rational of tibial osteotomy. I'll talk about complications, you know, how I approach them, how I think PSI can help. I'll give you a list of my dirty laundry and things I've learned over the years, and we'll give some case examples. So, you know, I always think of this, that we want to adjust the knee in three planes, right? You know, we're getting good at coronal, now we're getting good at sagittal, and ultimately we'll be getting better at rotational and then stability. And we're still rotational, we're not fully there yet, and I think PSI will help us, and how do we do complex rotational deformities with coronal and sagittal corrections, and also understanding soft tissue balancing, which Armando was talking about a lot. You know, this is, you know, to quote about when I was a fellow at Pittsburgh, this is what really, you know, opened my eyes when we first talked about the sagittal plane, and it was a, it was, it's a fascinating concept. You know, five, seven years ago, if you mentioned dog surgery, which is what, you know, all vets do, in a room at AOSSM, you know, people would laugh at you. Now, you can't go to an ACL room here and not mention slope. So, it's just funny how, how things have changed. Why I love osteotomy, well, you know, you can, it's preserving your cruciates, you're not cutting out ligaments. You can make any bad cartilage operation better, right? Because no cartilage operation works, right? Osteotomies work, and to make any bad cartilage operation better, and if your ACL is out, your PCL is out, it can help your ACL and your PCL. So, you can really manipulate that. Again, if you have any muffed up collaterals, it can make your collateral surgery better, and once you have them healed, I say you can do anything. I don't let people with a uni jump out of an airplane or, you know, and I say, oh, go run, play basketball. You know, sometimes they do, but I don't really tell them to do that, and ultimately, you know, this is a debate I have all the time with our arthroplasty colleagues, mostly my brother, and it's like, you know, family feud, and this is not, you know, uni versus, or toe and knee versus osteotomy. This is, I think, a joint preserving operation and delaying the need of arthroplasty. So, it's a different, it's a different animal, and as long as osteotomy is compared to arthroplasty and they look at, oh, the failure rate or conversion, it will never be a successful operation, but that's not how you have to approach it. You have to approach it as some degree of joint preserving and delaying the need of arthroplasty, and that's the most critical, or delaying the need of revision, or delaying the need completely. So, Seth talked about this, you know, what we really want to get when we're thinking about opening wedge osteotomy is proximal tibia vera, right? I always tell my residents and fellows, it's like, you know, you can just walk around, and I was literally walking from our osteotomy lecture to our osteotomy dinner last night, and I had two residents, and I'm like, that guy needs an osteotomy. We're on the street. That guy, you know, you know, that is what you want to, you know, you can just tell, and you have to learn how to look at the proximal tibia and saying, and exactly, and you can, and you want to create a library in your brain of the visualization of the proximal tibia and the knee, and associating with the long leg cassette, and once you create that library of experience, that's a powerful thing, and then even, you can almost not, you need less long leg cassettes, because you really start developing that library. We talked about, you know, opening versus closing wedge. I think closing wedge still has a role for slope correction. We wrote a paper on that. Obviously, two cuts are harder than one cut, and closing wedge, to me, is the other thing, you know, that's tough about that, is that the conversion to a total knee with a closing wedge is what's really bad. An opening wedge conversion to a total knee is pretty standard, and the other issue of conversion to a total knee with a closing wedge is that you have a different, you have a different wound to deal with, a different plate, you know, so I will routinely stage these for my brother. I take the plate out first, and then he does a meal incision to his total knee, let that lateral wound heal, versus an opening wedge, it's, you know, you could do it all in one, so I do think, and the data is pretty supportive, that opening wedge conversion is easier than closing wedge conversion, but there are a lot of other things. So, we talked about correction. I think this is probably the most interesting thing that we see developing, and, you know, three years ago, four years ago, everyone would just talk about Fujisawa's point, and that was it, and now we're developing more data. It's really not that much data, you know, Andreas has his one paper, but it's not that much data to really show where we want to go, because now we actually have tools, better than a bovie cord, to put it somewhere where we want to put it, and that's always the correction. It's the same thing when we talk about arthroplasty, right? I had one of the residents, a fellow here yesterday, he's like, well, total joint guys are now going to constitutional varus, right? They're under-correcting now, and I'm saying, well, that's exactly what we're doing in osteotomy, you know? You know, no one likes a deformed knee, a way over-corrected knee, and if your goal is Fujisawa's point, and you miss that goal, that's a knee that no one likes. If your goal is neutral, and you over-correct, well, then you're close to Fujisawa. So, that's, it's the principles of not only where you want to go, but what happens if you miss, and what's the consequences of missing, but osteotomy got a bad name on the varus knee when I was a resident, because a lot of females were over-corrected, and they all hated that. They got that kind of, you know, knee knock deformity. So, let's talk about the complications. You know, we, there are a lot of them, and I'd say I've hit almost everyone but vascular, and I think it's an important thing to understand. If you know your complications, then you can prevent it. You know, and here's some literature to show that, you know, there's still a pretty high complication rate, and the way I think about, when you have a procedure that has a high complication rate, what do you want? You want more surgical education, you want more surgical technology to mitigate complications. That's really the point of this ICL. So, how do I do that? Well, I think, you know, Larry Doerr, who was a mentor to me, was a very prestigious total hip surgeon, and he was the first one to really bring navigation in North America to total hip replacement, and he brought navigation robotics to total hip, and I go, I go, Uncle Larry, why are you doing this? And he goes, I want to know where I'm missing. I know I have my misses, but I don't know really what I'm missing, and Seth kind of alluded to this. It's just like, when you have better technology, you will actually see, oh, what am I really doing to patella height, right? How do I 3D template and say, wow, my CDI was, you know, 0.8, and if I do this osteotomy, it's 0.7. We never knew that before. You know, we couldn't really figure that, I mean, figure that out without 3D templating, so there's a lot of things he will tell you that I was consistently not accounting my saw thickness when I did my osteotomy templating, you know, and that's why I was like, oh, and I was under correcting, and I was like, oh, now I know why I was under correcting. Like, I didn't know that 10 years ago. No one, no one ever, like, said, well, add a degree because you're taking some bone away with a saw. I'm like, well, I taught myself. That was, you know, like, I was like, oh, that's great. So that's really the power of additional technology. It tells you where your misses, predicts your misses, and then it can help you then to do more complicated things, as Seth said. So it's, you know, it gives you more accurate correction, it affords safety, it gives you more efficiency, and you can really do multiple procedures. So this is the power of this new technology. It's a, you get a long leg cassette, and you get a 3D CAT scan of hip, knee, knee, and ankle, and then it overlies a long leg cassette on the CAT scan, or vice versa. And so it's really 2D to 3D templating. If you look at most robotic technology for total joint arthroplasty, they don't actually do this. It's just, they have a non-weight-bearing CAT scan. So this is giving us some soft tissue understanding, and it's giving us the concept of joint line congruity angle that we talked about, and that's always kind of a thing that we want to assess. Once we do that, you can do virtual osteotomies. You can play, do I want to do it on the tibia? Do I want to do it on the femur? Do I, you know, what's happening to my joint line? What's happening to my sagittal slope? What's happening to my medial slope? My lateral slope? You can, you know, play as much as around as you want to, and, or you could be minimal and say, hey, I don't want to play around at all, but it gives you all the indices on the left-hand side here of all the planes that you want. And it's, it's pretty simple once you start playing with it, and you recognize, wow, you've been, I've been doing this operation, I would say, blind. You know, my dad would always say to me, he's like, I don't need a robot. I don't need navigation and my car to drive home. And I'm like, well, I, you don't live in New York, dad. He's like, yes I do. I'm like, well, I always use Waze because there's a lot of freaking traffic. You don't know, you know, the, some random deformities. You don't know some bones are different. For the standard ones, yeah, you don't. And, and for the skilled osteotomy surgeon, you don't. But the more I've started using it, the more I've kind of liked it, relied on it, and it makes me more efficient. So it's really, you know, patient-specific jigs. It's, you know, it's a streamlined concept. It's a simple workflow. It's a guide. It's really, the operation is putting, once you template, it's putting that patient-specific guide on the bone. The reason why I like this, they're calibrated drill bits, which means you can, you just have to bury the drill bits, and the drill bits are all templated to the right depth. So, you know, it's, it's, it's hard. You have to go out of your way to put the guide on really poorly to, to hurt the artery. But, I mean, I guess somebody could do that. It also gives me this concept, if you see that, that hinge axis. So how I can manipulate that hinge axis. Because only when you understand that, that your, your hinge axis, do you really understand how I can manipulate slope. Do I want a small anterolateral hinge? Do I want a bigger hinge? And then ultimately, it really decreases fluoro time. But look, any new technology is only as good as a person using it. And if you completely rely on the technology, you're not a right surgeon. I, I did a case with PSI, where I increased slope. Because I completely relied on technology, and I just kind of abandoned, I remember, my principles of, of gap, you know, of wedge analysis. So, you still have to be the surgeon. You have to be the driver. Just like doing, you know, a robotic total joint. You have to still be, you know, when, know when to override the concept. So it's, you know, an osteotomy in a box. It's streamlined. It's simple. It's efficient. Reduced overtime. And, you know, it's, it's, it's more fun. This is a paper we did, which we basically looked at, we did some virtual osteotomies. And we were saying, hey, how do we manipulate slope? And we proved that a small anterolateral hinge, a more unstable osteotomy, is the only way to truly manipulate slope, doing an opening wedge osteotomy. Also, we said that if you want to manipulate slope, you need a larger correction. If you want to do a small coronal correction, it's very hard to manipulate slope. If you want to do a 7, 8, 9 degree coronal correction, it's much easier to manipulate slope. So these are all the things that we learned. And it would be impossible to learn this without 3D templating, because I can do the osteotomy in multiple planes. This is the thing that Armando did. We did a, you know, we basically did a cadaveric session, where we compared freehand to PSI. And we looked at multiple different measurements with pre and post CAT scans, with four, you know, you know, relatively competent, except for, you know, Armando, osteotomy surgeons. And we looked at wedge size, alignment, and radiation. And the PSI won every time. And it really isn't close. And if you look at this side, you see the variance using a PSI system versus, you know, a freehand. And this could be the same slide of any robotics or navigation, you know, alignment procedure that there's out there. And I still say, if this procedure is kind of based off, we want bony alignment, well then why are we using a bovie cord? Why are we using an alignment rod? That's the, that to me is a little bit outdated. So let's quickly get into complications, you know. How do I, you know, break down complications? Well, first of all, you can fail it with your preoperative planning. You can fail it, fail it in the OR, or you can fail it outside the OR. You know, and I, you know, this is just templating 101. If you just, we're just talking about the varus knee right now. Let's talk about bread and butter. Because we did, we had a long talk about the valgus knee yesterday. But not all varus is from the tibia either, all right. You know, a lateral distal femoral closing wedge osteotomy for a varus knee is a great operation, you know. So you want to look. And I remember, I saw this patient and I was like, okay. I was all excited. This was like 10 years ago and I'm like, oh there's a lot of deformity here. I could, I'm just gonna break the bone and put a big wedge, like a 15. Maybe I'll put, at this point I was using Iliac crest, you know, bone graft. And then, you know, and then eventually I was like, well that's, that's a lot. I'm like, what if I break something? And then so, you know, I did this with, and I was gonna oblique the joint line. I did this, you know, this is an old slide because we did with an EBI frame and I did it with a plating system that's a peak plating system. But it shows you, you know, I remember I canceled this patient on the day of the operation when I was like, this is the wrong operation to do. And then we did this and the guy still has his knee. So, you know, you know, always don't oblique the joint line. So what about, you know, what about slope? We talked about slope. Understanding gap balancing is really critical and, you know, what I'm saying, you know, you're wanting to, you know, one-to-one ratio is for a PCL deficient knee, one-to-two is slope neutral, and one-to-three is an ACL deficient knee. And that's kind of how you got to think about it. And the easiest way that I always teach how you do this, is you get proximal fixation with your plate and then you hyperextend the knee and then you lag the plate distally. If you do that technique, you will really increase slope. When I first started out, I used to do a lot of lateral x-rays. Now I almost do never a lateral x-ray. You know, I think exposure does matter and, you know, we have kind of, you know, two different ways to do it really here. We have, I would say, more of the American way, which is the traditional, just kind of a big sleeve. I used to keep the PEZ. Now I whack the PEZ out. I love doing it with an ACL because I have my hamstrings, so it's like I don't have any guilt anymore. So I'm like, okay, I'll take those hamstrings out and it's amazing how God put the PEZ right there. God put the PEZ to show you he wants to give everyone an osteotomy because that's usually pretty much where the cut should be. It's like, it's a perfect line. It's like, oh, yeah. But obviously, we hear about Al and Armando, you know, doing a T-cut to me is a great idea, too. This is not working. There you go. And then, you know, you want to let the bone breathe, right? You know, just, you know, stacked osteotomes is a very safe way and it's just, you know, that when I was a resident, the Mayo Clinic first started doing non-cemented femoral fixation and their instance of femur fractures was like three to four percent. And now, if you still do a total hip and male, they make you say hoop stress, hoop stress, hoop stress. So whenever I'm with the resident, I'm like hoop stress, hoop stress. I'm like, just let the bone breathe. Understand your gaps. So, you know, you know, it really starts, you know, with your pin placement, you know, whether using PSI or not. You know, I've had things that are, you know, too flat and too distal and crack laterally and I have things that gone into the joint. So understand the deformity and, you know, this is all when I was using Tomofix. I probably, for the one on the left, didn't need to use the plate, but it was a big guy and, you know, you always do that so you can sleep. The one on the, the intra-articular one is my only one I ever had and, you know, I realized when I was opening the wedge, I'm like, oh, I'm correcting this through the joint, not through the hinge. And I'm like, that's not good. Not good. So I put a screw in there and I settled for a smaller correction. And the other thing that you would do in that scenario, if you do that, is you go back with your osteotomes and you, you know, complete your, you know, your hinge, you know, or violate your hinge a little bit more so you have another stress riser out and not through the joint. So these are all different pearls that you have. Let me just go now to some case examples and some disasteromas and then we'll leave it up here. So there's a 45 year old history of medial knee pain, prior microfracture, failed, big, big guy, and this is the one I showed you before and, you know, you can see that, that line. I inspect my lateral hinge line on every case and if you got a CAT scan on every case, I would guarantee you, if you look closely enough, if you're doing any correction closer to 10 degrees, you will have a green stick fracture. You have to have a green stick fracture. But that's why you have to understand what plate you use. A good plate really does dictate of how much you can tolerate here. So I would say, with this plate, you don't need to do that lateral fixation, right? What you have to look for is subluxation. Any degree of subluxation, any degree of shift, then you need fixation. If you don't have any subluxation, you could probably get away with it. But in the beginning of your career, you know, my dad used to always say, you should put a screw in the acetabulum, your first 30 total hips, just so you can sleep at night. So that's just, you know, that's a lateral plate so you can sleep at night. And, you know, there's another one, you know, where I put staples on, another hinge fracture I had a long time ago. This is, again, you can see medial OA, and this is that case I showed you before where we put that screw. And I think I reduced the plateau pretty well, and this guy actually did very, very well. This is actually a case of a PCL deficiency, and I actually purposely increased slope, but I wanted to show the example of, like, how much you can increase slope. And it's, it's, it's a PCL deficiency, you know, even though this wasn't a complication, he actually did very, very well, is your best, it's your easiest osteotomy you ever do, because it makes your bad osteotomy good. So, so realize, just like how it's very easy to violate the lateral hinge, it's very easy to increase slope. We always increase a little bit of slope. It's something that you, you know, we, that most knees can tolerate. And if you really want to, you can really increase slope here, which you can see in this scenario. So this is another thing of early in my career, you know, this was a failed tibial plateau. One of my trauma guys sent me, and I'm like, I know how to do this. I can, you know, I'm just gonna break the femur, because that's, that's, that's easy. It's virgin. It's kind of similar to the case Armando showed with, of those famous orthopedic surgeons I've seen maybe 70 times. But, so, I, you know, I did, this is old-school templating. I did that, and you could see where her conda fell. Then I thought, did a pretty good job. It's good case. Joint line looks pretty parallel to the ground. I thought she did great, and she ended up with a toe knee. So, you know, maybe now I would probably try an intra-articular osteotomy, you know, if she was young enough, but it's, it's, you know, some of these can be complicated. This is another one our trauma guy sent us. She was, you could see, she was a plateau. You can see how her medial compartment's widening. She had an MCL repair, failed MCL repair, so I did an MCL reconstruction and a DFO, but this was early in my kind of, you know, valgus career, and I overcorrected her, and she, she did very, very well, but I put her to the medial spine. So, you know, I always say, hey, come back every year. I know you're doing well, but I know, and she was only 20 years old, I know this knee's gonna fail because I put her in too much varus, as you can see here. So, you know, you know, these are the things that you learn that, you know, we talked about yesterday. A valgus knee is different than a varus knee, and one of our rules is that valgus you undercorrect, varus you can kind of overcorrect, and that's one of those things Seth was talking about. Here's another case of a, this was actually a body CAD case where I, I did overcorrect, and I want to talk about x-rays, right? Your long length cassettes are actually not Bibles. They can be off for multiple things. One, how your feet are positioned, right? An old Peds surgeon at HSS, or my old gnome, Dr. Burke, was like, they've been shooting x-rays at HSS for 165 years, and they still can't get it right, and so, first of all, the consistency of where their feet are relative to each other, if one needs a little bit more in or out, one, and then also the rotation, and also how they're just like standing. So, you can see a lot. So, in our preoperative x-ray, she looked, she was in about like six degrees of varus, and then, and then I, there was an, her AP of her knee, she was a neutral to almost valgus. So, it was really the long leg cassette on this patient that threw me off, and I overcorrected her. She still has her knee, and she's still, she's still liking it, but this is that class example of even just using technology doesn't make you not be a surgeon. This was a state trooper I did, and this is the power of using a good plate. Did this osteotomy, probably violated the lateral hinge. I used fake bone graft back then. Now, I used BMAC with ileocrest, with just fake, you know, cotton wedges, allograft, and I soak them in allograft, but this was using more of a proprietary fake bone. Fake bone usually never works, and I got this CAT scan like four, six months, and you could just see a hole. He was walking, running on it, had no pain, but, you know, that's something, I took him back, and I did ileocrest autograft. If you have a powerful plate, you can get away with things. If you have a scringy plate, you can't, and this is after I bone grafted him, and he did fine. So, I'm gonna, I'm gonna end it there, just for, for sake of time. I think osteotomies are, you know, really biomechanically sound. They maintain high function. They preserve bone. You can do a lot of things with them. The more we're getting, you know, we're stretching the indications. One of the things you want to do with osteotomy is learn this concept of, what do I do altogether? What do I stage? One thing I love about osteotomy is, like, I got a plate, you know, I always want to take the plate out. I always have, like, a backup plan, but I could do another operation. It gives you, you know, tools, you know, tools in your toolbox. I really think PSI will be the future. There's no doubt. We're not gonna go back. We're not going to, you know, no one's getting rid of their iPhones, right? We're just, you know, no one's getting rid of technology, and really, the way you want to think about it, it's all about reducing complications. I had every complication, and it was because I was taught by Philip Lobanoffer. I went to Switzerland for a couple weeks. I did one osteotomy when I was a resident at one of the largest, highest volume orthopedic hospital in the United States. You know, so, I mean, it's fascinating how things have changed, and it's because of ICLs and things like that. So, thank you very much, and as my dad always says, the eyes only sees what the mind knows. Okay, thank you. So, any questions while I'm gonna bring up Al's talk? Right, so, I think we all struggle with that patient. When I first started Roots, I was treated by Chris Harner, and Chris was really one of the first guys to really talk about root repairs, and, you know, we were residents. We were taught, like, sponk, spontaneous osteonecrosis, all this, and we realized that's all wrong. It was just, it's all radial, it's all meniscal, you know, deficiency that's really creating that bone marrow edema. So, first, understanding the disease is one thing. I would never operate on a root unless the knee was pristine in the beginning. Now, I will operate on a root, grade two, grade three. It's actually one of the few operations, and Aaron Critch has shown this, that it's a disease modifying operation. If you ignore a root, that knee will end up with an arthroplasty two to five years. If you fix enough roots, you're gonna fail, you know. I bet 60 to 75 percent, but those knees stay in their body, you know. So, I have a very, very low threshold to do Roots. Historically, I didn't do Roots and osteotomy because I was like, how am I gonna do this with my screws? Just like, you know, meniscal allografts, you know, most guys, not the lateral side, but the medial side, you know, I'd stage them. Now, with the PSI guide, you know, I can show you a thing that they can give you the guide with your root tunnel, and it really makes it, it makes it simple, but for the most part, and I would open it up, I think a lot of times you can get away, and Bob LaPrade actually has a paper with high varus knees, just doing isolated root repair, and they still do pretty well. I mean, that's, I'm not sure I completely believe that, but I've gone now recently to doing more and more concomitant because of the PSI guide, because it makes the operation easier. I have a very low threshold for osteotomy and root tear, and medial root tear. You know, five degrees is my threshold. I think they do well. I think, you know, before I had a paper recently, Jala, better outcomes with osteotomy, a couple with root tear. I'm not even sure you have to fix the root in those situations. I do, but I think offloading that department is key. Well, there's a German paper that shows if they don't fix it and just do the osteotomy, 50% of the roots actually heal, they said in second look. That's what they said. I don't know. The challenge for me is that most of those patients are not the active, greater than five degree male who are doing osteotomy plus a root. It's the opposite. It's the three to five degrees of varus is a female. So, you're going to make a non-weight bearing for the root repair, right? I don't know that doing a small correction each to five degrees adds that much more energy to the operation, personally. I think, Al, you're pretty aligned in that. Yeah, if it's Kierkegaard, I straighten it. Really? Yeah. I mean, because I see a lot of 65-year-old females. Not 65, not even 65. 40. Yeah, 40, 45. The 40 is, you know, the female need to get an osteotomy and a root. The male needs a different sort of thing. I will always do the osteotomy. Yes, but males don't get menial meniscus root repair. Not as much. No, it's always a long-term thing. Well, recently in London, I see probably two to one being able to male that I don't disagree. The problem is your referral base. If you're picking up an acute root tear, having a conversation about doing an osteotomy in that patient is tough. I'm getting a lot of patients that are coming in chronically with a root tear, in which case it's a no-brainer, you're going to do an osteotomy. But ultimately, it just comes down to having a conversation. I always talk to them about osteotomy, and if they buy the concept, we'll do it. If they don't, all right, do the root repair, see what happens. Keep them on crutches for six weeks. If it fails, you're doing the osteotomy later. You've still won because you've bought into their psyche that you're going to have to do something with their alignment.

tibial osteotomy

complications

patient-specific instrumentation

cruciate ligaments

ACL injuries

virtual osteotomies