So I wanna thank you guys for everyone for coming and showing up. Welcome to Denver. We're gonna get right into this. Hopefully this will be as interactive. It's a pretty intimate group. I see a lot of familiar faces in the audience. So thank you for supporting this ICL. This is, I think, our third year of this. So if you guys want us to keep on doing this, please send in some positive reinforcement. We have an all-star lineup. First, Seth will be talking about intro to osteotomies from templating to mistakes he's made and things like that. I'm gonna talk about how I think complications are still relevant and how you can maybe avoid them using advanced technology and PSI. And then we're gonna focus on cases and complications with tibial osteotomy. And then from Armando Vidal, from Vale, he was the one who had the easiest trip here because Seth came from Stanford. And then Al will end it coming from Canada, talking about complications avoided with DFO. So the whole point of this ICL is there are mistakes out there. The whole point of education is that the definition of insanity is doing the same thing over and expecting a different result. So we've all made mistakes. We all want you to learn from our mistakes and avoid them. The difference between a lot of us is that a lot of us had to learn osteotomy kind of on the go. There weren't a lot of advanced training, especially in the United States. Al had the benefit of being in Canada, where there's much more osteotomies. And our European colleagues have much more osteotomy. So this is really relevant for, I think, the US trainee. And we're seeing a lot more. And we want you guys to learn from our mistakes. So Seth, why don't you come up here? And let's load Seth's talk. I don't think I can do that. Let's see if this works. Good. Good. So it's a, it's these, yeah, those are the buttons. Perfect. Morning, everybody. Excited to be here and really enjoy learning from this group. And so hopefully, we have some engaging discussions. We'll talk about getting it right and avoiding complications. My disclosure is that I'm going to be avoiding complications. My disclosures are available online. I think we're all here because we know about the power of osteotomy as an international solution. And it's our task to continue to bring this towards the US because we have these patients. And knee preservation, I think, is just really on the rise here. Osteotomy outcomes are about as good as anything else that we do, tools in the toolbox, as far as meniscus and cartilage. You can see return to work upwards of 80%, return to play upwards of 82%. And so these are really great solutions for challenging problems. When you have patients who have significant chondrosis that's symptomatic, and those patients need to be treated, we looked up a database study. And when you add osteotomy to your cartilage repairs, this actually reduces your rate of reoperation, similar rates of complications, and similar rates of overall costs. And so I think some of that might be considered counterintuitive. But the power of osteotomy is real. So we're talking about patient selection. Obviously, these patients have malalignment. The majority are physiologically young and active. We have, of course, the isolated unicompartment arthritis group. And in those patients, we're typically looking at thresholds above 5 degrees for corrections. I think the most interesting conversation piece in that group is selection between medial unicompartment arthroplasty and HTOs. And so you can see this really nice chart. When you're a little bit younger, we're leaning maybe towards the osteotomy side. When we have a little more osteoarthritis, KL grades 3 and 4, that might lean you towards unis. Higher deformities, maybe more towards the osteotomies. Activity levels that are higher would lean you towards osteotomy. Patients who can tolerate some pain when they're pounding on it, more of an osteotomy patient. Patients who just want pain relief for walking, living, playing with their family, maybe that's more of a uni patient. And it gets more confusing because now we have the medial implantable shock absorbers that are coming in vogue. And you'll see the data from the FDA here. And that sits right in the middle of this algorithm too. So then we have the other group, which is really the ones without osteoarthritis. These patients have cartilage defects. They have meniscus deficiency. They also can have malalignment. We may need to do things like macerosteochondrographs and meniscus transplants. And our thresholds here, I think, are a bit lower, really more in that 3 degrees. And so we want to be more specific here. If they're lying outside the tibial spines, I'm more apt to correct them. And these are smaller corrections. And these might be different types of corrections. And then we have the recurrent or refractory ligament instabilities. So if you have varus and posterolateral corner issues, then you might want to consider correcting that. We also can get more sophisticated with multi-plane corrections. And we'll hear a lot more about that from these guys as far as slope corrections for ACLs and PCLs and combined corrections. So there's a couple of red flags that seem intuitive and obvious. But we should go through them here for level setting. So you really don't want to do these in patients with major flexion contractures or range of motion loss. I'd say just for extremes of malalignment, particularly when you have the weight-bearing lines going inside to the medial aspect of the knee or outside of the lateral aspect of the knee, these are complex deformities and perhaps things that we might start thinking about measuring precisely and doing double levels. And we can talk about that as well. So those are just some things to think about, like patients that you see here. Smokers, I don't typically have many smokers in California. But I don't do osteotomies on smokers. Or if I did, I might consider closing wedges. And the same goes for higher BMI patients. And this is all about goals, expectations. This is all about compliance with rehabilitation and engaging patients. There is a complication profile here that is real. And we definitely need to educate these people beforehand. We need to establish rapport and trust. And this is, to some extent, this group is a pretty lifelong relationship. So when we talk about things, what is normal anyways? There's a bell curve for normal. So it's not cut and dry as far as where we're correcting to and why. It's definitely a range. We do, of course, get mechanical axis views on everybody. For me, the main take home here is looking for physiologic versus pathologic and certainly looking at asymmetries of malalignment. I'm more apt to act on alignment if one leg is more crooked than the other leg. I think that's just a simple principle. But things are dynamic and changing in that patient. And they're symptomatic. One thing that we are now also really moving towards is obviously measuring all the major and important ankles, not just looking at the global picture, but looking at where the deformity lies. Is it in the femur? We look at the lateral distal femoral angles. Is it in the tibia? We look at the medial proximal tibial angle. We're looking in the sagittal plane as well. So we're really using whatever tools at our disposal to measure everything and then looking where the main deformity or deformities are and then correcting them. We'll kind of go through that a little bit. And so here you can see other factors that we're looking at, not just looking at measurements within the bones, but looking at how they all relate to where we are as far as the joint line and joint line obliquities. And so this all becomes very important in templating and in planning. It can get confusing, particularly if you have multiligamentous knee patients. This is one of Aaron Critch's patients. And you can see because of the ligament instability, it looks like extreme amounts of varus. But if you change the way that you're imaging them and you measure the bones precisely, it's not that bad. So I'm not sure I know exactly how perfectly to handle things like this. But I think the most important point is to be aware of them, particularly in that very tough subset of patients. More correction is not always better. I think that that's a key point. And I think this is from Andreas Gamal's work just showing the different survival curves when you're correcting to those reasonable targets versus over- or under-correcting. And as we said, we want to be patient-specific, so typically right down the middle for cartilage restoration and meniscus transplants. And then going a bit more into the lateral spine, you can go to Fujisawa's point for the arthritics. And so templating, this is potentially a lost art. I think we need to understand it. And now we have tools in our toolkit and teams that can help us to template and to manipulate the templating. But if we don't understand the initial principles, then we can't even move forward to the complexities. And so in general, in our clinics or in my clinic, I'm drawing out the Milkowitz line. So I'm going from the center of the femoral head. I'm going down to the ankle. I'm looking at my mechanical axis deviation. And then I'm picking my point of target where I want to wind up. And that's based on the factors we discussed previously. And then if you want to draw this out, and I think you should at least know to do this, you can basically take a line from the center of the femoral head to that point of correction. You can do the same thing from the center of the ankle to the point of correction. And then you can see the angle that's made. You can transpose that to the area of your osteotomy as you see the red line. You can see where you're starting, distal to the joint line. You can see where you're aiming towards the fibular head. And you can get your millimeter measurement of correction. And so that's really the templating 101. It gets a lot more involved than that, but at least understanding that is important. What's interesting for this talk, and I think Anil will probably allude to it also, is what are the thresholds for choosing which type of osteotomy to do? For example, he pointed out in his paper here, if you're trying to correct both varus and slope and you're not doing a huge coronal correction, it's really, really hard to do that. So when we're templating or when we're thinking about what to choose, are we going to do an inter-closing wedge with maybe an asymmetric closing to correct a little bit of varus or valgus? Or can we do this with a medial opening wedge, which might be more familiar or comfortable to us? And there's really thresholds to do that. Again, I think one of the things that gets us is issues with joint line obliquity. And that'll come into play with some of the closing wedge osteotomies on the tibia. And so we just need to be aware that this can affect both clinical outcomes and it can also affect radiologic outcomes. So you really want to have that joint line as level to the ground as possible. I think just starting out, be honest about your surgical times. If you think you're going to be above three hours, use a Foley, pad everything, because you can get neuropraxias in the other areas. I used to not use a tourniquet. Now I'm using a tourniquet. So we'll see what the other guys say. TXA has come in the armamentarium. And I do this as a 23-hour stay most of the time. But I know my exit plan if things go wrong. I know how to transport to the hospital. I know who I need to call. I know if and where blood is available. I still use drains for these. I don't for my medial unis or PFJs. But that's still something that's good for me. And then I use adductor catheters typically for these patients. These are just some very recent articles on complications. Profiles, so this is over 240 patients. And stiffness, 17%. Some wound problems, 13%. Hemoarthrosis or fusion, 6%. Deep infection, 4%. So just good numbers to have in our mind here. Increased complications with smokers with concomitant chondroplasty and concomitant ligament reconstruction. So just some of the risk factors here. Also another very recent article, medial HTOs, 1 in 11 risk of hinge fractures. Lateral HTOs, which I don't do very commonly, 1 in 30 risk of perineal nerve injury. And then you see also some of these other things come up from time to time. And reoperation rates, I think 15 for hardware is a little bit low. I think maybe more, well, some people mandatorily remove their hardware on medial HTOs. But I think probably 20% or 30%. Al and I wrote a nice review on avoiding complications. I think one of the biggest issues we look for is the fracture risk and hinge fractures. And I think these guys will talk about how to avoid that. We can identify safe spots for where we want our hinge and how close we want to go towards the tibiofibula joint and towards the joint. And we can think about many different ways. I think each company that's out there with osteotomy sets have different ways that they might handle this problem of the hinge. So there are things called the golden pins or golden screws, as you see here. There's also other types of protectors that you could try to use. I think the most important thing, of course, is to have a plan. If it fractures into the hinge, then what are you going to do about it at that time? So it's really not something you're going to sweat out. If it fractures into the joint, what are you going to do about it at the time? So you need all the tools close by. I think we can get away with a lot more and tolerate with locking plate technology, whereas we couldn't in the past. And so whether we have to go to the other side, put a staple, or put a screw across it, I think really depends, to some extent, on how bad the issue is. Here you can see some of the solutions that we could do if we need to. And then protecting soft tissues, patella tendon. Of course, we want to protect. The MCL management is really challenging. And there are different ways to do it. Neurovascular is rare, but catastrophic. I think that's probably the biggest thing that drives people away from considering or getting into the learning curve of medial HTOs and others. And so I think one thing we have to look at every single time is the aberrant anterior tibial artery. It has a high takeoff. It sits inside the popliteus, and it sits on the bone. And so just be aware of it. Look at it in your axial imaging. I'm typically thinking about and looking about that when I'm doing my templating, just so that we're not missing these. And you can see there. And then this is from Al, talking about changing the slope or not changing it. So you want that two-to-one relationship from back to front. That maintains the slope. If you have this relationship, that will change and increase the slope. So if that's desirable for you, that's excellent. If it's not your intention, then you really want to look for that. Patellofemoral complications, we wrote about this fairly recently. This can be a problem more with medial opening wedge osteotomy versus lateral closing, and is a problem with larger correction. So just be aware of patella height and position. Factor it into your thoughts and your algorithm. But we're really not, in many cases, doing elaborate and different techniques for the tubercle. Of course, you can do tubercle osteotomy and put the tubercle wherever you'd like it. You can do cuts like this, where the proximal piece incorporates the tibial tubercle. And then you don't change your patellofemoral height. So when needed, you can, but it's pretty rare. And then these are just some numbers from the literature as far as complications that we need to think about and educate our patients about. Conversion to totals, technically demanding. But I think, in general, we would say outcomes are controversial, but not necessarily inferior. I think our joint colleagues don't love doing this. They have to take out plates. They have to manage soft tissue differently. These patients have maybe been through the wringer. And so they may have a lower ceiling as far as their ultimate outcome. But in general, you can get good outcomes and good survival rates, as you see from this paper. So hopefully, that was a good introduction to the more nuanced topics that these guys are going to discuss. Alignment, of course, is critical to knee joint preservation. That's why we're here. Osteotomy is a very powerful tool in my toolbox. And with proper patient selection, it can and should be in yours as well. The technique varies based on the patient's concomitant issues, amounts, and location of deformity. This is really personalized, individualized. And I think that's why we're all, for the most part, leaning towards patient-specific type planning and or instrumentation. We avoid complications with thoughtful plans and meticulous techniques. Bernie Bach taught many of us to like our patients and love your complications. And so if you have a complication, engage them. Run towards them. Give them your cell phone number. Give them access. And be there. Be their doctor. And they'll get you both through that. And if you don't do that, you're going to have some real troubles. And so with that, I'll turn it over to Anil. Thank you. Thanks. Thank you, Seth. While I get my slides up, just a quick show of hands. Who here right now has a software system that could digitally template an osteotomy of the audience? And so who is still using manual x-rays or cutouts for their osteotomy template? And who are using kind of advanced technology to help template, whether it's a proprietary company? All right. So it's interesting. I mean, the one thing I think Seth was stressing, and that's an excellent talk. Seth is great at giving this talk. That's not working. There we go. I do have some disclosures that are some relevant to some PSI companies that we will be talking about. And that's not one. How do you advance the slides, Seth? Just with the arrow? The arrow. Yeah. All right. We're talking here about the bad things of osteotomy. I don't want to see a lot of young faces, or I'm just getting old, balder, and fatter. But I don't want to scare you from osteotomy. I want to enable you from osteotomy. And we could have this whole lecture, which we've done, which we're doing tomorrow with Volker, about why osteotomy is great. So I want to really still always stress that principle, and how, as Seth said, a powerful tool, and how many bad arthroplasties I've seen on people who were unindicated for arthroplasty, and how many bad meniscal transplants or bad cartilage procedures. I always debate osteotomy versus osteotomy and cartilage procedures. You probably just need to do the osteotomy, right? And the other thing is that there's all these other ICLs and cartilage procedures. I'm not bashing my friends. I can hear them next door. But that room, it doesn't work. If you do isolate cartilage, it doesn't work. Say it louder. Yeah. I don't want to. So although we're talking about all the bad things here, I want to still stress all the good things. And that's something that I think can get lost here. And some of the good things is that, you know, the biomechanics of osteotomy are sound, and they've been going on for a long, long time, right? We can control the knee. We first learned the frontal plane. Then by controlling the frontal plane, as Seth and Al were showing in some of those videos, we realized we screwed up the sagittal plane. And then we're now looking at the rotational plane, right? So it's really understanding the knee in three planes. And that's really, you know, these are, and I don't want to always invoke my father, but these are total knee principles, right? But we're doing it, we're using bone to drive the knee. And it's how do we redistribute forces. This thing all started for me when I was in Pittsburgh when I was a fellow with another Canadian, Bob Giffin, who basically was the first one to show that slope really does matter. And this has changed the way how we all look at ACLs. Now, whether you believe in or how aggressive are slope correction, there's no doubt. If you have a high-slope knee and you reduce that slope, that knee can, you can bring that ATT back. Likewise, if you have a knee that's flat slope and you increase the slope for a PCL-deficient knee, you can create like an endpoint, much more powerful than any PCL. So it's something that I really want to say, why I love osteotomy, well, because you don't cut the cruciates out, as you do with arthroplasty. It makes any cartilage procedure look better. You can work on the sagittal plane for ACL or PCL. It makes any collateral surgery better, right? That picture that Aaron showed, the whole point of that picture is that you don't do a 15-degree correction. But if you just did a post-filaral corner on that patient, that patient would fail in a week. You had to do a small correction, but still do the post-filaral corner. And it makes that post-filaral corner look better. And as Seth pointed out, once you do this, I let patients jump on airplanes. And, you know, we're not talking versus arthroplasty. There's a role that, you know, in this kind of now, this armamentarium of knee preservation. And it's getting more and more interesting, right? Because when we started, it was meniscectomy and arthroplasty, total knee. And now, then, you know, uni, Oxford came around, and that kind of changed a lot of things. Then osteotomy was like, we were always here. Houston Americans were stupid. And then osteotomy came back to America. And then now, as Seth pointed out, there are hinges, there's resurfacing, there's all these other things. So there's a lot of powerful tools, but understanding alignment, to me, is still the most powerful tool. So it's not always versus, it's the armamentarium. So, you know, Seth talked about the ideal invocations. And if we're talking about tibial opening wedge, I want to stress one thing, is that it's a bone-reforming operation, right? I'm taking proximal tibia vera and making it parallel to the ground. That is the principle of doing a total knee, right? You want a 90-degree perpendicular cut so the force is distributed throughout the knee, versus some people are in more proximal tibia vera than others. And you have to learn to look at that person on there and you see asymmetric verus on that right knee. And you have to make a mental picture in your brain of that person, that gait, and that long-leg cassette. You make that library and you'll eventually start saying, you know, you'll start understanding long-leg cassettes better. Seth talked about this and, you know, we still debate this. I think closing wedge is a lost art. Stefano Stefanini, I think, is talking about it tomorrow. It's still something I think it can be done. But clearly, when you first start, opening wedge is easier, it's a more comfortable approach. You don't have to worry about the nerve, but, you know, there are complications on both sides. So, you know, Seth did talk about this, you know, in terms of how much correction. This, to me, is a constant debate. I think now that we have better technology, we can really dial in the correction to where we wanna be. But correction always based off what is your templating, How accurate your templating? The one thing, oh, we lost it. We didn't talk about is the accuracy of your long leg cassette. Don't settle for a bad long leg cassette. You could see rotation in the proximal femur. You could see rotation in the feet. The patella may not be aligned. You can have an adduction moment in the feet. All those things I have seen, and no one really taught me, and all those things that's made me muff up my ultimate operation. It's orthopedic 2001. You start with a good x-ray, because that then builds off everything else. For if you say you have a bad podo, the whole case goes bad. Same idea. You have a bad x-ray, the whole case goes bad. So let's get into the complications. There are a lot. So why do I think, why do we get here? Is every ICL wants to talk about complications, because no one really wants to talk about it, and that's really what, if you want to show your dirty laundry, shows you that you are either an experienced surgeon, or you're getting older, or you're getting more confident. So there are definitely complications with osteotomy. This is why, in America, we all went to arthroplasty, because it became an average surgeon's operation. My goal for this, our goal for this, is to make osteotomy, in the next 10 years, an average surgeon's operation. That's really the goal. That when you can, there's still, the majority of total knees, and ACLs done in the United States, are done by surgeons who do under 50. And we know that's a criteria of outcome, that number. It's the same thing with osteotomy. So we really want to make sure that we can get outcomes better. So how can you do that? Well, I always think technology, there's enabling technology and disruptive technology. Kevin Bozic's terms, right? So this is enabling technology, I think PSI, because it gets you help with your templating. So whether you're using an X-ray, an X-ray sketch, or a CT program, or whatever program, it also, with a patient-specific jig, it will afford you safety, in terms of those things that pulse in the back. It can give you more efficiency, and help your workflow, and decrease fluoro time. And then it can really make sure that you're not muffing up in other planes. And how does it begin? Well, it begins first with a 3D scan. And unlike other, you guys, I'm sure, all are young enough to look second in the audience, is that there's a lot of robotic technology that uses CAT scans, but they don't do this. They don't overlay a CAT scan on a long-legged cassette, because this gets into your joint-line obliquity. This gets into some ligaments understanding. So this is a powerful tool of incorporating 3D and 2D technology, when you overlap the two. So it's a very interesting thing. And then you get to this concept here, where you can now do virtual osteotomies. You can say, okay, am I gonna break the tibia only? Am I gonna break the femur? I have all my parameters. I have my MAD, what Seth was talking about. My, you know, there are a lot of angles, and I think people get angleitis in the beginning, and they get scared. It's really not that hard. If you just focus on the proximal tibia angle, maybe, and the sagittal angle, and then eventually you start adding angles. But don't try to, you know, don't try to jump and hit every angle in the beginning. But that's something that's powerful with these tools. And, you know, it's a line that Al goes, and I don't wanna steal his thunder, but I don't care what level of technology you use, but I think if you're not using digital templating in 2024, when I gave this talk at West Point, and I'm like, you guys defend our country. You guys fight at nighttime, and you guys use night vision. Have you ever used night vision goggles? You could see at nighttime. It really works. It's enabling technology. And all these green brains were like, yeah, that's freaking cool. And I'm like, but why, when I did it in ASEAN with you, you guys used a bovie cord. And they're like, oh. Hmm. I'm like, yeah, thank you. So, you know, if I sell anything to you, I would sell digital templating. And, but then once you get a PSA guide, that really, and you fit it to the right spot, that really makes your understanding your hinge plane, your hinge axis, your angle, it's all kind of in your preoperative templating, and it's very easy. And then with this system, and there are other systems you can use a saw, but I like this system, because it uses drill bits, and drill bits don't heat bone. Opening wedges don't heal, right? Closing wedges, you can break fractures. So, you know, using drill bits decreases thermal energy, and it helps things heal faster. And then it's, you know, it's more efficient, because then once you have this, this system has its own plate. So the plate, you can design the plate. The cool thing about this, you can put screws divergent. So if you're doing an ACL, it gives you room for your tunnel. If you're doing a root, you can have a guide pin for your root. So it gives you a lot of efficiency and workflow. And it really helps you for complex cases. So we talked about double-level osteotomy, multi-planar deformity, all these things, but I don't want you guys to even think about this. I want you to learn how to do a standard H2O and a standard DFO, and learning all this stuff. Last, we talked about a hinge axis. Seth stole my thunder, but, you know, just to understand, I did a lot of slope correction through the medial side, and I figured out, wow, it's really hard to change slope. And we have another paper showing that closing-edge osteotomy is much easier to change slope. And then, this was all before the sagittal plane osteotomy came about. So it's very interesting. Actually, one of my former residents wrote a paper with us comparing osteotomy freehand with using a PSI company. And basically, the point is this. I can put a slide of every robotic or every navigated arthroplasty total hip is that the human hand will lose to the robot every single time in accuracy and precision, and will also reduce outliers every single time. So why do we want to always rely on the human hand? So complications I've had and fixed and avoided. So the way I think about this is that, you know, a bad plan is a bad operation. And I always make my residents and fellows send me their preoperative plan the night before, because you can avoid half your complications there. But so whether it's planning with your technique or even your postoperative care, we talked about this in terms of preoperative planning. Look to the femur. There's varus on the femur. Not all varus comes from the tibia. Not all valgus comes from the femur, right? That's just like, you know, you'll understand that once you start drawing your angles. Seth talked about big deformities. You have to do double-level osteotomies. If you're, I call it the plumb line, goes medial to the joint, then you know you're going to have a bigger correction. And if you did, you could. Historically, we did that. And they did that a lot in Veil. And they have a lot more hinge fractures. A lot of data show once you get to a 13 wedge, the risk of your hinge fractures go up. Surgical technique. The one thing not only about the wedge height I want to talk about, but I want to talk more so about the correct exposure. You know, how you deal with the MCL, to me, is the most common question I get from the young surgeon. Am I doing a, I'll call it an Armando L flap? Am I doing a Fowler MCL cut with posterior release? Am I doing the European double window? Or am I doing an HSS total knee approach, skeletonizing the proximal tibia? There are four different approaches. And once you understand those four different approaches and how they're the pros and cons for all of them, and what osteotomy you're doing, it can help you. Lastly, you know, pin placement, right? If you, you know, when you're getting hinge fractures, you're probably starting a little too high, coming too far across. If you're going to the joint, maybe starting too distal and going too acute. So understand your pin placement. So the last thing I want to talk about is rigid fixation. You got to go back to your trauma days and understand how are you, if you're doing an opening wedge osteotomy, I want to compress the osteotomy gap. So I want to over-correct, get proximal fixation, and then mainly reduce to a tension band technique to close down that wedge. That will give me a tension band technique, and that will help healing of your osteotomy. Lastly, post-operative, you got to move these knees. I think osteotomy's got a bad rap because people were scared, they thought it was a broken leg. You know, this is rigid fixation. These people can move, and you can put more weight on these. If I ask the panel right now, they'll say every year they've done it, they're more aggressive about weight bearing because we're more confident in our fixation. Tibias and femurs are different, you know, opening and closing, you know, all osteotomies are different, but we're all getting more aggressive about how moving your knee. So let's get into some case examples quickly. So it's a 45-year-old big boy, varus deformity. Of course, he had a history of a meniscus repair and a microfracture. Guess what? That doesn't work. Cassano, you did it, I know you did it. First case, you can see he's varus. Doesn't look that bad. Big boy, I broke, I went to his lateral hinge. I did this maybe 10 years ago. It was like my fifth osteotomy. I put a lateral plate on just because I saw a little crack. With this plate, you probably don't need to do that. But you sometimes, I always, my dad used to say the first 50 total hips you do, you put an acetabular screw so you can sleep at night. That's a lateral plate so you can sleep at night. Here's another guy, 40-year-old guy, metal worker, history of a meniscectomy. You can see meal arthritis. This one, I went through the joint. So this one was an interesting one. When I went through the joint, I started seeing, oh, wow, I'm getting, I'm opening my wedge and I'm opening it intra-articulately. That's like, oh, it's like, first time I did that. And so, so what do you have to do? Here, you got to go back to the osteotomy because why is it going through the joint? It's because you didn't open it up laterally. You need to go back, take your osteotome, redirect it, go more, try to create a lateral hinge fracture, opening up there and then, you know, reduce the proximal fracture, put a screw across it and then finish your osteotomy. And I would say for this one, I'm going to accept a little bit of a under-correction here. You know, I'm not going to go for the home run because it's, there's a lot of forces at play, but it's something that you just have to let the bone breathe when you open the osteotomy. Here's a slope case. You can see meniscectomy, a lot of medial wear, medial disease, I increased the slope. You know, the natural tendency of an opening wedge osteotomy is to increase slope. You really have to pay attention to control slope. And it can be very hard because it's most likely is that you're not working enough posterior laterally, you're not, you have a posterior lateral kind of strut. So wrong indication. This is a young lady that was in a motor vehicle accident, she was sent to do my trauma surgeon and had a tibial plateau that, and then had her hardware taken out and had this. I did this thinking I was good and she did great for like five years. But in reality, now I would have been an interticular osteotomy. I didn't have the toolbox to do that back then. Now I do. And I have a case now where I've done on an elite skier an interticular osteotomy done by a very good surgeon in VL, not Armando, but just collapsed a little bit. We did an interticular osteotomy and did phenomenal. So, you know, even though I corrected her alignment, the knee is not normal. Overcorrection. This is an example of, if you look at her patella, her patella is a lot of externally rotated. So her varus wasn't that bad. She had a bad MRI, but I did a seven degree correction. I thought it was good, but it was because of the rotation of her leg to begin with. I ended up with that. And this is actually with an advanced templating system. So it wasn't the templating system's fault. It was my fault for accepting a bad X-ray. You can see all that valgus in her femur. So just because you have a robot, just because you have a fancy tool in your OR, you still have to be the surgeon. You still have to understand that technology is not completely free. This is a guy referred to me by one of my old residents, had multiple knee surgeries, New Jersey State Trooper, did a high-table osteotomy. Thought I did great. And then I see this and I put in like fake bone. This was early in my understanding of fake bone and other companies said, we have the way to make bone. Everybody says they can make bone. Nobody can make bone, except for God. Just use real bone. Now you can use cadaver bone, but this was like, you know. This guy was running on this test. But eventually I was like, I didn't feel comfortable. So I took him to the OR and this is what the power of rigid plates. He was, he didn't lose any correction. I just had to scrape out the non-union, put in some real bone and some iliac crest and he did great and healed it in game busters. So I'm quickly just gonna talk about a PSI case. This is a 35-year-old, chronic knee pain, had a history of ACL and a meniscectomy. She was a young, active female. You can see she's in varus. You can see in her MRI, her meal compartment is failing and she's got bone marrow edema. Bone marrow edema is what every osteotomy surgeon loves. Right? It's an overload compartment. What does osteotomy do? We protect overload or we heal overload and that's all you wanna do. If you just, you don't have to do anything on the inside of this joint. Now I did some fake junk in there just because we are sports surgeons, but you didn't have to do that. So we did advanced templating, six millimeter correction, shows you your angle of your cut. You can see right there is a great example. That's your hinge axis, right? It's your hinge point and your hinge axis and it's that old rule of 1.5 to one centimeter, right? That's kinda where we wanna live and with this case, her ACL was intact. I wanted to avoid her ACL, which was fine, so we have a spraying of the screws versus other systems that you have to take, not use a screw when doing an ACL. If you only have two screws and you're taking one screw out, I don't think I like that and then whatever, I did a typical microfracture. You could see that and I did a snowman and she did very, very well. So look, I think H2Os are biomechanically sound. They're highly versatile. They're highly durable. They make every cartilage surgeon better. They're great for collateral surgeries as well. I really think using more technology will help you. It will get you over that surgeon's learning curve and there's data to support that and it will help you minimize your complications, which is really where we wanna get to and as my dad would always say, the eyes only see what the mind knows. Thank you very much. Now Armando is gonna go to the tibia. Before we go to Armando, just is there any questions right now just to kind of open up the forum? If one of my fellows doesn't ask a question, I will find you. All right, thank you Neil. Let me get this talk loaded up here. I feel like these complication talks are always, they're kind of cathartic. I feel like I'm at confession. It's like, forgive me father for I have sinned. You're gonna see some of my greatest hits here. Neil gave me a hard time last year because I didn't have any complications in my complication talk. So I changed it up a little bit this year. So my name is Armando Vidal. I'm up at the Sedman Clinic in Vail and I love osteotomy. If I have, it's funny. I have it up here. Sorry guys. Would you just advance me to your side? Double click on this thing? No, I have a different screen. Give me a second. I'm not sure what's going on. I'm gonna close this out. Always true people from Denver don't like their surgeons from Vail. Isn't that one of them? I don't know if that's true. Okay, sorry. What'd you do here, Neil? I'm fine. Just double click on the, and now just advance that slide. Yeah, sorry. So it's there. Do this. No. Just use the arrows, maybe. You can just watch that video of Vail play over and over again. It's very nice. It's a cool video. Yeah. So if I have a disclaimer, it's that I love osteotomy. And if I have a disclaimer, it's that when I was fresh in practice, I probably undertreated a lot of these cases because I was scared. I just didn't, I thought the operation was too morbid. I thought that my risk of a complication for all the things you just saw, hinge fractures, wound complications, vascular injuries, and I probably over relied on some of the technology of articular cartilage repair. And I think that there's been an awareness that we probably are undertreating malalignment. And I think Neil indicated earlier, sometimes that's all you need to do. So I love that you're all here because you wanna be better, right? And you wanna avoid some of the complications and the errors that we've all made in our learning curves. And inevitably, if you do this operation, you'll find that it's very rewarding. It does make you a better cartilage surgeon, but you are gonna have complications, right? So how do you avoid them? When you've encountered them, how do you deal with them? Reach out to friends, reach out to colleagues when you encounter them, because I probably get more calls about osteotomies than any other case. So I really love the fact that everybody's here to talk about this. So I do work with BodyCat. I don't have any financial remuneration, but I do give talks for them because I am a big believer. And again, I'm trying to just get the word out on osteotomy and how to make it safer and more effective for people. So it's interesting because if you look, in the 70s, our modern arthroplasty really came into vogue, right? And that's in its current iteration. And that pretty much killed osteotomy for its classic indications of offloading an arthritic compartment. And then you look in the 80s, you start seeing this increase or really the advent of articular cartilage surgery, the introduction of microfracture, ACI and OCA, and meniscus transplantation in the mid 80s. And what you start seeing is an awareness of the things that influence our outcomes, right? BMI, bipolar disease, alignment. And in a lagging fashion, you see this increased renaissance in literature on osteotomy. And it had largely gone away because of the issues we're talking about today, because results were inconsistent, outcomes were inconsistent, and complications were not insignificant, right? And there are a variety of different techniques. So we didn't have any of the technology that we talked about today. Any of you that sit in our cartilage ICLs are probably familiar with this Venn diagram. We talk about the nexus of meniscal insufficiency, instability, malalignment, and subchondral bone, but the reality is in my mind, this Venn diagram looks like this. We always represent it as equal circles of a Venn diagram, but I'm not actually sure that that's the case. And the Europeans think we're crazy, right? Because we'll present cases with a microfracture of the tibia and a bipolar cartilage graft and an osteotomy. And I'll tell you, you probably could get away with just an osteotomy alone. And I think there's something to be said about that. So again, I think just to make a pitch for the importance of the power of osteotomy to offload these compartments. So if you accept that as fact, then we come back to where we're at today, which is how do we avoid getting into trouble, right? How do we get the outcomes that we desire and how do we avoid the complications? So in my mind, I'm gonna present a few cases of mine. I'm curious to get the panel's perspective on some of these things, but I think these are the most common ones. I'm gonna focus mainly on medial opening wedge osteotomy just because it's probably 60 to 70% of the osteotomies that I do. It's gonna be the most common one that you guys do. But for me, it comes in over and under correction, wound complications, neurovascular injury. I think hinge and intra-articular fractures can be lumped together and then the sagittal plane. So all topics that you've heard here, and these are all issues with the exception of neurovascular injury that I've had. I'm not gonna spend too much time on over and under correction. I think you heard a lot about templating from Seth and PSI from Anil. I do think there is value. I don't think it's necessarily readily available to everybody. There are a couple companies that live in this space. There are a lot of people that are looking at even just the planning portion. I think it could be automated and machine learning and AI, even just based on your laptop or phone, probably could get to the point that the planning part of this can be done with relatively minimal computing power. The surgical execution I think is something else, but you've heard a lot about how to template. I think that's your best way to avoid over and under correction. So I'm not gonna spend too much time on that. So wound complications. Most of these patients have had multiple surgeries. It's pretty rare that you get an osteotomy that's had maybe just a knee scope. A lot of these patients have had previous ACLs. They've had previous articular cartilage work, and you get a patient like this that has a BTB incision. They have some intramedial incision. They have a medial meniscus repair incision, and you've got all these parallel medial side incisions. The medial side of the knee, in my opinion, is pretty unforgiving. There's not a lot of soft tissue. Lateral side's way more forgiving, but you just have skin, fat, and tibia, and some of the biggest complications that I've seen, and we all have them, and we all have pictures of wound complications or in cases like this, because it's far more common in patients that have had previous incisions, and it's an important part of the preoperative planning. We talked about getting ideal x-rays, about measuring your angles, using PSI, not using PSI, but knowing this, I take a picture of this and put it in the chart, because I may not be operating on this patient for a couple months, because I wanna remember where their incisions are, and I go through a thorough history of when was that incision, what did they do, and when was it opened, right? I've gotten burned. I'll show you a case of a bind where I got burned. So these are two cases of mine. This first one on the left, he had a BTB ACL in Montana. The ACL was probably a decade prior. I asked him about it. He said, no, that's from 10 years ago. What he didn't share, and I should have caught on, because he didn't have a screw in the tibia, is that they had opened it up a year prior to remove his tibial screw, so the wound actually was relatively fresh. It went on to die. You can see it here on the left, and then this case on the right is one that he unfortunately looked very similar to a Neal's, where he broke this old Pudu plate, and I had to go back in and revise him, and then he developed this sinus. Now, if you look at these, which one looks more concerning to you, the left one or the right one? I'd say the left one, right? The left one looks terrible. It looks awful, right? That one actually healed wound care, never required surgery, and the right one ended up with this. It's a problem, right? This is like, this is a firefighter. I'm trying to get a good outcome, and he ends up with a gastroc flap and a skin graft because that was overlying a tomofix plate, and it never healed. We tried local wound care. We sent him to a variety of different wound care specialists and plastic surgeons, and this is where he ended up. So what I wanna ask the panel is, how do you deal with this? Al, you do a ton of osteotomies. You probably do as many as all of us combined up here. What do you think about when you're preoperatively planning? How do you talk to these patients? What are you thinking about? Do you worry about these things? Have you had any major wound complications in this type of case? I certainly worry about it. I think you've hit it all, you know, the nail in the head. It's just, you know, it's good preoperative planning. I just get local care of your soft tissue envelope. Okay, so really just good surgical technique. And yeah, just really trying to get ahead of it. So if I see, if I pick up issues at an early stage, you know, it's really getting ahead of it and not letting it evolve too quickly. Be aggressive with surgery if you need it in terms of debridement. But yeah, I've got no magic solutions for this, unfortunately. I think, again, pick your patients, smokers, diabetics, much higher risk. So I think that's the key there, is that you just, you know, you're really trying prevention better than cure. And I think to some extent, you know, becoming efficient with surgery. So expedient surgery, I think can help. So that just speaks to repetition. I don't typically use Bovi much down there. So I'm really just, you know, trying to use a knife and get in the soft tissue planes. I think, you know, when you do have these problems, you know, obviously getting them back in the clinic and seeing them early and often, getting your whole team engaged is critical. We try to, if we can't do it with local wound care, it's not granulating, you know, once it's declared it's open, you know, and it's not improving, then getting back to the OR pretty aggressively, you know, makes sense and getting your plastic colleagues. I would much rather, we all would want just the small rotational flap, but we've all ended up with the big, you know, gastroc flap and that, that's psychologically damaging for these people. So you really need to engage them. I've had several, more at Missouri, I don't think I've had one yet at Stanford, but a different protoplasm of patient and risk profile, truthfully in the Midwest versus where I'm at now. So yeah, I think that this is the like, like your patient, love your complication. And the only thing that first case, you know, you regret of not using the BTB incision, right? That's, I would always say, you know, parallel incisions, you can do it, but it's age of the incision. And then you found it, so you got burned. So I would have just taken that BTB and extended it, made it a toe knee incision. So, I mean, that's, but, you know, it's something that you have to always think about, an incision, the mobility of the incision, right? That's something you can always test. Lloyd Gale taught me a lot, a plastic surgeon, and a lot of, you know, you don't, you know, but when you do a lot of multiligamous knee, we do a lot of incisions, and then also your meticulous closure of the sub-q fat. That's the other thing. So proper closure and, you know, using, now we all, you know, use a sylvedine dressing. Those are all little kind of pearls of, because these are very commonly, multiply operated, sometimes good protoplasm, sometimes bad, multiple incisions. So you got to think about that before you get to the OR. Al, what are you going to do if they've got like an oblique hamstring incision, like not longitudinal, it's coming, you know, three centimeters, it's right where you want to make that intramedial incision for your HTO. How are you going to handle that? Very easy, because most of my primary osteotomies are done through an oblique incision. So that's just golden for me. And the thing about using an oblique incision for an osteotomy is you actually end up with a very small incision. You've got a huge soft tissue envelope overlying your plate. So I actually quite like that. So I've got no issues with it at all. Yeah, Seth, how would you do it? I'd probably extend it up and down. Yeah, which is what I've done too. So I think what you're hearing, right, is these things can happen. It's a lot of these patients have had previous surgery. I think you need to have a thorough history of where those incisions, when they were performed, what they were for. I've been burned again, because I probably wasn't as inquisitive as I should have been. And sometimes you have to get creative, right? I'm a longitudinal. This is an HTO of mine. This is slope correction. He was a fourth time failed ACL. That old intramedial incision, this guy healed fine, was relatively new, so I just reused it. And the challenge of using a BTB incision, as Anil indicated, is you need to get around the back of the tibia, at least for me. And the further anterior incision is, the harder it is to get that soft tissue envelope reflected back. So you're robbing Peter, you're not robbing Peter Paypal, but you're taking risks on either side, in terms of not getting a wound complication, but increasing your risk of being able to protect the back of the knee. So I think oblique incisions can be helpful. And having that as a skillset, I think incorporating them into more of a curvilinear incision. But I think this is an important part of your preoperative planning. And this is how you avoid some of the mistakes that we've all made. And avoiding diabetics and smokers, I think is key. So let's talk about neurovascular injury. This is probably the one, this is pretty rare. I mean, knock on wood, I don't wanna jinx it, but I haven't seen it yet. I'm sure, I do enough osteotomies that it's gonna see me at some point. So I, and I tell our fellows that all the time, like this is gonna happen at some point. And some of the best surgeons in the world have had this complication. Thankfully, it's pretty rare with a medial opening wedge. Seth indicated that peroneal nerve injury can happen with lateral closing wedge. I don't really do a lot of lateral closing wedge HTOs, but thankfully this is pretty rare. And I think this is a lot about soft tissue management and about understanding that aberrant tibial artery. So I'm gonna show you my exposure, as Anil indicated. There are a lot of different ways to skin this cat. I'm an MCL cutter. I think that most people fall into one of two categories or either MCL preservers or MCL cutters. It's about 50-50 as far as I can tell from talking to osteotomy surgeons. Al, you're a cutter, right? I think the Canadian cut, is that what Anil calls it? No, I actually don't do that. I actually do a double window. Oh yeah, nice. I've been doing double window for like nearly 10 years, so. The Fowler, the Fowler traditional Fowler way is the superficial MCL cut. It wasn't originally, and then Giffen's been doing a cut. And so we've sort of gone back and forth. I mean, ultimately it doesn't really matter. It probably doesn't matter. Can you explain, oh, go ahead. So this is my exposure, and it's probably just easier just to show it to you guys. So I, as Anil indicated earlier, I do this inverted L. So I'd make a periosteal flap just off the tibial tubercle. That horizontal component's about a centimeter distal to the joint line. This guy also had an osteochondralograft, so it's a little bit more extensive approximately. And I'll just skeletonize it. I like to do this with a bovie. It actually creates a great flap, and I need to be able to get my finger around the back of the tibia. Now, this is key, and I tell our fellows, you need to feel bone. There cannot be any soft tissue between your finger and that tibia. And the reason why is because of that aberrant tibial artery. That's how you stay away from it. So I protect the patella tendon, and then I'll place a radiolucent retractor underneath the back of the tibia, and this perfectly outlines the cut of my osteotomy. That will go to the tib-fib joint. I wanna feel the back of the tib-fib joint when I get back there. This is what Seth was talking about earlier, so the aberrant tibial artery. Thankfully, it's only about 2%, but it's not, so it's uncommon, but it's not rare. You can see it on MRI. It sits in front of the popliteus, right? So if I put, sometimes I'll make that dissection. I'll put my finger around the back, and I can feel some soft tissue in the back of the tibia. That's not acceptable to me. I'll take a little cob. I'll free up around the back, and I'll reestablish that plane. And I wanna know that there's nothing between my finger and bone, and then I'm safe the rest of the case. I can place a radiolucent retractor. Again, you can use PSI and a variety of different technology to avoid it, but you can see on this MRI, this axial cut, where you can see the main popliteal artery and that smaller arrow is that aberrant tibial artery at the level of an osteotomy. This paper is great, because it shows you where it is at each level, whether or not you're doing a total knee, an osteotomy, a TTO, et cetera. So this is at the level of an osteotomy, and you can see where it sits in this little cove, really, in the back of the tibia. They show this in their picture. It's kind of interesting, because that's a lateral retractor, if you pay attention. That's the fibula. I don't really go from this side, but I think the point is well taken, which is it's a reflection at the level of an osteotomy where that retractor needs to be to protect that aberrant artery, which, again, you can see is anterior to the popliteus. So if you feel soft tissue back there, at least in my opinion, you have not completed your dissection. You are not ready to initiate your osteotomy. So I'll start with Anil. Anil, any pearls on avoiding neurovascular complications with medial opening wedge osteotomies? Yeah, I mean, the pearl is what you talked about is your exposure and hitting the fibula. And I'd say every young surgeon, whether you're doing a knee replacement or a osteotomy, you start with a big incision and you get smaller. We all did the lab that Seth pointed out that it was a great Issacoss combined AOSSM lab. And doing Al's approach, which is very elegant, for a young surgeon, I would say I don't recommend that. That's something that Al moved his way to because you can do it, but by the end you actually will bugger up the MCL too much. So I say start with a big exposure, and as you get better, get your, not just skin, but MCL exposure, and then it gets smaller and smaller and smaller as you get better and better and better. Yeah, I think practice this in the lab every single time, because once you get facile with this approach, and I think my fellows who are here are getting to the point where they know they can shut the fibular head before they start the game's over, and then the nerve acid stuff is protected. I got in trouble once with trying to pack an osteotomy or a cob with a lap back there, and oops, a little slip, and then not the main artery, but one that required attention. And so for me now, it's all manual, frankly. Once I release posteriorly off the tibia, I flex the knee, and then I use manual blunt dissection. I often find there are bands that are going proximal to distal that I need to kind of go along the posterior muscles and release them up and down, just so that it's free flowing. You can't move on unless you have that free space back there and then you stay safe, and then the rest has nothing to do with it. So I think that's a really good point. I don't take a cob to the back of the tibia. It's all blunt finger dissection. I'll use a cob sometimes around like the first centimeter, centimeter and a half, where I can physically see it to elevate and get in the plane. So I can elevate that palpiteus off, but I never take a cob back there. And I have friends that have gotten into trouble. And if you're using PSI, you almost have to do it the way that Armando's describing. I don't know, Al, can you do the double window and use the PSI guide? It's probably a little trickier. You can, but you just have to put the PSI guide over the top of the MCL, which I think is a better way of actually dealing with the MCL. But I do use a cob at the back of the knee, but as long as you stay on bone, that's good. I don't look for the albumin artery on the MRI because it doesn't change anything I do. So if you just do a safe exposure, you're gonna be fine. Yeah, so I think Al's point is really good, right? Which is if you do the exposure this way every time, you don't have to really worry about the adrenal artery, because you know that you're gonna be accommodating for it, right? You can look for it. I do look for it, but it doesn't change my exposure. I'm gonna treat it as if every patient has, as if it were 100%. And I think this is the way, in my opinion, to avoid it is to have a way that you can get around the back of the tibia and you know you're behind, you have bone all the way across and there's no soft tissue. So let's talk about the next one. We all have this complication, which is in fractures. In fact, this is gonna happen. Even with the best of techniques, even with the most perfect surgical execution, you're gonna get hinge fractures. It's part of the deal, right? They're pretty common. Thankfully, a lot of them are relatively innocuous, but they can occur anywhere from three to 30%. I think Seth indicated it's about 20% on average. But depending on the pattern and the clinical scenario, this can lead to instability, displacement, non-union and recurrence of varus. In fact, I think with opening wedges, if you get a hinge fracture, your biggest risk is that they collapse into varus. So loss of correction on HDO, over-correction potentially on a DFO. And I probably get more calls about this complication from my former fellows than any of the other complications we're gonna talk about combined. Is this okay? How would you manage this patient? Would you have done something differently in the OR? So I think it's gonna be interesting to talk to this group about how we all manage them. So they're really, I think just to set the stage, there are three types of described hinge fractures, Takayuchi fractures. By far the most common is this one on the left, a Takayuchi type one, which is just a lateral extension. You can get Takayuchi twos, which are distal extensions. Those can be very unstable. And then Anil showed one of these type threes, and I'll show you a case of mine where it extends into the joint. And those also can be very unstable. You can almost tell when you get a type three, because the tibia starts to move a little bit differently, actually, as you start to open it up. In fact, I've been with fellows where I was like, we have an inter-articular split. They're like, how do you know that? We don't even have florals. Like, I know it. There's just no other way for this tibia to move the way it's moving now. So the best way to avoid it is what Seth and Anil talked about, is that safe zone, right? And to be specific, you wanna be about a centimeter and a half from the joint line, and you wanna be about a centimeter from the lateral cortex, right? If I'm gonna have a fracture, I'd much rather to exit out the lateral side than inter-articular, right? So I'm accepting that I've got a risk of having a hinge fracture, and of the hinge fractures, which is one that I can tolerate the best. But that safe zone, the preoperative templating, again, potentially the use of PSI are all helpful to try to avoid it, but you will have this complication. So Takeuchi One's lateral extension, like you see here, I actually don't use this plate anymore, and I don't use that bone graft anymore, but this is a pretty good Takeuchi One. They're about two thirds of all hinge fractures. They're typically benign and can heal without consequence. So Al, you get one intraoperatively. How are you gonna manage it? Do you do anything different? Not really. So easiest thing to do is take your instrumentation out and see if it reduces. So as long as the osteotomy reduces and there's no translation, then by definition, it's a stable fracture. It's really just, it's a radiolucency. You've got a whole heap of soft tissue around there. So you've got periosteum. This is not an unstable problem. Put a decent plate on and you'll have no problems. I think put a decent plate on is key, right? So I think most of the modern plates, some of the older plates that I've used and we've all used, probably I wouldn't trust as much, right? Some of the smaller stainless steel plates that are two screws and two screws, I've had those break. Man, I've had the plate break. I've had the screws break. I think if you're using a plate like this, which is a rigid fixation, I think that this can tolerate a hinge fracture. Seth? I would just add, this is not one that I'm gonna let them run away with the rehab protocol. Yep. Because a lot of the HDOs feel too good and we'll start weight bearing on it early. So I'm gonna try to, well, one, I'll disclose it to the patient and I'll be a little more cautious with weight bearing. Anil, you're gonna put a staple across that? I mean, I did for the first three or four of these I did and then I stopped doing it. The ones I showed, they were morbidly obese big guys. So I don't think you have to do a staple, but a staple can also just make you sleep at night. You know, there is this rule, if let's just say, what about it? You have a hinge fracture when you're opening and you want to, but you haven't got your full correction. That's a different scenario. That's where I would definitely put a staple in and to protect it and then maybe open a little bit more, but, or I would just maybe accept under correction. So those are other pearls and whether you, you know, and if you, but I think Al's point's really good. Once you, first of all, when you take off your, if you've got your laminar spreader or whatever device you have to open it up, if you want to take that out slowly, because just by taking that out fast, you can create a hinge fracture because it's, but when you take it out slowly and you see that there's collapsibility in the bones breathing and not rotating, then you know you have a, as Al called it, like a functional hinge. So that's a very important point. Yeah, so I think those are all great points, right? Open it slow, take time, tell a joke, you know, let the bone breathe, so to speak, so that, so I think if you open it up too quickly, you're going to get a hinge fracture. The bigger the correction, the more likely you are to get one, especially as you start getting above like 10 millimeters or 10 degrees. The majority of these you guys are going to have, you're going to detect in the office. You're probably not going to detect in the OR, is the reality. You're going to get that post-op x-ray and you'll be like, ooh, I didn't see that. And it's probably okay. So I think for me, the keys are open it slow, try to aim for that safe spot, that safe zone, and use rigid fixation. And most of these Takayuchi ones will do okay. And if you have to delay them, as Seth indicated, take it a little bit longer non-weight bearing. Actually, we should ask, like for an opening wedge osteotomy, I'm six weeks non-weight bearing and I transition off crutches week seven and eight. So their weight bearing is tolerated week seven and eight, but still on crutches. Al, do you do anything different? Two weeks touch weight bearing and then weight bearing is tolerated for two weeks. So pretty aggressive, Seth? Yes. Yeah, I'm more like 30% partial and then full weight bearing after three weeks. Yeah, so it's a lot- I mean, not with the hinge, I'm saying if I'm feeling good. I do think patients kind of auto-regulate. Like I think if they're having pain, they're going to stay on crutches a little bit longer. So I think there is an element of that, that you could be more cavalier, but I'm still pretty conservative. Sorry, are you bracing on these people? Yeah, they get a tracker brace, but it's really just until their quads improve. So it's not doing an awful lot. It's more just giving them a little bit of comfort, a little bit of protection. Probably more mental than anything. Yeah, we get a brace because if you don't give a brace to an American patient, they feel like it's a bad doctor. But the, and you may get paid for it too. I can say that. The other thing is that osteotomies, if you do an opening wedge osteotomies, routinely have less pain than some BTBs. I agree with that. It's, you know, so it's sometimes disconcerting because they will weight bear very quickly. And that's where I learned, when I saw them just walk on it, and he's laughing at me, like, why are you not letting me walk on this? Then I, that's what pushed me. So Takayuchi-2s, thankfully, these are pretty rare. I'd have a low threshold to CTDs because they can be hard to distinguish from a Takayuchi-1. These are more unstable. And these are the ones that can lead to high-grade instability of your osteotomy, but also can heal uneventfully if identified and treated correctly. If you see this anele in the OR, right? Let's assume you're going to see it in the OR, because if you can see it post-op, you really only have one option at that point, which is to restrict their weight bearing and slow them down, which I think is what most of us would probably do. But if you see this one in the OR- But get advanced imaging, as you pointed out, and get much more imaging, right? You know, the thing that I get disconcerted is when I see people with a problem and they don't have more imaging, right? And they don't have more what? More imaging, right? It's just like, well, you need an X-ray for eight weeks? Like, so you could have intervened at four weeks, you know, and it would have been a much easier problem to intervene in. So that's, you know, whenever you have a clavicle that you're treating non-operatively, you get more X-rays versus the ones that you treat operatively, because you know it's going to fix. I mean, you know, so it's just principles like that. This one, obviously, I would probably put a, you know, if I saw it in the OR, I would expose it and, you know, put like a little, you know, put a plate or it'd be, I've never had one. It'd be hard to get a staple here. I think you'd want to maybe plate this. Al, any other thoughts? Would you treat it differently? Same here, you know, stable fixation. So lock and plate, and then just go a little bit slower with rehab. I think the key with both Takeuchi 1 and 2 is really is just preventing them. So it's all about where your hinge point is. Takeuchi 1 is probably a decent hinge point, but you've just taken it too far or you've opened it up too quickly. At Takeuchi 2, you're just too low. And you're now down to the cortical bone. It's not as viscoelastic. It doesn't open, it cracks and breaks, and then it displaces distally. So, you know, people talk about your hinge position being at the level of the fibular head. I think that's a stupid thing to talk about because the fibular head changes, right? So I always aim for the fiseal scar. Fiseal scar is an absolute perfect place to put your hinge because you know that you're far enough away from the joint. And then you just got to watch as you're doing your osteotomy to make sure that you don't go too far. Your Takeuchi 3, which we'll get to in a second, is all about basically you haven't made your cut far enough across the back. And those will always then extend. If you're again too aggressive, they'll extend up into the joint. So all of this stuff is just all about good technique. And the one thing is you have to look for subluxation. If you ever see any subluxation, that needs contralateral fixation. Yeah, so I think that those are great points. And hopefully that everybody caught what Al just said, which is this is usually a problem because your osteotomy is too low, right? You're not in that metaphyseal bone. You're closer to the cortex and that's where it's going to exit. So preoperative planning and surgical execution in terms of your hinge axis is really going to be key. And if you get one, I think that with modern plates, I think you probably are still okay. You just need to slow them down. Maybe an obvious point, but when you're templating these, opening versus closing wedge, your width of your hinge is totally different, right? With the opening wedge, you want to preserve that length, like a centimeter, like Al just said. And with closing wedge, you kind of have to get almost all the way to the cortex to be able to effectively close it down. So just things that may be intuitively obvious, but if we're not thinking about templating them differently, you can get into trouble. Just, you're not actually, just go back a second, Armando. The next one back. Yeah, so you're using a peak implant there, yeah? Yeah, this seems terrible. Stop using this. If you're using that, it's a reasonable thing to use. There's been some good results with it. But if you run into a complication with it, you need to make sure you've got a decent plate on you. It's a bit unfair to call it a decent plate rather than this one, but you need to have a backup. You need to have a locking plate fixator that if you do run into an issue, swap it out. Don't stick with your original fixation. Yeah, I did. I used to do a lot of these and I liked them because they were elegant and you didn't have hardware complications. And we actually presented our data, our S1 year, and I think we had about a 15% loss of correction rate, which is, when I tell our fellows about osteotomies, it's an amazing operation. It's super powerful. When they go south, they go south really fast. It's pretty binary. And I had a lot of these. This is the post-op long alignment film. You can see he's still in varus, because again, when you lose that lateral hinge, and what happened is they would collapse around this peak implant, they collapse back into varus, so they lose correction. So I've gone away from using this. And you also remove bone. You take bone away. Yeah. Take a lot of bone away. Those two lugs. Yeah, so I've gone to just plate fixation. I just feel much more stable. But I think Al's point is well taken, which is I always have a very rigid, osteotomy-specific plate as a backup in the OR for all these cases, even if I'm doing PSI, because it just gives me every option. So that's another good pearl in terms of getting yourself out of trouble. Takeuchi threes. Unfortunately, I couldn't find the fluoro shots from this case when it happened, but we've all had this. Al hit it on the head, which is that you're not far enough across, especially in the back, right? So you're trying to open up this osteotomy. You have way too much resistance, and the energy exits intraticularly into that lateral plateau. You can see it immediately. Like as I indicated earlier, you'll start opening it up, and all of a sudden the proximal tibia starts moving relative to the metathesis. You see a shift in the A to P dimension. It goes lateral to it. You just know when it happens. These can be difficult to manage, and Anil indicated this in his talk when he showed one, because you start opening up through the intra-articular fracture, right? You start opening this thing up, and if you just keep powering through, you just get more displacement. You actually don't get more correction. So Anil, you showed this case, like what do you, this one you're gonna detect intraoperatively most of the time. Occasionally you see a little crack on a post-op x-ray, which is a non-event. But you see this intraoperatively, the osteotomy, you cannot open it up without displacing the fracture. Yeah, so I mean, as you said, as I said before, you go in the back more. This case was early on in my career where I didn't have, I wasn't comfortable having a big enough posterior exposure. So I was always a little afraid to go in the back, the posterolateral aspect of the tibia. And so now I would refresh my osteotome, go in the back, and then once I did that, I would see whether it's moving and then put a screw across and then we go back to my osteotomy again You know try to make a lateral hinge fracture and then put my plate on now any additional thoughts Reduce it. So take all your instruments I get it back reduced put a screw in so fix the fracture and then redo my osteotomy. Yep So it's exactly right. So you see this is what you do You put a screw from lateral to medial big rafter screw You complete the osteotomy because you got to address the issue that you were why you had this in the first place I use an osteotome and I you know stay there stacked Osteotome or those osteotomes that you can kind of split apart I get beyond the fracture, right? So I want to I want to open it up over the course of the entire Osteotomy so I bypass the fracture. I don't necessarily create a hinge fracture and then slowly open it up So I'm essentially supporting that entire proximal tibia And generally that actually works pretty well these patients and at least in my experience heal as well as any osteotomy I'm not seeing any major issues steps one quick tip as far as talking to patients I'm always saying, you know osteotomy is a controlled fracture and sometimes it can become a fracture fracture and we might have to have alternative fixation strategies and if you do that beforehand than any of this is just part of the process and Bones healing right totally and I have that on my consent intraoperative or post-operative fracture, you know, because it is it's a you know Technically an unstable environment for a little bit while this thing is healing So the last thing I want to talk about is sagittal plane deformity. So maintaining slope So this is a patient of mine. He was a failed ACL young guy cartilage damage medial compartment You could debate whether or not I should have done a medial opening wedge HTO Or a close anterior closing wedge HTO I decided at that time that I thought his medial compartment disease was more significant than his causes for ACL failure So my goal was to correct the coronal plane and to correct the sagittal plane But I didn't decrease the slope if anything I increased the slope I can now identify several things I did wrong now that I look at this x-ray But Al how many different things that I do wrong on this case because I did several I know Yeah, what did you do wrong I mean I'm presuming you probably put the hinge in the wrong place So you didn't get far enough across the back You probably had a slight abnormal obliquity of the of the of the osteotomy position to me It's all about hinge position, you know people talk about you know, having if you've got a parallel parallel osteotomy That's parallel to your joint line. You'll not change slope. I think that's BS. It's BS so it's all about hinge position and if you know You do have to just make sure that you're comfortable and putting your instruments across the back of the knee and that comes back to Your exposure if you've got good exposure, then you're you're in good shape. So Yeah, the key there is that you just haven't done it Osteotomy right there across the bar. I mean, I also think you're I know your exposure is bad here because your plates Oh, even though it's rotated. It's not true. It's too interior, which means that you weren't you know You were you were afraid because your osteotomes was going a little for 80p Right, so you're going more ATP versus medial to lateral and then your osteotomy went short Not only did it not go in the back. It also didn't go lateral enough and then so but we've all had that x-ray Yes, this is a humbling one because he had multiple ACLs. Yeah this I did this I was like home run. This guy's doing great. And then he moves to the East Coast. He sees a very well-known surgeon After he failed the ACL reconstruction my revision and he's like Armando I think his slope is still pretty high and I was like, oh, it's actually higher than when I started So this is a challenge, right? Our tendency is to increase slope right La Prada shown us that variety of other people have shown us that so with medial opening wedge We tend to increase slope by about two or three degrees It's there are a lot of different ways you can look at this Neil showed this in his talk in terms of the gap, you know It needs to be bigger in the back than it is in the front And ideally you want to keep that plate more posteriorly. So for me, it was my hinge axis It was the fact that I didn't do this This is a paper we published in arthroscopy where you can see the back of the wedge is bigger than the front This is just to maintain slope And and placement of an anterior plate So now I'm very mindful by keeping a posterior plate a hyperextension moment and making sure that my wedge axis is Is oriented as it is there and again, you can use PSI to help create hinge axis that you can't achieve Easily with a freehand technique. So to summarize I do think HTO and EFO of an increasingly important role in joint preservation ligament reconstruction I think accuracy precision and safety are key to success And it's important that you understand the most common complications how to avoid them and you're gonna get them how to manage them And I think you can leverage technology for its benefits in terms of precision and safety. Thank you guys Thank you, and now we're gonna have I'll get good close it out with the femur and I actually think The femur can sometimes be easier and sometimes be harder. So Let's have I'll get up his slides All right, thanks Neil and Right. So I think my complications last year of the tibial osteotomies were so Not nauseating that they asked me to talk about the femur this time All right. So let's see trying to try and not cause anyone to have any angular. What's an angulitis? New word, right good So no specific disclosures regarding this specific talk, okay So some tricks to avoid complications to me. It's all about comp about counseling your patients Hardware removals massive particularly on the with an HTO You know, we just we show is actually about 50% with the tomofix on the tibial side less and less so with the femur But it's definitely with the femur if you do a lateral opening wedge Your hardware removal is gonna be extremely high medial closing wedge much less. Okay. So again warn them about it I don't think it was a complication. I've told them about it. That's gonna happen. You're gonna expect it That is not a complication. I knew what was gonna happen Avoid osteotomy and pretty controlled diabetics. I think that's you know, I don't you know I think you're asking for trouble if you particularly if they smoke as well Larger corrections lots of things you can do to protect your hinge So hinge wire screw and then think about doing a double level correction. We'll talk about so again That comes back to Seth's talk is all about adequate planning, right? So do your planning properly appropriately do your technique appropriately and I think you can avoid complications Smokers, you know, I think this concept of telling people to stop smoking before surgery, you know Even you know, you can do was it urine tests and everything? Let's just think it's complete waste of time as soon as you do the operation They'll be sitting outside the hospital having a fuck So, you know, but you know essentially mitigate risk through a closing wedge technique Okay, so things that you can do to try and mitigate your risk We did a systematic review a while back and looking at outcomes of various of Yeah, various osteotomies on the femur Essentially showing that you have pretty good survivorship. Not quite as good as what the tibial side is And the complications that the major complication was removal of hardware. But again, we've already said that it's not a major complication, right? So what about so this is the first case so avoiding creating deformity So it's not really a complication, but it could have been if I hadn't done adequate planning So it's a 29 year old guy who's a medical student is actually one of my ex master students So trying to avoid operating on people that you're gonna see every day in your clinic Okay But radiographs lateral wear and of course we enlisted him for a DFO because you know classic thinking a lot You've got valgus disease lateral compartment. You're gonna do a DFO, right? But actually when we do the planning we can see that most of the issue is actually is based on the tibial sides This is a tibial deformity. We can see from multiple studies This one in particular showing that it's not just you know We've got to get away from this classic valgus equals the femoral deformity varus equals the tibial deformity You can have the complete opposite. You can also have mixed deformities So basically look for it determine where the deformity is and then plan appropriately I did a medial closing wedge on the tibia got him neutral and he's much happier. Okay, so think about your planning again I'm not gonna go through this because Seth's already showed that you're doing a very similar plan with regarding a DFO So you can you can plan where your osteotomy is going to be primarily to a medial closing wedge for the femur Then you can translate that That length of correction to your angular correction and that gives you then the amount of wedge that you have to remove Okay, so that's the wedge that we would do to get a neutral alignment on the femur So this is the technique that I do for a medial closing wedge DFO So it's essentially a subvasus approach. We've gone through the fascia. We're now gonna lift the vasus medialis You put a big nice retractor underneath that I use a minimal amount of cautery I don't really love dissecting with cautery too much And the main reason for that is I think it creates a lot of dead tissue and therefore you risk of infections higher You've got the vessels there. That's a really nice marker for where I want to be I put a retractor back there and then I'm going to put my my pins in I'm going to show you a little bit about how to manage the hinge here when you're doing a DFO That's really important in my next couple of slides coming up But we're going to mark out the osteotomy and I'm going to do a biplanar cut and again I'll show you exactly what that's all about and then the osteotomy is completed using your standard sagittal saw oscillating saw and You know, you've got your retractor all the way across the back. I've also got a sponge that's underneath the retractor Vessels are well away from where I'm working so I can actually use the saw all the way across So it's a very very controlled. I hate the Terminology of breaking the bone. This is a very accurate specific cut that you're doing You know, we when we talk to patients about but knee replacement we don't talk about an internal amputation of their knee So I'm not breaking their leg. I'm doing a very accurate correction Take a little wedge of bone out comes out like we can complete that Always comes out like that, right? Mm-hmm Okay, Kerrison ronjures, okay, so use it use the ronjures from the spinal surgeons You can take a little bit of bone out when you're doing closing wedges This is making sure that you complete the osteotomy at the end So your anterior cut if you don't do this You're gonna run into problems because you basically gonna have a connection over there and you got a fracture use a drill just to cause a controlled osteoclases of the hinge and Then it just should close down nice and easily and then you put your locking plate fixator on there Okay, so I don't think I need to show you that. All right, so tips and tricks So stand on the same side as your approach fluoroscopy comes in from the other side and Use the vessels on so that's basically through what we call the three sisters They sit right on the metaphyseal flare of the femur. You can use those as the start position for your osteotomy and Managing the hinge is absolutely critical. So here's just a radiograph. I'm just gonna put out some pins You've got the posterior condylar flare of a lateral formal condyle So I want to be above that some people will talk about actually going into the condyle I find it's actually it's it's a much more stiff construct It's very very difficult to actually get my clothes and I've had some fractures if I have gone into that So I want to be just above the posterior condylar flare That's my hinge point right there and I'm gonna put my first pin in Okay so if I put my first wire in You would think that if I put my second wire gonna come straight to that point and that's gonna be ideal Right The problem is that we then put your saw in and you put your saw on either side of the pin you end up With a hinge that is actually much more medial and now you've created a fulcrum so that when you then try and close that down Your hinge is gonna spring open at the back So what I want to do is actually place my pins a little bit separated so that my saw goes all the way To my hinge point, okay And if you can't do that if you're struggling you can always then when you're doing your second cut you can take your most distal Pin out just remove it and then advance your saw so you get to that point Okay, so that is the key thing for the for managing the hinge you can obviously put a wire across there if you wish I don't really like using hinge wires But those are techniques that you can use biplanar osteotomy I think is really important for both the femur and the tibia, you know Armando showed on the tibial side there those takuichi ones If you do a uniplanar cut on a tibia and you end up with it with a takuichi one fracture What's essentially gonna happen is your PES tendons are going to want to rotate the tibia off Okay, it's going to want to end so it's going to want to internally rotate because of the tension on the PES tendons If you have a biplanar cut that's sitting on the metaphysis, so you basically it's buttressing It's not going to rotate off. So it's much much more stable. So what we mean by a biplanar You can see that everything is just rotating about that medial hinge and that anterior cut is just sliding Okay, this way, you know, whether you've got any flexion extension It also controls rotation. It increases your surface area and bone contact and these heal up absolutely beautiful Okay, Kerrison rangers I've mentioned for posterior bone resection Perforate the hinge to aid in closing and then you can use a hinge pin or or screw or wire Okay to be able to protect that hinge when you're when you're closing it down. Okay, so now we get on to some complications All right. So this is a girl that presented to me. She's 36 year old female She had previous total hip arthroplasty and she has this deformity when the arthroplasty guy suggested What would you do a a distal frontal osteotomy to correct that? So sure. Yeah. Sure. I'd love to alright, so Put my wire and do everything as I said, I did a lateral opening wedge. She's a bit short So I wanted to lengthen her leg as well Think about leg length too If you're gonna use a medial closing wedge You'll often shorten the leg if you want to gain length then you can do a lateral opening wedge Okay, so I do that looks pretty good get this radiograph post-operatively the radiologist very kindly points out Yeah, the hinge fracture. So guys, what would you do at this point? If you see this radiograph? Let's say this was two weeks post-op Anil I would It also depends on if it's just two weeks post-op like this and she has no medial pain and I would just watch it The more common thing I've had is that I had that x-ray had nothing and They were doing great at two weeks and then at three or four weeks They're so walking a little bit more putting more weight and they say I've medial pain and I see a blush of bone there if I see that I get a CAT scan and I think about putting I've done a medial the lateral screw and You basically You got to control the rotation. It's it's this is a different animal than an open tibia Okay, so it gets better. So, all right, so I Only learn all that stuff because I didn't do that the first time Oh, yeah, I kept it pretty quiet for a while kept her on crutches and she did fine pain settled on she managed to increase Her weight brain. She was a bit overweight Unfortunately when she was out one day she stepped off a curb and she felt their legs go and felt a crack okay, so then I follow and this is maybe not projecting very well the next one does but essentially over the Next three months, there's no question. There's an element of Rotation in here as well. There's issues at our hip, but this is this is failing, right? So she we've not got a failing osteotomy. She's getting a progressive deformity You know and I tried to try to convince myself This was secondary to a flexion that she was just flexion contracture and rotation, you know Yeah, that sort of thing where you know, it's nothing to do with my osteotomy couldn't be right. That's fine, right? But of course it's it's failing. Okay, so All right, so what do you do nice so we've got a hinge fracture and you've got a failing Armando, what do you do? You know, these are challenging as we discussed earlier these medial hinge fractures can can they're mechanically unstable So I would replayed it reborn grafted. I'd put a little plate medially as well I probably would do the plate medially first to reestablish the hinge and then Revise my osteotomy. All right, so you're gonna so you're gonna double plate. Yeah. All right So I did I took her hardware, right? So that's sorry. I took her proximal screws. I reestablished the correction and Then double plate it safety happy with that Yeah, that's that's what I would have done there But I also you know would consider if you have to do more to fix her alignment Otherwise maybe going because that's a huge correction start and we're in deep trouble, right? And so now we need to remeasure precisely everything and then do what we think our best operations It also has the real infection, of course. Yeah, we did Why you know the Europeans went to medial side why you went to the other side and why you know You don't do a huge correction laterally, you know, just you know This was a failure of this is what we all started the failure of planning more than anything else. Yeah, so All right gets better Yeah All right. So over the next six months and you know, she's getting more she's so so I got her straight She felt good and then over the next six months she continues All right. So now we got hardware failure. She's got fresh She's she's broken her screws and the lateral side medial side starting to come away. All right, you know guys what I do not She has a total hip up top I'm calling in a friend on this one I mean this is gonna need that I'm not saying convert to you know, the complex orthoplasty, but I think this is out of my jurisdiction now this might need external Fixators and things like that. Yeah. Yeah, I mean I would say this is where I'm getting my trauma I mean even from a totally perspective. This is a disaster. I mean Hinge, I mean, this is a disaster regardless, but I'm getting a trauma colleague and I'm probably Taking that out putting in a nail in refixing the medial side and Bone grafting, I don't know. I mean You can see when you have a problem things can start to escalate right and you know How many times you in an operation even if it's an ACL reconstruction could be the most simple thing But as soon as one problem starts to happen and then it just cascades, right? And this for me isn't a great example of one issue and it just is a cascade of complete cluster All right. So what did I do? Well Exclude infection Seth's already mentioned that so did flammatory markers everything absolutely normal Okay, so and then Neil said well, yeah phone a friend. All right, right you can share these problems, right? So I contact who you're gonna contact in that scenario trauma surgeon, right? So I'll contact one of my trauma colleagues and what's the issue that we're dealing with? Well, we've got we don't have stability. All right, and we need to improve so we need to improve our stability We need to improve biology. How are we going to achieve that? So Neil you mentioned using a nail so nails great option What we ended up doing which the first time I've ever done it was actually a really fun operation was to do a Endosteal fibular strut graft. So you take a fibula allograft? Pop it up the the thermal canal and then you ram it down into the metathesis get your correction with that So it's essentially an allograft nail and then put a long Plate construct over the top get really good Stability and so with that then I was able to achieve stability Both from an end from a endosteal point of view as well as then the lateral plating So stability is improved and then by putting the allograft in there You're also improving the biology and so with that she actually healed so she did she's she's done very well from an osteotomy point She's not gonna absolutely kill her anterior knee pain. So maybe Maybe she's done a distal femoral replacement Mm-hmm. Yeah. Yeah, so we've got a correction So that that was a win eventually But it was one of those patients that every time she came back to my clinic a little bit of me died I'll say this we see I see this a lot more where the arthroplasty colleagues don't want to put in hinges on young people and In those cases, I don't go for a perfect correction I'm just getting them much more in the ballpark so they can put in a standard total knee So that's one of the different indications where I would have just because you know, she's a low-demand. She has a hip already I'm just gonna do this one quickly just because I really haven't touched on it All right So this is a guy who? Significant for us and number one Thank you Neil was you said that if you see that the weight-bearing axis is not even in the joint She'd be thinking about double level corrections, right? All right, so that's what I did. I did a double level correction This actually probably was one of my first double levels I'd ever done So this was a case about 10 years ago then a medial opening wedge on the femur medial opening wedge on the tibia Didn't quite get the correction that I wanted but he did very well. I was very happy and he went back in So, you know, it's a little bit under corrected. So that's number one problem, but not a big deal He still was quite comfortable with it. Second one went back did exactly the same thing Now first thing I've learned from this case is that I don't do medial opening wedge on the distal femur anymore It's good to increase length, but it is ridiculously unstable Hence that when he went when he went to Cuba for you know for New Year's Was dancing this like four weeks post-op and he was dancing on a on a on a tiled floor in Cuba and slipped and this Happened. All right, so thank you very much. So but he was very apologetic that he screwed up my great work So when he came back, so anyway, so we brought it back and of course guys we're gonna revise this, right? So I was running a double room that day so I was in a different room doing a high tibial osteotomy and my fellow was doing this and all he had to do was take the plate out and I got a call to Join him in or seven stat It's never a good call that you want to go through Okay, so I ran through the OR and this poor guy's holding on to something and he says It's bleeding it's bleeding so you'd caught the vessel so he caught the superficial femoral artery And so we got to let go to let me see it since you let go it's hitting the ceiling So anyway, so vascular vascular issue, you know, so, you know, the result was actually was pretty good Okay, so problem number two non-compliant patient number three vascular injury I would say that you know removal of hardware is not without its problems Know your anatomy and He just got a little you got a little bit overzealous with his coterie as he got as he went a little bit more proximal So be very careful. If you are doing medial closing wedge on the distal femur Just be aware of where you're getting you're not getting too close to hunters canal But otherwise and so vascular that's my only vascular injury that I've had and I wanted to share that with you So it does happen. I've got the vascular surgeon in and we basically did a vein or a vein patch And he's done very well. He's just now on aspirin for the rest of his life So anyway, I think we're probably out of time, aren't we? Yeah, thank you very much for your attention Thanks. Yeah, that was phenomenal We have maybe 30 seconds for any questions if there's any compelling questions I'm sure the panel will be here to stick around to ask questions That was great. But I do want to reiterate what Armando or just said it's like wow These guys will never want to do an osteotomy now That's that's that's not the point the point is to learn from these and for It's if you plan it It's a very reproducible operation and realize there are a lot of other operations that we do that we see disasters So don't know so I think The eye sees what the mind knows the more you understand and understand each complication you can avoid them So, thank you very much You

osteotomy

knee deformities

patient selection

complications

case studies

Patient-Specific Instrumentation

hinge fractures

surgical techniques

distal femoral osteotomies

preoperative planning

biplanar osteotomies

fixation techniques

advanced technology