revision for sure, and a valgus osteotomy. Valgus osteotomy. In France, we don't have easy access to meniscal allograft, unfortunately. So the only option we could have is a valgus osteotomy. All right. Walt? Well, probably the same, and have the discussion about a transplant. You know, she's 31 years old. She's already got changes heading in the wrong direction, so she has a full thickness chondral lesion already on the medial femoral condyle, and so I would probably have the discussion about addressing all of it at the same time. Al? Anterological closing wedge, proximal tibial osteotomy, no transplant. All right. Revision ACL, same setting, LAT. And Volker? Yeah, probably trial her with an unloaded brace, but you know what the answer is going to be. It's going to work. She's hating the brace, but it works. This is very tricky because you must correct the varus, yet the slope is so massive, and I say massive only because the translation on the tibia was really much. And with the medial opening wedge osteotomy that I usually do, I don't think you can reduce the slope all that much to your satisfaction, so you may even have to go in there twice. Yeah, that's a really good point, which is which plane is more important to you. I ended up doing a medial opening wedge osteotomy with a slope correction in her case. She's done well. She's now three years out. I'll just show you her final pictures, and I think we're probably over time after that. But I did an osteolographed her medial femoral condyle. I actually fixed her medial meniscus root. I overcompensated a little bit and did not do a transplant by overcorrecting, and then a quad-auto ACL reconstruction. This is her post-op X-ray. Al asked when I show this because I don't think it's a good estimation of her slopes. That's her pre and post, sewed side by side. So we had about a two- or three-degree reduction in her slope, and this is her post-op coronal plane, and she's back to skiing. So with that, thank you, guys. I want to thank our panel. That was rapid fire. We had nine minutes to go through two complicated cases, and thanks to all our speakers. Thank you.

Rachel M. Frank, MD

Armando F. Vidal, MD

Michael Alaia, MD

Adam B. Yanke, MD, PhD

Richard Amendola, MD

Nicholas I. Kennedy, MD

Alfred A. Mansour, III, MD

Anil S. Ranawat, MD

Travis G. Maak, MD

Alan M. Getgood, MD, FRCS

Walter R. Lowe, MD

Volker Musahl, MD

Bertrand Sonnery-Cottet, MD, PhD

distal femoral osteotomy

high tibial osteotomy

patient outcomes

high-level athletes

Tegner score

return to sport

concomitant procedures

complication rate

patient counseling

osteotomy techniques