here, but now that I heard your talk, it's gonna be easy. I mean, you basically made one argument, you showed two x-rays with very bad fixation and said that's why you can't do it. So it's gonna be easy. Alright, listen, it's like this. So here are the three choices you can do. As I understand Al, you I think chose number two with the tubercle, although I thought you go number one. So I'm gonna talk about this third one below the tubercle. So the sub-tubercle osteotomy was, as you correctly mentioned, you know, I think came up in Germany with Wolf Paterson to reduce the complications associated with tibial tuberosity detachment and patellar tendon impairment. There are very few outcome studies. This one is from Beijing. It's actually a very nice study. You can see they all had high slope. It was reduced well. There weren't any complications and I was suspicious to read that, but the largest study, your honor and everyone, is from Germany and it's about sub-tubercle osteotomy. It's really the only body of work that we can use here. It's on 48 sub-tubercle osteotomies with, not my words, there's no procedure related complications. So here are my arguments, okay, there are eight of them and I'm gonna nail every one of them out. Surgical exposure, okay, so look at Alt's bloody exposure on the left and my beautiful clean exposure on the right. They're both minus, okay. You have to be a master if you go super-tubercle. You have very little real estate to work with. You have to constantly worry about the patellar tendon and if you go below the tubercle you don't really have to do that at all. Now the patellar tendon, when you go super-tubercle, you have to move it to the lateral side. You have to move it to the medial side. You constantly have to change your retractors and your saw blade will constantly nick near the tendon. So you have to really worry about it and you may even lose that. Now the proximal bone reserve for fixation depends a little bit how tricky you get with your biplanar cuts, but if you don't do a biplanar cut as originally described, then you have about a 1.5 to 2.5 centimeters left and all you're left with is staples. Now staples may be good enough, but I would argue that if you use a plate you have the possibility for early aggressive rehabilitation. What do you think about that, Al? Next, surface area for bone healing. So the orange cut is assimilated the super-tubercle and the green one is the sub-tubercle. So it's a longer, more steep cut with a larger area for surface healing. And placing the tibial tunnel, you have all the real estate that you want if you go sub-tubercle. And this is something nobody else really talked about here, so I'm a little bit surprised Al you didn't go there, but you will change with a super-tubercle osteotomy a bit of the patellar station. Now you may want that if somebody comes in and they are stiff and have a short patellar tendon, you can lengthen it a little bit, but otherwise you will induce some ulta. And then lastly, the hyperextension. If you do this procedure on somebody that failed their ACL twice and you know they have a slope of greater than 12, they oftentimes are the hyperextensive person. So you really have a tough time, you want to go too hyperextensive. Now if you go below with the tubercle, your point of, your angle, your hinge point is slightly more distal, and therefore you have a little bit less risk for vicarotum deformity. So in conclusion, there's still a lot of points unclear, you know, we need more studies and I applaud everyone in this room that came and brought their papers, that excited me a lot. We need more objective data, we need larger scale than nine patients or in our CS23, and more biomechanical and clinical studies. Here are my arguments, just for a final slide. Surgical exposure, easier. Risk of injury, patella tendon, none. Remaining proximal bone, much, much more. Surface area, greater. Modification of patella height, much less. Tibial tunnel, easier. Technical difficulty, really not so much. Effect on vicarotum, lower risk. That's it.

sub-tubercle osteotomy

knee surgeries

complications

tibial tuberosity detachment

patellar tendon impairment