we'll shut it down in about 10 minutes and I'll map where you're going. It's always easy to go after Neil because he basically does all his complications and we don't need to talk about ours, so that's fantastic. It's an absolute win. So these are my disclosures. Say what you said last year. So yeah, we did throw him under the bus a bit last year and actually didn't present any complications, so I might throw one or two in here. The only problem is it's difficult to find your complications because you try and keep them out of your mind. They go, disappear. So okay, so yeah, so if you think about, this is a study that one of my co-fellows at the time when we were at Fowler Kennedy, Robin Martin, looked at a historic series of HDOs at Fowler Kennedy and he broke it down into class one, two, and three in terms of complications. The take-home was that smoking and diabetes have higher risk of complications, so no-brainer there. We redid this with myself and Bob Litchfield's series. These are all tomofix plates. The previous was mostly non-locking plates and we see that there's basically smoking, diabetes again. One of the biggest issues was removal of hardware. You could argue whether or not removal of hardware is actually a complication because I tell them 50% needs a hardware removal. So again, it's warning the patient and setting the scene. So some tricks to avoid complications. Warn patients of the risk of hardware removal. 50% with the tomofix. I think with some of the newer plates, more low-profile plates, you probably have less issues. Avoid osteotomy or really try and avoid it in pretty controlled diabetics. So you really gotta make sure that they're optimized medically. There's a high risk of hinge fracture with large corrections. We know that. That's in multiple studies, so most of the studies are showing anything over 11 millimeters, you have a high risk of hinge fracture. So you can protect with a hinge wire or screw or maybe even do a double level correction to two smaller corrections rather than one large correction and I'm sure Amanda will cover that. And smokers, I hear people say, well, just don't do an osteotomy in a smoker. Well, that's maybe one option. You can ask them to stop. They never do. But I tend to just, in this case, just mitigate it with a closing wedge technique rather than doing an opening wedge. So a few cases then. So one thing you wanna do is avoid creating deformity. So this is a guy who's actually a medical student. He was one of my master's students as well. So he had a basically lateral OA. So he's got lateral disease and of course, if you don't engage your brain, you would start thinking, well, that's clearly a case for a distal femoral osteotomy. But if we go through a process of doing a deformity analysis, we actually see a lot of the deformities in the proximal tibia. And so if we basically plan that out and do a virtual correction, you can see by doing a proximal tibial osteotomy, it's a win. And of course, the deformity analysis, some of your papers now really very clearly showing that a lot of the deformity is not just in the tibia. So we actually have to look at, you gotta measure your angles. So you can see in the varus knee, yes, most of it is tibial, but there is certainly some femoral deformity in the varus knee. In the valgus knee, there is also some tibial deformity, but primarily varus. Or sorry, primarily femoral. So think outside the box a little bit. So this is a small closing wedge. We originally, when I first started in practice, I was doing more opening wedge proximal tibial osteotomies on the lateral side. We published on that. I think, Seth, you showed that paper. I've transitioned more to going to the medial closing wedge again, just for faster healing. And I find it a little bit easier. So yeah, so that did very, very well. Okay, our case two. So osteotomies don't always have to be extra-articular. It's very similar to what Anil just presented. So this is a 45-year-old with a previous Schatzker 6 tibial fracture. And you can see she's got extreme level amount of valgus. She was extremely debilitated by this. I mean, just constantly collapsing on that sort of a valgus thrust. And so in this scenario, trying to do a large bulk osteochondral allograft is, can be problematic. And so I just basically maintained her own tissue and did an intra-articular correction. So using the hinge point in the center of the knee. So you can do intra-articular, you can do this. And yes, you use an alignment rod in these scenarios because it's very, very difficult to essentially predict. And it basically is to open it up, put a thermal head allograft in, and then put a plate on. This is her film post-operatively. So again, it's not perfect. So again, setting expectations. This is a salvage operation. It's not gonna make her knee what it was like prior to her fracture. But certainly she stopped having that alignment issue and she stopped collapsing into valgus. And again, it's done very, very well. Be aware of increased tibial slope. We talked a lot about slope yesterday in yesterday's session. And this is more of some of those sort of extreme examples where you see this lateral full leg tibia. You see marked anterior tibial boring, significant increased posterior tibial slope. And then you get the anterior translation, but you also have a coronal plane deformity as well. Failed, multiple failed ACL reconstructions. This is just an absolute nightmare. And so with this one, we did both the double level correction, so on the thermal side, but also then changed slope on the proximal tibia. So lots of different options to try and address some of these issues. And of course, we know what the issue is around tibial slope. We've talked about it a lot yesterday. We'll just go over it again. So increase in tibial slope is directly proportional to the amount of strain on your ACL. Similarly, reduced tibial slope has increased strain on your PCL. Okay, so you can actually alter slope. We know that 12 degrees has been shown to be an increased risk factor for ACL injury. So my indications for slope changing is a failed ACL reconstruction with increased posterior tibial slope of greater than 12 degrees. Remember, 12 degrees is the number that's been measured on short films. If you take a long leg film, that will usually give you a much higher number. If you're using 12 degrees and you're measuring on a long film, you're gonna be doing more osteotomies than you should be. Okay, so just don't forget about that. They're also looking for anterior subluxation on the lateral weight bearing via an extension. And so if you've got more than 10 millimeters of anterior translation, that is a problem. Trying to correct that with a soft tissue graft, good luck. Okay, and then so in terms of caution, you wanna think, you know, does the patient have hyperextension? Yes, you can still do it, but you just gotta be careful. You may have to do a soft tissue imbrication posteriorly. May need to keep them in a brace a little bit longer to avoid getting a hyperextension thrust. And certainly in the primary ACL reconstruction, think about doing a lateral tenodesis instead. And the slope increasing, so this is for a failed PCL or PLC reconstruction. And this is actually, I love this operation. It's one of my favorite operations. Patients turn up with a hyperextension thrust, incredibly debilitating. You just give them a little increase in slope, reduce the hyperextension thrust, they're very, very happy. So in terms of the sagittal plane correction, you need the lateral weight bearing view. And then we think about basically one millimeter of correction equaling one degree. It's pretty basic, but ultimately we don't really know what the exact amount of slope that you can correct to. So this is an approximation. And I think as time goes on, I totally echo what Neil and Seth have been talking about with PSI. You're gonna be able to have much more accurate corrections. And then you can measure and you can actually, hopefully we can work out where we should be correcting to rather than using a rule of thumb, which we've been doing for the last number of years. So the approach to slope reduction, if you haven't done any slope reductions as yet, then it's always a good idea to start with a TTO because essentially it's just a much better exposure and it's much easier to work with. So this would just be my approach for doing the TTO. So essentially this is just splitting the sartorius fascia and then we just undermine the MCL. So once we've done that, you can place a scissor just underneath the patella tendon and it works as a nice retractor. And then the TTO that I use is a wedge shaped TTO. So it's not a flat shingle. And I think this is actually really, really important because you're really getting down into the metaphyseal bone and that metaphyseal bone has got a great components for healing. If you take a flat shingle, it can run into problems because when you change the geometry of the proximal tibia, that flat shingle no longer sits flush onto the bone. So now you're gonna have to start finagling and actually cut away bone to try and get that sitting down or even bone grafted. Whereas with this wedge shape, you can actually just sit it back in and I'll show you that in a second. So here's the TTO coming off. And now once the TTO is off and you've got retractors, both posterior medial and posterior laterally, you're looking directly at the proximal tibia. You can put your pins in. So these are two parallel pins proximally, two parallel pins then distally. And that's just based on the measurement that you're using. So I just take the little ruler that you get with the marker pen. You cut it down to the correction size. You can do an asymmetric wedge if you like. It takes a little bit extra off one side or the other. So then you can affect a coronal plane change. And then we take the saw and we just run the saw across and then finish it up with an osteotome. And of course, here's the osteotome going in. And really important that you get as far posterior lateral and as far posterior medial as you can. Otherwise you're gonna get hung up. It's not gonna come down nicely. And you look basically as you go and just take your time with this. And it's just, of course, every single time you're just gonna pull a wedge out like that. And then with your, this is basically, I'm just gonna pause that for a second. One thing that you can do is if you take your osteotome and just score the osteotome along the back. Okay, so you're just running along the cortex. You're just removing a little bit of bone and then you can perforate the posterior cortex again just to loosen that cortex a little bit so that it closes down nice and easily. And there it just closes down and then you can fix it with a staple and then you put the TTO back in place. And the TTO goes back in place nice and easily. Hang on a sec. There it goes. Yeah, that's not, okay. So essentially that wedge just sits very nicely in that gap. Now you can leave the tubercle on. This is a much more difficult operation to do but once you're happy with the first way of doing it then this is actually just the natural transition because you can be a little bit more aggressive with the rehab protocol because you haven't taken the tubercle off. So you're putting the pins in exactly the same position but ultimately you just have to work around that tubercle and so it's a little bit more challenging and you just got to take your time, use your osteotomes, take out a little bit of bone. And one thing I would say is that do a biplanar cut, okay? So if you do that, so you can actually then do a biplane cut here but you've got to take a little wedge of bone out behind the tubercle. Otherwise you're just not going to be able to affect the closure because essentially the metastasis is going to buttress against that tubercle. So you've got to take a little bit of bone out. You can close it down. Gives you a little bit more real estate for doing your ACL reconstruction and then you can fix with a couple of staples. So we talked about when to add a TTO. So large corrections, and particularly if you're doing an asymmetric correction and when you're starting. And then in terms of what you're aiming to correct for, dial it in a little bit. You don't want to cause too much hyperextension. And then as Anil said, you can really change your, depending if you're looking at the coronal plane correction, you can look at the hinge axis and try and affect it that way. We've recently published our series, it's 23 patients. And I think the thing is, whether or not this is a complication or not, Anil, I'm not sure, but ultimately our results aren't that spectacular. Our patient reported outcomes are not that great. And it's probably as a result of the fact that most of the cases that we did are in second and third revision ACL reconstruction. So multiple operations that are not going to do so well. So maybe we should be doing these in a much earlier timeframe. But it's, again, that's a tough conversation to have with patients. So what about slope plus coronal plane? Okay, so there's slope issues, got a bit of varus. Okay, so this is a patient that we did an anterolateral closing wedge, proximal tibial osteotomy. And then she ended up requiring revision ACL reconstruction, as well as a medial miscosaligraph transplant. So again, doing pretty well. What about if you have a reduced tibial slope? So this is a complication. This is a patient where I did a multiligament reconstruction, ACL-PCL postelateral coronary. Unfortunately, went on to fail after I actually had to reconstructed her a couple of times. Her grafts all stretched out, coronal plane neutral, flat slope, hyperextension. She was a patient that was complaining of hyperextension thrust, with significant hyperextension. And so I did an anterior opening wedge. So same pin position, but instead of putting pins in, where you're taking wedge out, you're making one cut, lift it up, put the tubercle back on, and then fixed it with a plate just to make it a little bit more stable. And six months post-op, you can see how much you can get, really increased that slope. Didn't cause a fixed flexion deformity, reduced her posterior translation. Again, she was very happy from a point of view of reducing those issues. Okay, so this is probably one of my most significant complications to date. So this is an 18-year-old with recurrent patella instability at a failed TTO, MPFL reconstruction. You can see still got fairly significant patella alta, even off the back of a previous TTO. And so in terms of reasons of failure, yes, he had type 2D trochlea dysplasia. He had external tibial torsion of 35 degrees, caton de champ with 1.25, with a 24-millimeter TTTG. So there's some axial plane issues as well as some patella height issues. And of course, he had the trochlea dysplasia as well. So what I intended, well, what I did do was this. So I did an internal rotation, proximal tibial osteotomy, took his tubercle off, internally rotated him, brought the tubercle down a little bit, and fixed him, and that all looked good. Young kid, he wanted to go to his graduation prom, and so he comes back with the tubercle starting to lift off. And sorry, those aren't animating properly, but essentially the tubercle had pulled off, you can see on that, on this view over here. And so I went back in and fixed his tubercle with a plate. But even at this point in time, you can see some callus formation. You get an impression, maybe it's just starting to collapse into varus. And, you know, should I have done something about this at this point in time? Well, hindsight's a wonderful thing, and yes, I probably should have, but I didn't. And so that started to become more of a problem, and ultimately I had to go back in and revise it with a medial plate, and use Iliac crest autograft. So this was certainly a hypertrophic non-union, so this is really an issue if this didn't have good enough stability. So again, when you're doing rotational corrections, of course you've got to complete your osteotomy, and you've got to change your hinge. You don't have a hinge anymore, so again, it's a little bit more of an unstable construct. I was doing exactly the same case last week, and I did the construct that I did first time around, and at the end of the case, I just suddenly remembered, maybe I should put on a medial buttress plate, that actually might be a good idea. I did it before. And sure enough, we did. And so, yeah, don't make the same mistake twice, right? Okay, and then this one's an interesting one, right leg deformity, you can see. This guy had, he was really, had a problematic reverse tibial slope, and, you know, we did, he's got basically a proximal tibial deformity. He's got mid-shafts, or diaphysial deformity as well, and again, very disabled. There's his cora, so not your classic implants. We did a CT scan, just to try and understand that a little bit better. And this was in the days prior to having access to any of the concurrent, the current proprietary PSI. So we tried to do this in-house. So we have like a metal 3D printing facility at the university. So we came up with these guides, and I thought what I'd do is I'd just freehand the anterior opening wedge, but then do this diaphysial correction with these guides. So we made this closing wedge, and did the opening wedge to start with, did a closing wedge on the tibia. Couldn't correct everything. It was just, you know, really crazy. And I think, you know, again, this could have been a really good option for Taylor spatial frame. We don't, we don't have a, really, I don't have any expertise in framing. So for me, this was definitely the way to go. It was difficult probably because it didn't do a fibular osteotomy. So it's actually difficult to try and get that correction. So we did have to put two plates on. And so this is the opening wedge, two allograft wedges going in there. Tubal goes back on. But, you know, he really wasn't very, I mean, his diaphysial osteotomy took a long time to heal. You're in cortical bone, it's a bit of a challenge. So I just got going with some pulse ultrasound, and sure enough, it goes on to heal. And yep, he's got, his coronal plane's a little bit better and certainly his slope was better and he got rid of his hyperextension thrust. If I was going to do this again, this definitely would be 3D planning with PSI. And I think you could actually confer a pretty good result. So with that, I'm going to shut it down because Armando needs to get up here and get some of his pearls, okay? Any questions on any of those cases? I think it's a good rule that you said is that if you do an unstable rotational osteotomy, you need to have two planes of fixation, you know, whether it's the femur or the tibia. And that's just, I think, it's a thing that I don't like to do a lot and because of that fact. And so that's something that I think that adds a lot of morbidity, you know, because then you have a bone sandwich. But I think that's something that getting a better fixation constructs to, that's what I'm saying, controlling, you know, to get, because I do hip too. So version to me, how we address or tibial rotation, that's to me the next frontier. And, but it's scary because they're unstable.

orthopedic surgeries

complications

hardware removal

diabetic patients

hinge fractures