So for our final video, this Volker who needs no introduction will be talking about correcting the slope. Thanks David. So let's talk about slope a little bit. Disclosures are on the website. So Bruce Ryder who sits right here in front of me always writes wonderful editorials, you should read them. This one is about the slope which is slippery. So it's very good because it kind of forces us to think a little bit and not go too far on one side or the other. This is experience from his fellowship. So then nothing here is new. Now a few years back, I think six or seven years back, I presented at a local specialty alumni society my first case of a slope osteotomy. And they said, you're doing dog surgery? And I said, yeah, I sure am. So this is a 40 degree slope in your usual golden retriever. And if you do an ACL in that, it's not going to work. So I'm going to talk about these one and two, these top procedures there. The difference currently is going above the tubercle. And that's, I think, an easier way to do it through the tubercle. So this patient here is 30 years old and is a typical disaster patient with three failed ACL reconstructions. Now, you may think this is all allograft, so just switch the graft. You may think, well, that lateral x-ray shows an awful femoral tunnel, so just do it right. Well, that's true. But that 15 degree of slope will persist. So what we do here is if you want to correct it about 10 degrees for each degree, about roughly one millimeter, there's no exact science. There will be a 10 millimeter anterior closing wedge. And this can be fixed with staples or a plate. So just real brief, a short video. What it affords is a very meticulous medial MCL exposure as well as a lateral IT band and anterior lateral structure exposure. The patella tendon is right in the middle of all this. So it will have to be protected throughout the case, once from the medial side, then from the lateral side, back and forth. It's not always that easy to remove the wedge like it is here. Of course, I'm not going to show you a complicated case, am I? And then once this is out, you simply close it and put a fixation in it. So I'm going to spend just a little bit longer time on the second patient. Now, the story is, again, very similar. Two failed ACL allograft reconstructions. He then underwent a stage one procedure for bone grafting. And only then, he's from about two hours north from us in the middle of Pennsylvania, he drives himself down to Pittsburgh. And he says, I had two ACLs with allograft done by the same surgeon. They're preparing for the third allograft by the same surgeon. Should I think about something else? I'm like, wow, you want to become a resident here? That's very good. Really smart guy. So, no, I don't think you should do the exact same thing again. So in this kid, 12 degrees of a slope and neutral coronal alignment. Unfortunately, the medial joint is already collapsed, postmeniscectomy, et cetera. So sometimes this can be done in a second stage. Now, this is not a PSI type of slide. This is just a surgical technique that we recently published. You can most certainly use PSI on this. This is all in development. But the plan here is to do a through-tubicle osteotomy. So here's the video. This guy already has a little bit of hyperextension. So you've got to be very careful. If somebody has 10 plus degrees of hyperextension, I don't think you want to do a slope correction osteotomy that extends them even further. Clear pivot shift. And it's my left hand, by the way, that does the pivot shift there. And so here is just an anterior, very straightforward exposure. Again, this is the medial, very meticulous medial and MCL elevation, subperiosteally. Then the patella tendon gets exposed. I like to use a curved Mayo scissors for this. And then you do a tubicle osteotomy. I think this is a very predictable way to do it. This is just the first three and a half minutes of this procedure. Once the tubicle is elevated, you then aim with a guide pin. And my left hand thumb is feeling the posterior tibia, which is where I'm trying to aim that guide pin. Only one shot, always, of course. And you put four such guide pins in an array, one medial, one lateral. And then the two distal ones in the amount of planned correction. Here's the wedge that then gets elevated. You've got to be careful not to go too posterior, obviously. But you leave about a centimeter intact. And there's a thick PCR that will protect you from breaking that cortex. And then, again, this is the closure just by hyperextending the knee. And then you can put any type of system on there. I like using a locking plate system that is low profile. And we also use, of course, a compression screw as your first distal screw to use the advantage of a closing wedge. You can really weight-bear them relatively early. And then if you want to, you can do a concomitant ACI reconstruction at the same time or in a second stage if there's more to do. This is not a return to sport type of procedure. This is a knee preservation case. I think this is very important. So I tend to overcorrect. So here we went to three degrees. We can argue about that. They do toe-touch weight-bearing, range of motion as tolerated, and then sometimes stage procedures. Very few articles in the literature, but very good ones if you look at the authors. The series are small, five patients, nine patients, 20 patients, 18 patients. You can see that the slope always gets corrected. David Dujour likes to overcorrect it. That's what I do currently as well. Again, you can argue about this. Relatively good outcome. We just published, Gertgud and I, with HERD together, so a series of 23 patients. The slope was overcorrected to about four degrees. I think this is currently our goal. The translation gets corrected. We do have some graft failures. Now, these are all salvage cases. They're all two, three, four times ACL failure. And the IKDC is quite sobering. It's 52. It's not 80 in our case. But these patients have a stable knee and are relatively happy after all the stuff they've been going through. So in summary, so it's a technically demanding procedure. Do a lot of measurements prior, during, and after. Don't forget the cartilage, the meniscus, the ACL, the corners, et cetera. Currently, some indications. I know people like these types of slides. But currently, after 12 degrees in the second revision, I will go after that. And almost all of your second revisions have 12 degrees or more. That's just how it is. You cannot unlook it. In first revisions, maybe 18 degrees. And in third and fourth revisions, sometimes you can only do this slope osteotomy and it actually works. And then the stability and radiographic parameters, they're very much correctable. But the IKDC and PIOs are sobering. Thank you very much.

Dr. Volker

slope correction

ACL reconstructions

slope osteotomy

failed reconstructions