one workup, but that's for a non-union. They'll get a thyroid, they have a whole non-union panel, but for, that's like going in a little too negative for us. I've done that for, I do non-unions for osteotomies, and I will do a metabolic workup on those. Those ones, right. We have a big Indian heritage patient population in the UK, particularly in London, so for my Indian patients of Indian heritage, my wife's an Indian extraction, so all her family's on vitamin D3, so I find out much more commonly, and most of the patients who are non-white European heritage, or whatever that term, are actually low in vitamin D3. Yeah, I give all my. There's no sun in London, so it's like. Yeah. I do give all my osteotomies, I put them on calcium and vitamin D post-op, and in a max dose, like pregnancy dose, so that's a no-brainer. Has anyone used a hinge pin before opening your osteotomy regularly? Like some sort of, like to protect the hinge, you're saying, like some sort of K-wire or something? Yeah, exactly. I have not, I think for some of those, so it's interesting, if you look at the BodyCAD system, the guide goes on, you do the cut through the guide, then you remove the anterior portion of the guide, and then there's this, essentially, caliper that goes on the box and opens it up, but you're really, it's a long lever arm. Some of those bigger corrections, I actually use either stacked osteotomes, or I'll take Arthrex, and their old osteotomy set has these two osteotomes that go together, and then you screw them, and they separate, so I like to open up the osteotomy over its entire length to minimize the risk of a hinge fracture. I've not routinely put a screw or a pin in there. There's some systems that do, this kind of golden K-wire. I don't know if you guys. That's what, yeah, the Nuclip system has the golden pin, and I think, and Matthew Olivier is doing, he's doing that much more routinely. He does, you know, a lot more Al crazy shit, and so, I mean, it makes sense. I mean, it's a type of thing that you can just freehand it, too, you know? And a lot of guys now are just putting a screw, and not even a wire, so, I don't know. I think a screw's a better construct. I think that's what worries me, is if you put a pin across, and you do your opening, so you play them, and you take a pin out, what happens then? Well, either it's bent, but then what actually happens at the hinge, in terms of actually the force that's built up in there. Yeah. So I tend not to do it on a routine basis, but also, you gotta recognize your hardware that you're using, because there's some plates that are available that can create a compression of the hinge. Some of the other plates don't create compressions, so you might need a hinge screw to create that compression. Right, I mean, that, to me, is the AO technique. I always try to create compression, and I always over-distract to my template, say, if I have template 11, I make a 12, and I wanna compress it, you know, that's why I always want an oblong screw distally, but, you know, that's, just how you, when you do stacked osteotomes, you have to be careful taking it out. If you have a big correction, and you just, you know, so that's, but I think compression is key to faster healing, but you can sacrifice your hinge. Stacked osteotomes, stacked osteotomes are great, but don't stick them all in to the point of your hinge. Right. I learned that the hard way. Yeah. As my fellow was knocking it in, knocking it in, and it suddenly just went, right. So it's a long slitter. So, yeah, but that's, and that's why I think, you know, starting with the tomofixes, because the way they have it, they can't, they won't let you do it, because they're all L-shaped, so each one goes in less, and less, and less. Yeah. You know, that's, you know, but I never, even the first one, I never go to the hinge. I'm always about a centimeter shy. What do you all think about tourniquet use? I use TXA, I do use tourniquet. I'll just let it down again, but so you can see what's bleeding, and I don't do the OR until that thing's down, but I do still use tourniquet. I didn't use tourniquet in the beginning, and then now I use tourniquet. I use tourniquet for everything, just take it down before I go over it. Yeah. Yeah, right. So you can see in the back, you know? And I think, we talked about this yesterday, proper exposure, you know, surgery's fun when you can see. Surgery's fun when you can feel in the back, you know, and I would never, you know, doing a minimally invasive osteotomy, you know, that's one thing I love about Michael Lea, you know, all of his incisions are Ranault-style. I mean, you know, it's always Filet-O-Leg, but I think that should be your, you know, that should be where you start, and then you can bring your incision smaller with your experience. Actually, would PSI make bigger incisions than if you freehand it? 100%. Yeah, that's what we talked about last night. Yeah, PSI definitely needs a bigger incision to fit the guy to the bone. There's no doubt about that. All right, thanks very much. Thank you. Thank you so much.

non-union patients

osteotomies

metabolic workup

Indian heritage

protecting the hinge