Okay, so what we're going to do is we'll just start on time. How about that? I think it's a good idea we start on time. So welcome everyone to this beautiful Friday morning in cool Denver. I hope you're all staying hydrated. I'm not, so my voice is a little bit crappy this morning. But anyway, it's been a beautiful meeting. Thanks for coming. We've been doing this ICL with this esteemed group here for, I think we've done this for almost 10 years at varying meetings. Of course, this is year three of the AOSS MICL. But it's really fun. I learn every time from these guys. I will actually not give a talk this morning so that we can have a longer time for discussion. So you can all ask questions and we go through some cases. So I'm just going to introduce to you the speakers real quick. We're actually going to start with Anil Ranawat from New York. And then David Dijour will speak from Lyon, Argette Goode from London, Ontario. And then Stefano Safranini from Bologna, Italy. And we'll go through all the basics of closing wedge, opening wedge. We go also for the ACL, deflection osteotomy, hot topic, as you saw yesterday. And then the femur. So without further ado, I'm going to ask Anil Ranawat to come up and talk to us about medial opening wedge osteotomy. Okay. Thank you, Volker. This has always been a great honor to be here and really to be with this faculty. I am a consultant for BodyCAD and Nuclip. So I will have to talk about PSI at the work. So really, I always have a problem list and I always have a talk outline. So I really always want to talk about why I love osteotomy, why I think medial opening wedge is a way to dabble your toe in coronal plane osteotomy. And then you talk to the sagittal plane, and then you talk to femur, and then you talk to closing wedge osteotomy, and then you talk to deflection. It's kind of a, I teach a transition of osteotomy. I'm eliminating tubercle because I don't really call that an osteotomy. I call that an American osteotomy. It's too easy. And then indications technique. We'll talk a little bit about PSI in the case. I did the wrong thing again. So why I love osteotomy. You know, osteotomy is a truly joint preserving operation. You don't have to worry about the cruciates. You don't have to worry about with the uni. You don't have to worry. You know, to me, it makes any cartilage procedure an effective procedure because cartilage procedures don't work. We had a poll last night with six surgeons, and how often are you doing isolated cartilage procedure in the knee for a condylar knee injury? It's quite rare. Maybe in the setting of an acute chondral shear, you know, fixing it or something like that with an ACL. So it's really, it makes any chondral procedure effective. And then questions whether you actually have to do the chondral procedure in the first place. It also aids, as we're talking about the sagittal plane and ACL and PCL knee, it's a very powerful tool. It can make any failed collateral surgery, any multiligament surgery better. So really it is the workhorse of the knee. And then once you fix an osteotomy and once you're healed, I let you jump out of an airplane. And I have plenty of military people who do that. You know, I think meniscal allografts was a big trend when I was training. I don't think that's a return to activity operation. I think osteotomy can be a return to high impact operation. And everyone always wants to compare this versus arthroplasty. It's not a comparison versus arthroplasty. It's a different procedure. But sometimes it can delay arthroplasty and sometimes it can obliviate arthroplasty. So it's all the gamut. So why did I get here? Well, when I was a resident at HSS 20 years ago, I saw one osteotomy in the coronal plane. And I saw maybe hundreds of total knees in 40-year-olds. And all those knees in 40-year-olds did bad. And then I met Philip Lobenhofer and that really opened my mind. And then I kind of fell in love with the tomofix plate and that really opened my mind. Because so much of orthopedics is about going back to the future, reinventing a procedure, whether it's ACL repair, lateral extraticular tenodesis. It's always a renaissance. Everything about orthopedics is a rebirth. This was a rebirth of very old operation, but with a better implant. And the better implant or better fixation really always drives new technology. The data on osteotomy has always been bad because there was bad fixation and bad rehab principles and maybe not all of this was related to opening wedge. So what was always the problem? This is why the arthroplasty surgeons gained so much power. Well, one of them is because they had expensive implants. And then they would say, look how hard this operation is. You have to immobilize. You get nonunion. You get progression of arthritis. You get Baha. The conversion was bad. All I did when I was a resident was convert lateral closing wedges to total knees and we had these offset tibias, which was really annoying. But I thought many of these were closing wedge issues. Why I like opening wedge the best? Because, you know, well, it has every year we come out showing better survivorship, better PROMs with RCTs. The conversion is very easy. My older brother is an arthroplasty surgeon. So if I ever have an osteotomy convert, I have to hear it at Thanksgiving. And he doesn't really worry about it. The kinematics are improved. And obviously, you know, slope is always an issue, but, you know, we understand slope now better and we can really minimize changing in slope or actually try to manipulate it. And then there's, we can control our complications. So as we talked about, you know, survivorship is getting better and better and opening wedge is now showing in long term to be a little better than closing wedge. You know, the bottom line in terms of comparing the two, and I don't like to compare the two because I think they're for different indications now, but in terms of RCTs and PROMs, they're pretty close in skilled hands. You know, kinematically speaking, probably opening wedge is a little better than closing wedge from the frontal plane and also in the patellofemoral joint, but maybe a little bit more Baja with opening wedge. As we talked about ease of conversion, this was literally my residency, these offset tibias, that's all we did. I don't even want to go back. And as we talked about posterior slope, I actually think posterior slope is an advantage of closing wedge. And we showed in the paper that it's much easier to manipulate slope with a closing wedge than with an opening wedge. And we've done more and more in the way. If you want to manipulate slope with an opening wedge, and I've written a bunch of papers on this, it's really hard to do that without advanced technology because you have to really destabilize the posterior lateral hinge, and you really have to make a small anterior lateral hinge. So it's quite difficult and you're lucky if you can get five degrees out of it. And as we said, the complications are probably a little higher with closing wedge in terms of hinge, but it's more disastrous with closing wedge in terms of perineal nerve. So in summary, I think opening wedge and closing wedge both have their role. I think opening wedge is the way to start because it's one cut, maybe one and a half cuts, if you call it a biplanar cut, and you have really strong fixation. So here are my indications. Really, you want to focus on proximal tibia of error. I always ask the young residents to look at a plain person standing in front of you, then look at their long leg cassette, and build a library in your brain of connecting what proximal tibia of error looks clinically and what it looks on a long leg cassette, and then correlate that to an AP, because when my father, he never had a long leg cassette, and that's really what I've done, and I can look at a patient and tell you their coronal alignment. That's really what you want to start thinking about when you are truly looking at alignment all the time. There are roles for other technologies and roles for frames and bigger deformities now. A lot of my limb lengthening colleagues use expandable nails and other stuff, so not everything needs acute corrections. I think this, our panel here is more of acute correction times, but I work a lot with my limb lengthening colleagues about other ways to fix especially complicated rotational deformities, which you can do with a plate, but the risk of nonunion goes up a little higher. So really, in terms of my technique, I really want to focus on you guys understanding the MCL exposure. Which is the classic total knee exposure, which was you just cut a large medial flap and wrap around the tibia. I used to preserve the PES, now I sacrifice the PES. I love doing an HGO and a ACL in all the patients, because I think, you know, I'm going to cut the PES anyway, and I'm just going to, you know, God put the hamstrings right there to tell me where to start my osteotomy, and I have my hamstrings there to do my ACL. God wants us to do osteotomies. It's pretty simple. The PES was put there to break a leg. You can also do the L-flap, you know, which is a much more aggressive exposure where you have that same exposure, but then you cut around the proximal tibia and include the deep MCL, and you have a good retractable flap. That I use much more when I do PSI, because you need more exposure in PSI. It's something I always want to tell people, you need more exposure to put a big jig on. When I use a tomofix, I have a smaller skin incision, smaller exposure. And then you can actually do the traditional Fowler technique, where you actually just cut the superficial MCL and make a window poster of the MCL, and go behind the MCL right on the bone. And then you can do now probably the most elegant technique, where you make an MCL flap in the front, and then you go behind the MCL. So there are a lot of different ways to do this, and how you respect the MCL, what do you do about the PES. I always believe in getting proximal fixation, over-expand my osteotomy, then do a tension band technique. So if I'm templating to a 10, I expand to an 11, and then do my distal fixation with a cortical screw, so I have a tension band construct. And that's really the power of the tomofix, and that's how it was designed. And then you do a combination of that point, once you have that one distal non-locking screw, the operation's done, it's a stable construct. So this is just an old video we talk about. I always respect the next operation, so I don't believe in oblique incisions. Here's me dissecting that, first the sartorius, and then you make a large flap here, so this is the traditional total knee approach, we've gone all the way around here. Here you can see the PES right below me, you know, and you really want to be aggressive around the bone. Then you have to make your proximal release by the patellar tendon. You put your K-wires in, I measure the K-wires, I measure the saw cut. You know, I actually, sometimes I use a tourniquet, that's the biplanar cut, sometimes I don't. Bone likes blood, blood makes bone not die, so if you're using a saw, I actually sometimes leave the tourniquet, or I do an aggressive irrigation. And then that's the biplanar cut, and then graduate osteotomes, right? And this is where you believe in hoop stress, right? When the Mayo Clinic first announced cemented fixation, their proximal femur fracture rate was 7%. They broke a lot of femurs. So you got to let the bone breathe, let the bone breathe and do stacked osteotomes. This is your distraction device. You know, learning this technique is to me learning how to do a total knee with basic jigs, or it's learning how to do an open shoulder. The problem with my residents, they learn only arthroscopic shoulders, so when they do an open shoulder, they're like, ah. Or they only do a robotic toe knee, so I'm like, no, you have to do a standard, you have to start with the basics. So if you go right to PSI, you don't understand the principles that a lot of people in this room taught me. So I always think you have to start with the basics, and then you can, you know, your first osteotomy should not be a sagittal plane osteotomy. It should be a standard needle opening wedge. And then that's what it looks like. You get your proximal fixation, you open your gap in the laminar spreaders. This is an art of laminar spreaders, right? Front has to be half, back has to be, you know, a full, right? You want to have that triangular wedge so you don't increase slope. You have an oblique distal screw, and that gives you a tension band, and once that screw goes in, the operation's done. So you know, quickly, I'm just going to talk about, so we conquered tibial osteotomy. I thought we did, and I was very happy with my opening wedges until I started really critically looking at them, and I'm like, wow, I do increase slope more than I like. I don't really understand rotation. I don't really understand the femur. I need some help with some closing wedge. I need some help with templating. And so that's when I looked at, you know, PSI. PSI, to me, was the evolution, right? I was saying this, I gave this lecture a couple weeks ago to West Point, and at West Point, I said, guys, I did an osteotomy with them before we did the lecture, and I go, we just did an osteotomy and used a bovie cord. Last night, you guys did a drill. We jumped out of the helicopter and had night vision goggles. If you ever wore night vision goggles, you can see at nighttime. It's like they're really powerful. It's technology that really works, and so is computer technology, right? It's always more accurate, always more safe, always more efficient, always more versatile. And the simple fact is, even if you don't believe in all PSI, digital templating is the way to go. And now my thing froze. And digital templating is basically you get a 3D CT and a long-length cassette and superimpose on that. So you get soft tissue concepts as well as bony concepts. And then from here, when you overlay the two, a Mako robot does not do this. A Mako robot just has a static CT. You get both a 2D to 3D construct. And then from there, you can do digital templating, where you have all your coronal plane and your sagittal plane's numbers. You can play whether I want to do just a tibial osteotomy. Do I want to do a combined osteotomy? How is that affecting my sagittal plane? How is it affecting my rotational plane? Where's my hinge axis? Because of this, I really learned and respected hinge axis. When I was taught osteotomy, there was no such thing as hinge axis. Now we can't talk about osteotomy unless we respect hinge axis. So once you understand new technology, you understand your failures and your common mistakes. That's really, Larry Doerr termed that with robotic total hip. That's really one of the fundamental reasons why you go to enabling non-disruptive technology. There are many different systems. You know, there's BodyCAD, Nuclip. This is BodyCAD, and I like it because it's using drill technologies for opening wedges, so it's less exothermic. It's calibrated, so the drill bits, you can't break your hinge, and you can't hurt your posterior structures, and it's decreased radiation. There's the drill bits right there. And then you can contour your plate to what you want to do. So we're going to get to this later, but it really helps for the more advanced procedures. We did an outcome study, which showed, and this is true for every robotics navigation paper ever written, right? The robot or the computer is always better than a human, right? It's the rise of the machines, every single paper, and even in expert hands. So quickly, let's just do a case. This is a 35-year-old. She's very active. She's had an ACL reconstruction with a BTB and a meniscectomy about 10 years ago. She had PT injections and had, you know, now medial pain. She's got a pretty good looking, you know, she has a little bit of anterior translation, but it's actually a 2A Lachman. She had a good endpoint. So her ACL was still intact, her slope wasn't horrible, and you can see in various, but more importantly, you can see the osteophyte of her medial side, and she's breaking down her medial side. And on MRI, you can see bone marrow edema. If you are a cartilage doctor, and I am an osteotomy doctor who does cartilage, there are plenty of cartilage doctors who don't do osteotomy. I think that's a problem. What we love is bone marrow edema, right? Bone marrow edema, if you look at the drivers of arthroplasty, and you look at the epidemiological world, not the orthopedic world, because the epidemiologists are much smarter than we are, there are four drivers of arthroplasty, which means what makes people get an arthroplasty? It's not X-ray or Kellgren and Lawrence. It's bone marrow edema, malalignment, BMI, and pain thresholds. These are two of those four things that you can modulate with an osteotomy. You can fix malalignment, and that will fix the bone marrow edema. So this is one of my favorite patients, because I know I'll make her better. This is a PSI planning system. This is how it goes. We wanted to avoid her ACL tunnel, because her ACL was intact. Using the calibrated drill bits, you can see that hinge axis very clearly there, how the PSI guide fits, and this is what it looks like, and that's what it looks like when she was done. So in conclusion, I think opening wedge high tibial osteotomy is how you have to enter osteotomy. It's also the workhorse, 60% of coronoplane or tib-fib osteotomies are from the opening wedge tibia. It's biomechanically sound, it's highly functional, it's versatile, it's durable. It's bone-preserving, right? You're restoring the medial column. So total joint surgeons like it, unlike a closing wedge, which is actually bone-dissolving, but I don't want to mess with Stefano Savinini, don't mess with an Italian, because I'll beat you every time. I do think PSI is a great way, once you understand the fundamental principles, and you've done a couple standard osteotomies, it's a great way to then expand your osteotomy practice, to understand osteotomy better, to understand templating better, and it should be a tool in all of our arm interims in knee surgery. And as my dad always says, the eyes only sees what the mind knows. So the more you know, you will see the complication, you will see the error, and you can avoid it. Thank you very much. Thank you, Anil, that was great, as always. And so next up is David Dijoux. The only way to advance it is you have to click here on this. Thank you. Thank you so much. Thank you, Volker. And now, so we still stay in the field of the osteotomy, but related to ACL. And I think that we are not talking about arthritis, but we are talking about intrinsic factors in ACL tear. So when you look at what an ACL, you have a component of anterior tibial translation. This is controlled by the slope, by the meniscus, and by ACL. And then you have also the excessive internal rotation, which lead to the pivot shift and to the instability. And what is very important is to look at the people when they're walking and during the stance phase. And when you do that, and when you look at that, you will see that you have some strain on ACL, and you will have some strain also on the meniscus. So I will focus only on about the anterior tibial translation and the stance phase. So the slope and the anterior tibial translation is related. And why to do an osteotomy, a deflection osteotomy? Definitely, when you have some compression component, you will have some shear component. And then this will stretch your graft if you did an ACL before, and that's why sometimes you have some ACL rupture by fatigue. So the slope is really important on that. To look at that, you need to have some weight-bearing x-rays, because it shows exactly what happens when you're walking. So it's definitely a primary intrinsic factor for ACL tear and re-tear. The slope, when you use this method, the normal value will be 9 degrees. And everybody knows that after 12 degrees, it may be the threshold for doing something. But look at the meniscus status, because it will give you also a soft tissue slope. And look at the cartilage status also. And this may change the threshold for a tibial osteotomy. The slope and the static anterior tibial translation are directly related. So more you have slope, more the anterior tibial translation on your knee is important. And you see the difference between ACL tear and a normal. In the normal setting, it's 1.3 millimeter. When you have an ACL, usually it's above 5 millimeter. So this is what we know about the stance phase and the relationship between the anterior tibial translation and the slope. And if you look at the literature, you will see also that the slope is related to the pivotive, to the rotatory instability, of course. So when to do a deflection osteotomy, when to do this osteotomy, is just to protect your graft. Because the graft will decrease the dynamic anterior tibial translation, but the graft has not a real influence on the static anterior tibial translation when you walk. We did some studies about that, and it doesn't change so much this value. So if we look at this failed ACL, first, second, or third ACL, the perfect indication would be definitely an early re-rupture, which means that you have a biologic failure of your ACL graft. And the biologic is maybe due to the mechanical setting of your knee. If you have no technical mistakes with a good tonal placement, a slope over 12 degrees, and maybe a slope under 12 degrees if you have an anti-artebral translation, the static one, over five millimeters, because it means that you stretch your graft whenever you walk. And of course the meniscus status is very important in terms of this. So if you look to this patient, for example, it's a failure eight months after an ACL and you look at the tunnels, they are not too bad. The femur is a little bit vertical but it's okay. The tibia is perfect but the slope is 14 degrees and the anti-artebral translation is 10 millimeters when she is walking. So she stretched that ACL graft and this is the reason for the failure. So you have to do something else and not only an extra-articuloplasty. The tibial slope will change definitely the biomechanics of your knee. So how to do it? One stage, no tibial tuberosity, osteotomy at the level of the tibial tubercle. The target slope is four to six and a light fixation. The goal of this osteotomy will be to control the anterior-posterior translation, protect your graft and also unload your meniscus and the cartilage. So the sequence is first the tunnel placement, then you will do the osteotomy, then you will fix your graft. And if you want to see this video, you will see how we do. First of all, we do the skin incision depending on the graft that you will harvest. We will harvest the BTB. We usually use a graft that is available, I would say. Then you look at where the pituitary tendon is inserted. It is the key on the medial side and on the lateral side. And then you will release the medial and the lateral side. On the medial side, you will do as Aniel showed you. You detach the deep MCL. You will have no laxity and you go very far posteriorly. And on the lateral side, you do like a lateral closing wedge osteotomy. You release the fascia lata and you release the tibialis anterior. So doing that, you have a fantastic exposure on the upper part of your tibia. And then you will set your osteotomy. And how to do, you use some T-wires. You reach about one centimeter below the tibial plateau, just below the PCL insertion. And you try. You will not change too much the varus or the valgus. You can, but you have to choose what you want. Decreasing the slope or doing a varus or valgus osteotomy. And then you mark your osteotomy. Usually, we use one millimeter for one degrees. It works pretty well even if you do some very strong and intelligent calculation. It might be a little bit different, but one millimeter, one degree is really perfect. You put some T-wires on the second part of your osteotomy and you will cut below the first T-wire and above the second T-wire. So you will join and you will have a perfect inch at the posterior part of your knee. And when you do an osteotomy and when you use your sole, your power sole, just knock on the door, on the cortical. This is the best way to get a perfect inch when you do an osteotomy. And don't be afraid of knocking on the door. When you have done this with your osteotomy, you will definitely finish with a light osteotome. And you have to check the inch. But the inch in this type of osteotomies is always very good because you have so many things behind. Don't worry. We do a biplanar osteotomy, of course. And then you check how is your inch. The inch is perfect. It's moving very well. So you will be able to remove the wedges on the middle and on the lateral side. What is a little bit tricky sometimes is to remove the bone just behind the patella tendon because you don't see it too much, except if you take the BTB. But if you have another graft, you cannot see it too much. And then you will go to the full extension, the hyperextension, to close the osteotomy and then you fix it with two staples. I use staples. I think it's very light. It's very easy to fix. Personally, I think it's a good way to fix. It's a compressive osteotomy, so you don't have any... You don't care about any malunion. Definitely, it works all the time. And then you re-drill your femoral tunnel to pass your graft. What you have to do is to fix the graft at 70 degrees flexion to prevent hyperextension. So this is the way I'm fixing the graft at the very end with a screw or whatever. So when you speak about slope, you need to know the way you measure the slope because you have different techniques and the value, the thresholds are a bit different. This is the study where I was talking about one millimeter, one degrees. Frankly, it works well. We can speak about that. The target slope is four to six. This is what we have published in arthroscopy because we related the slope to the static anterior tibial translation. So if you want not to have a posterior tibial translation, don't go below four degrees because you will have some inverted tibial slope and this is not very good. About the results, we started with a second ACL revision and we published this seven to 15 years follow-up study with a small number of patients but no re-rupture, no new surgeries, no meniscus injuries. So it definitely stopped the natural history of an ACL. About the arthritis, we didn't get a high grade of arthritis. So the goal was reached and it was working so well that we do more and more on the first ACL revision. This is a two to seven years follow-up study, no re-rupture, only one meniscus suture, no arthritis. So it means that this surgery is very safe and very efficient in terms of the future of your craft. So what to do? So definitely evaluate your ACL and evaluate the amount of instability, objective and subjective. Use x-rays, weight bearing x-rays is very important and look at the ACL but also to the environment and having a ruler with a pen measuring things, measuring the slope is something very important and if you do that, you will definitely be more protective on your graft and on your patient. Thank you so much. Thank you David, that was great as always and we're going to hold our questions until all the speakers are done. So next is Al Getgood and Al is going to talk about the femur. Okay, thanks very much Volker. Great to be here this morning, nice turnout. So I'm going to be talking about distal femoral osteotomy. None of my disclosures are relevant for this talk. Okay, so the thing is if we think about our general indications for osteotomy, pretty much covers the whole of knee surgery. Okay, so there's not many things that you can treat in the knee that you can't treat without an osteotomy. So it's a very, very versatile procedure and should be a major part of your armamentarium when treating your patients. And certainly when I think about the complex knee, I always go through this sort of concept of addressing the biomechanics before biology and when thinking about that, real osteotomy is right at the top of the list in terms of the first port of call for my procedures. Traditional concepts when we would look at patients with, certainly in the coronal plane, with coronal plane deformity, think of varus knee, you think okay we do a tibial correction and then with the valgus knee, a femoral correction. But that thankfully is starting to change and we'll be a little bit more specific in terms of actually looking for where the deformity is. And if we do individual deformity analysis in our patients, we will often pick up either a deformity actually on the other bone or even a combined deformity. And so there we need to make sure we truly understand what is going on in regards to what the deformity is that we're trying to address and then picking the most appropriate treatment. And so these are cases where with proprietary software, it's very straightforward where you can actually do a very quick deformity analysis. There's even AI tools within a lot of these programs that will spit out these numbers very, very quickly. And so you don't have to use your ocular goniometer to determine as to whether or not actually there's a deformity present where it is. In this case, this was a femoral base deformity. I sort of did a femoral correction. This is another guy. He's a 23-year-old medical student. He had lateral disease. And of course, you know, the first thing you'd think of is that well he's got lateral disease, surely we should be doing a DFO. But of course, that's maybe not the case. Because when we do a deformity analysis, we can actually see that his deformity is primarily in the tibia. We did a tibial correction rather than a distal femoral osteotomy. So lots of different options to be able to treat these difficult challenges, these challenging cases. Now, one little tip I would say is if you don't have planning software and you see a patient like this with severe valgus, and we just drop the Michaelis line and you have a look and you can see that it's not even within the joint, the likelihood is that you've got a deformity on two levels will often require a double level correction. So not only just the distal femoral osteotomy, but also the proximal tibia. So think double level correction if you see a mechanical axis that's not within the joint. Now in terms of the DFOs that I do, you can go obviously we can do a lateral opening or we can do a medial closing. The lateral opening is probably the more traditional approach. It's a fairly easy approach. It's generally a one cut. You're able to titrate the correction because of the opening wedge. And as long as you use stable locking implants, it tends to be pretty reproducible. Problem I find with it is it has a lot of hardware issues to the systematic review a bunch of years ago. So there's a very high rate of hardware removal on the lateral side and there is an increased risk of hardware, sorry, of loss of correction. And so my preference now is to do medial closing wedge distal femoral osteotomies. You get really nice soft tissue coverage over the plate. It's a very, very stable fixation. It tends to be less painful. We can actually, we have done cases where we've done bilateral at the same sitting and these patients get up and weight bearing pretty quickly. But certainly if the patient has a large vastus medialis, then the approach can be a little bit more challenging. And because it's a closing wedge, it may be a little bit less able to dial in your correction. But if you go with your preoperative planning, that shouldn't be an issue. Now there are obviously things that are different combinations. Sometimes you may want to be able to use an opening wedge over a closing wedge. This is a young girl with short stature, secondary discoletal dysplasia. And so in this scenario, I did something slightly different where we did the lateral opening wedge on the distal femur and a medial closing wedge on the tibia. So again, having these different tools, different techniques to be able to address deformities in both the tibia and the femur. And then also trying to think about leg length as well. So if you do a lengthening operation, doing a lateral opening wedge can actually give you a little bit of extra length. This is another case of a guy who had a multiligament knee injury. It was a smoker. And if we did it just a single level planning. So if we, you know, thinking he's guys in various, so you're going to eat his deformities primarily on the tibia, but he also has some femoral deformity. But if we just did a tibial planning and did a medial opening wedge and a smoker, that's going to be challenging, particularly when it comes to do his ligament reconstruction later on. So when instead we did a planning looking at a double level correction where we can do both femur and tibia, you get a much better joint line without joint line obliquity. And then we were able to do the corrections a little bit later on because of the closing wedges. Okay. Now the evidence for various osteotomies, particularly on the femoral side, the evidence isn't probably quite as good as some of the data that Anil showed regarding the tibia. Survivorship isn't quite as good as tibial osteotomies, but it's still approaching, you know, up to 80% at 10 years and about 45% at 15 years. But we do see significant improvements in functional outcome scores. But as I mentioned, there's a common issue of hardware removal, particularly on the lateral side. The planning that we do, so it's fairly standardized now. So you basically can draw your lines. You can take a line from the hip down to your center of correction. So for the femur to try and get from valgus into a neutral position, that correction point is going to be at the center of the knee. We don't want to over-correct into varus. And then you drop a line from the ankle up to the similar point, and that gives your angle of correction. My medial closing wedge, I'm going to draw a line from the medial femoral cortex down to my hinge point. I'm going to talk a little bit about the hinge point a little bit later. And then you can transpose that line, so that distance of the osteotomy, to your angular correction. And then the blue line is now the distance, the millimeters of correction that is required, the amount of bone that you have to remove to be able to achieve your correction. One tip I would say is because you're essentially calculating at the joint line, but performing the surgery proximal to the joint line, there's a tendency to over-correct when doing distal femoral osteotomy. So maybe you can reduce the number a little bit just to prevent that over-correction. Okay, so that's our planning. So if we go now to the technique. So this is a vastus approach, basically a subvastus approach. So you go through the VMO fascia, and then elevate that, and then lift the muscle. And so you get a very nice, easy exposure. Use the cautery just to do a subperiosteal dissection, and then put a cob right across the back of the knee. And essentially this really opens up a nice large space. You can put a sponge as well as a blunt retractor at the back there, protecting your vastus structures. The pin placement is at the level of those three vessels, the three sisters. And so we'll just place those two pins. I'm going to just use two pins based on the amount of correction that I wish. And then I'm going to mark out an osteotomy, basically in the sagittal plane, but also in the coronal plane, because I'm going to do a biplanar cut. That is then completed with the oscillating saw. And so we'll do that under direct visualization. You've got the retractor at the back of the knee, so you can actually run that saw all the way across the posterior cortex. You've got a retractor there. There's lots of space. It's very safe, as long as you've got your retractors in there the whole time. Then you're going to finish up the osteotomy with an osteotome. Again, running that all the way across the back of the knee on the posterior cortex, making sure that it's released. And then the little wedge of bone can be removed. I wish that they always came out that easily, but sometimes they do, sometimes they don't. And then we can bring the osteotome right the way across. I often use the spinal instruments, the Kerrison-Rongeurs, just to remove that extra little bit of bone along the posterior cortex. And then very importantly, it's really important that we finish off that biplanar cut at the front. I like the biplane cuts because it really provides some rotational stability, but also prevents the flexion and extension. So you can really understand where you are. And then I'm just drilling the cortex on the lateral side, just to loosen that up so it closes down nicely. And then you're going to use your fixation of choice, which is an angular stable locking plate in a compression mode. And so you can get really good compression across the osteotomy site. And it's a very, very stable construct. So that's the technique. So the tips and tricks, we stand on the same side as you're doing on your approach. The fluoroscopy comes in from the other side. I use the vessels as the guide to my start position. So when you see the three sisters, the three vessels that you're going to find, just proximal to the medial femoral condyle, metaphyseal flare, that's your general start point for your osteotomy that you're going to be able to put your pins in. You just need to make sure you cauterize those vessels to make sure that they don't get excessive bleeding. Managing the hinge is important. And so my hinge point, I just want to be a little bit more proximal to the posterior condylar scar on my radiograph. So here, this is going to be my hinge point. And when I'm putting my pins in, the first pin is going to hopefully hit that target. The second pin, you would think you would want that to meet up exactly at that hinge point. The challenge, if you do that, is that when you then bring your saw in either side, so both in between the two wires, the saw is actually going to come to a confluence a little bit more medial to that hinge point. And you're going to run into a problem, because when you try and close that down, potentially it's going to work as a fulcrum, and you can get a hinge fracture. So what I really want are my wires to go either side of that hinge point, just get a little bit of separation, so that when I put my saw and my osteotome in, I can actually get it to my hinge point and get it to my hinge axis. I think that's really, really important. The other thing you can do is just take one of the wires out while you're bringing your saw in on your more distal cut. The biplanar osteotomy is very helpful. I do like this approach because it just provides more stability to the construct, really helps control flexion and extension, also gives you a little bit more surface area for bony healing. The cuirasson rangeur is for bone resection, and then perforate the hinge to aid the closure. You want to loosen that hinge. If it's not closing nice and easily, then you just need to keep working on it to make sure that you're not really going to force the issue. A lot of people are using hinge pins now, so you can put in a hinge pin or a screw. So this is just a wire essentially going across the lateral hinge point, and then you can put a screw in there if you feel that is necessary. Okay, so take-home points. Deformity analysis is absolutely key. Correct on the site of the deformity. You've got to know both opening and closing wedge techniques. My favorite is the closing wedge, but certainly I'll use opening wedge when indicated. We try to avoid excessive joint line obliquity, so again, that comes back to your deformity analysis. Use a biplanar osteotomy, and management of the hinge really is the key to our success. Thank you very much for your attention. Yep, you've got to protect that hinge, that's for sure. So thanks, Al. And then last but not least, we'll have Stefano Safanini from Bologna talk to us. We're going to go back to the tibia for a moment and talk about closing wedge, the original osteotomy that you should not forget. Yes, thank you. Thank you for inviting me, and okay, yes, double click. So this is my disclosure, and the goals of all the osteotomy should be to unload the fat compartment, stabilize the joint, increase function, decrease pain, protect the menisci and delay as much as you can the total knee replacement. And you should correct the whole plane of deformity if you have some. So starting from the biomechanical different effect on proximal tibia of the closing wedge with respect to opening wedge, in fact there is increasing medial shift of the tibial axis, and you have less valgus bony correction angle, but you should work more on the soft tissue correction. So there is a better correction of joint line congruence angle, and this is even if you have no difference in post-operative alignment with the opening wedge. So also the Fujikawa point for me is a little bit old positioning for having this type of osteotomy closing wedge for post-arthritic changes, and now I try to correct as much as I can, trying to maintain the MTA angle no more than 94 to have the line obliquity that Alan was telling just before. And for the post-meniscectomy syndrome, I normally stay trying to reach the zero axis, so 180 degree for the HAKA. So in the last 20 years, I think there is a little bit decrease of the use of closing wedge osteotomy because it's more technically demanding, there is a risk of nerve injury, there is a tibial proximal syndesmosis disruption, it's difficult sometimes to have subsequent TKA and there is a bone of stone loss and the breakage of cortical hinge can be deleterious. But in the last years, this paper just came out and you see that in this retrospective economic evaluation, it seems that the closing wedge is better cost effective than the opening wedge, probably also in relation to the fact that the closing wedge, normally you don't remove the hardware like you have to do all most of the time with the opening wedge. But also the meta-analysis that you are available, there is no significant difference in pay and survival rates between the two technique and for me, there is not unable to point out which technique is superior. So for me, it's not the closing wedge or versus opening wedge, but it's a different surgical indication for me and I try to show you what is my opinion. So if you have a leg discrepancy, obviously you should work on, decide what type of osteotomy you can do because with an opening wedge osteotomy, you normally have increase of seven millimeter of your leg length. If you do a closing wedge, you normally have decreasing of length of four millimeter. So this you can choose depending on the leg discrepancy that the patient has. And so my preference is to have in a virus patient with advanced OA deformity where you have a previous medial meniscectomy or you have to perform associated procedure, I normally do my closing wedge osteotomy and I preserve to do opening wedge only when I have bone virus patient and smoking habits. And the pros of closing wedge is you have lower hardware related problems, you have no bone graft, you have autologous bone on bone healing that is allowed to have a faster recovery, easier to combine with additional procedure and you have a higher survival rate if the previous meniscectomy respect to opening wedge osteotomy. So this is the closing wedge survival from TKA is good to excel in survival rate and long-term follow-up. This is a paper by Ollier and you can see that even at 20 years, you have a patient that have 80% of survival rate. And this is a Constantin paper that have shown the prospective study were evaluated 95 patient underwent closing wedge OA in advanced OA, minimum 20 years of follow-up. If you have the over-revise survivorship of 44% but you have the right indication, so age less than 55, preparative pain more than 45 and BMI less than 30, the results coming up to have 62% of survival rate at 20 years of follow-up. That is not bad. The closing wedge contrast is you have the peroneal nerve injury, you can have this disruption as I said before, and the bone stock loss and the breakage of the medial cortical hinge. So this is my technique, this is really, I normally do an S incision and I normally want to see the nerve all the time. So I go and release the annulus fibrosus that can, if you close the wedge, you can create a problem. Then you start using the saw, also in this case you have to do the double in front, the double osteotomy in order to be sure that you have a sliding of the patellar tendon. Then you finalize with the scalp and then you close. And usually a normal crack of staple that Smith and Neff doesn't know even to have this type of staple. And at the end is this one, and the result is really good. So this is our series that is a retrospective analysis of our institute, isolated closing wedge HTO from 2008 to 2019, and fully available clinical records, preparative full-length radiograph available, and the exclusion criteria was revision HTO or post-traumatic deformity. And we evaluated the surgical failure, conversion to TKA or ATO revision, and global failure, surgical failure or clinical failure. And we evaluated the vast pain scale, lysome, and we have radiological evaluation. So the surgical techniques, the target correction for me is 180, as I said, and maximum 182. We use the crack of staple, and you have also to isolate the peroneal nerve injury and to remove the annulus fibrosus. Then this is a 67 patient with 73 knees, age of surgery was 43, quite early age, preparative mean Kelgren-Lawrence 2.6, and we evaluated at the minimum of 10 years follow-up. And we found that we have no peroneal nerve injury policy, and we have eight surgical failure, so 11%, and nine global failure, 12%. And vast pain score was 3.1, lysome score 79, and Kelgren-Lawrence reduced to 2.4. And we have 77% survival rate with Kaplan-Meier curve. These are our results, and as I say, I tried to have the MTA angle very nicely correct and maintained, and we have a slight three degree of residual virus at long-term follow-up of 10 years. Also we found that comparing to open wedge, we saw, even if it's a trend, it's not significantly, but we saw that the joint-line congruous angle before surgery is much higher for the closing wedge, and you have a better reduction of these, and so you have a more effect on the joint-line. But we found that there is no difference between opening wedge or closing wedge about slope changes so far, and no difference in patellar height. So even evaluating with Caton de Champ or Rensa Salvati, both technique are quite okay in maintaining these results. So finalizing my presentation, I think the closing wedge is technically demanding procedure, but we have still available high survivorship and good clinical outcome in long-term follow-up, and it's cost effective. So it will be my first choice in moderate bony virus, risk of vipermitri with opening wedge. Previous median meniscectomy is the right indication. Advice in the way with interarticular deformity where you have to increase the joint-line congruous angle is the right choice, and you have a better control of tibia slope, and you can even reduce the tibia slope if you change a little bit the line of correction with the closing wedge, and you have a low patellar height, and obviously it's easy to perform with associated procedure. Thank you very much. So, great, if I can ask all of my friends here to come up, all the speakers come up, and we have some time for discussion. So you may all ask questions if you wish, and then we have some cases we can go through as well. So really great presentations, really appreciate it. Maybe I can start out by asking Anil. So an interesting part of our job is you're doing sports medicine, and you're doing knee preservation and also arthroplasty. Now you do all three, so you don't have to refer somebody out for arthroplasty, you do that yourself, yes? No, I don't do total knees, I do partial knees. My partial knee practice is less and less, but I know a thing or two about a total knee. Yes, yes. Well, let's do this, let me show you here some cases. I do, I mean, while you're loading that, I do, I've always been more intrigued, historically in the United States you had sports medicine doctors and arthroplasty doctors, where in Europe it was more likely that you were a knee surgeon or a hip surgeon, they were soup to nuts. And there are pros and cons for both systems, obviously, but I always found in the European system or the non-North American system, they always were better with their indications because they had the whole armamentarium, versus in the United States, let's just say if you see a sports guy, you're getting a knee scoped, and if you saw a joint guy, you're getting a knee replacement. And not necessarily, so that's one thing I've always pressed upon my trainees, is that that's where our system could improve on, because so much of this is about proper indications. Absolutely, and you preserve the joint. I think return to sports is fun, but preserving the joint, I think, is what we need to do. David and Stefano, you do also knee replacement or no? Yes, I do also knee replacement. Two-thirds sports medicine, one-third osteotomies, partial and total knee arthroplasty. Osteotomy for me is 60% sports medicine, osteotomy, and 40% is total knee or replacement total knee. And I will tell you that I love doing that, and I definitely think that when you do osteotomies and you are used to do some approach for total knees, you spoke about that, you are really confident with detaching the deep MCL, because you know that you will have no laxity, it will heal perfectly. If you do only arthroscopies and you never open it, open the joint, you may be afraid. So looking to those techniques, and the way we do, should make you very confident with the technique, and don't be afraid of cutting the skin. Absolutely. And the bone. Alec, do you do any total knee arthroplasty? No total knee, but lots and lots of open procedures. So I'm very happy cutting skin, cutting bone, cutting anything that needs to be cut. And I think you need to. So I think for those of you in the room who are still in training, if you think about it, it may make sense to do a full knee fellowship rather than just a sports fellowship. So this is very good. So in this spirit, I thought I'm going to show you this case here. I brought this case a few years ago to the same panel, so you may or may not remember it. But at the time, I was just asking you a question of what to do, and I didn't have outcome yet. So this is a 55-year-old, so basically he's just like us, he's a surgeon, and he's athletic, he likes hiking, he likes swimming. He had a meniscectomy about 15 years prior, and he has a great range of motion, he has a bit of a varus, it's not huge, about five degrees. He does have quite severe pain, especially when outside of the swimming pool. Some patella crepitus, and then the cortisone injections kind of don't work anymore. Had good success with an unloader brace. And this is the MRI. So this is a knee, you know, well, it's more than at risk, it's a troubled knee, right? So you have edema, you have joint space loss, you have cartilage loss, the meniscus is not there anymore. And yeah, what do you do with this guy? 55, surgeon, active. Yeah, I mean, if he wasn't a surgeon, I would definitely push him for an osteotomy. I mean, surgeons are the worst patients out there. Also, it depends on what type of surgeon, once in a while, you can get lucky if you're like a hand surgeon, and you sit down all day or something like, you know, there's some surgeons you can get lucky with. I would still push him for an osteotomy. But I would say to you, and I would like to see his patella femoral joint, but in two or three years, two or three more shots of cortisone, that compartment will collapse and he'll probably end up with the uni because he wants to get back quicker. But I would always try to push for an osteotomy. If you do a uni, it's sort of the beginning of the end though, isn't it? I would not do a uni here. If you go back to his x-ray, he still has a joint space, right? So if you do a uni here on this guy, with that hot bone marrow edema, he will have elastomodularity differences and he will not like that uni for a while. So you got to wait till his bones scleroticize. So really, either you do an osteotomy or you do nothing and say you got to wait five years or two years or whatever for a partial knee. Al? Osteotomy. Medial opening wedge. And he's, though, like most Americans, he's like, well, the uni, I know what I get from a uni. I can probably go back to work the next week and people are afraid of the cut. How do you counter that in your conversation? I think a uni is a great operation. Totally is a great operation. But if it goes south, if it goes wrong, which they can do, then it's a problem. Whereas I think with an osteotomy, even if you get the complication, you've got more of a salvage. So again, I'm really pushing for preserving the joint. And if he gets a good result with an HTL, he'll be very happy. Stefano. In the preoperative conversation, how do you explain cutting the bone? How do you take the fear out of the patient? 55 years old, he's a young guy for me, and he's a surgeon. So he wants to have his capacity very normally, as much as he can. And for me, I definitely do an osteotomy. But why you leave the knee without any meniscus, medial meniscus, these are questions for me. So if I have to do something, why don't do for the best? So for me, it could be a candidate for even a meniscus transplant in combination with the osteotomy for me. Yeah. So you do a meniscus transplant and osteotomy. That's a good point. The question sometimes is, you do it staged and then find out, well, the osteotomy is so powerful, you may not even need to do the transplant afterwards. I personally shy away from doing transplants when there's too much chondral loss. But that's, of course, nice too, the new stuff that joined up. And David, anything different? I would love to have a weight-bearing X-ray on the shoes position, Rosenberg view. If you have a true joint line narrowing, I'm not super king of doing an osteotomy when you don't have any constitutional deformity. He has no constitutional deformity. The deformity is mostly due to the wear deformity. And when you do such osteotomies and when you have no constitutional deformities, you create a little bit of vicious callus. And so nothing is really perfect on this patient. An osteotomy and a uni, I would not do a uni on this patient. I think he looks good to be there, I know. I would try to ask him to do some cycling activities and wait a little bit before. But I think whether it is or not, it's hard to tell on X-ray. That's a very critical point because osteotomies for pure interarticular deformity versus osteotomies for tibia vera are different animals and one does better than the other. The tibia vera versus the pure interarticular. And Matthew has a paper showing that. So yes, that's a very important point to the audience. Okay, very good. In the room, give me a show of hands, who's going to do a uni on him? One person. Two persons. Who's going to do an osteotomy? A few more. And I guess the others, nothing on him. But I actually would not do a uni on him right now. I would not. You'd have to wait until he gets more arthritic. Well, that's, you know, they're very, I mean, if you look at this case and it's not your patient, you're like, of course, let's just stay cool. Now again, he's not overweight. He's not too crazy active, but he is active. And he's suffering, right? And he's in your office every three months, even though he's a surgeon, he doesn't have time to come to the office. Volker, if you do an osteotomy, what do you, and let's just say the tibia looks okay and the femur is bad. Are you going to do anything to the femur from a cartilage perspective? No, I don't touch it. My God, no. What if he was 35? Well, then maybe I do an osteochondrograph, but I would, so that's something Chris Harner kind of taught me. Now I'm not, okay, I'm going to go on the record by saying, I'm not a fan of stage surgery. It's a lot of burden for the patient to go up there twice, right? I see you over there, Derek, give me one second. And so, but in this case, a stage is something that Chris always did. You do the osteotomy and you will realize the power of this osteotomy. And then, you know, if there's still issues and effusions, then maybe you go after the cartilage, certainly if they're younger and this guy, I wouldn't. Derek. One question. Yes. They said he was, he was light activity level, right? He didn't want to go back to, that would be the determining factor. He's hiking out west. He likes hiking a lot. And of course, like I said, he's a swimmer, which should be perfect for this type of knee. That's why, that's why I would choose the uni because of his activity level. Uni is going to probably survive just fine. Original indications for unis were for older people, but we're obviously doing younger people now. You're right with the complication possibility. So what's your next move is a total knee, but at 55, he's not very active. Now, if he's very active, then the osteotomy becomes something I would think about. That was the reason I went to the uni. No, it's, it's, it's a great point. And we had, again, a few years ago, I forget exactly when we brought this to this panel, we had about 50-50 in the room. Stefano, you then also said the transplant, so you stay true to that. And I remember Roland Beck, I mean, there were a lot of interesting opinions now. This is interesting. Yes. So I do osteotomies. I do unis. I don't do totals. So he asked if he can get another opinion. In fact, I asked him if I can present his case here and he said, yes. So he asked if he can get an opinion from my arthroplasty people. And so he did. Now what he doesn't know, but what you all know, and we just discussed, he goes to an arthroplasty person. He does not get the osteotomy as an option. It doesn't exist. It is the devil, right? The arthroplasty groups hate osteotomies. And so an interesting argument that came about, and I want to see if you've heard this before, kind of pissed me off a little bit, is, well, I use robotics now. And so with that, I cut less bone and the revision is going to be much easier. True or false? I mean, I've used robotics for 15 years. So look, you can still do a uni very well manually. Although there is now some data that has come out that robotic unis are showing finally survivorship superiority to Oxford unis. But look, that's not the point of this talk here. I would say the thing that I would guarantee you when he sees an arthroplasty guy, it wouldn't be osteotomy versus uni. The arthroplasty guy would say uni versus total me, because he's going to say, oh, your patellofemoral joint has some wear, you have some crepitation, I have to overtreat that. That's where I think joint guys get so aggressive. They see any amount of disease in the front of the knee, and it jumps to a full knee replacement. That's something that, you know, he had all his relief from his unloader. You know, a lot of people can survive. And even after a total knee, guess what, 30% of anterior knee pain. So that to me is the big mistake here. If he goes to arthroplasty, he gets a total knee. Yes. If he's 55 years old, he's not doing well with a total knee or even a uni. Yes. But do you buy the argument that with robotic unis, you cut less bone, and therefore your eventual revision to a total is easier? No. But I mean, you can... Marketing gig. Yes? Yeah, everything's a marketing gig. It's a marketing tool. Anyway, so that's what he got. He's very, very happy with that. This is a robotic uni. He was very happy with it. He got all his motion back, and he's two or three years out from this now, so... We're in osteotomy conference, Volker. What are you doing? Hey. Again, this is, yeah, on the other side of the river. But that's okay. So I think this is a cool case, because this conversation, arthro, the uni versus HTL, is always, always, always going. Obviously, if he had had an osteotomy, he would have done a triathlon by now, but that's... Of course. Of course. And I agree, you know, David, you said the deformity is not huge. It's only five degrees. And I think he would be very upset if you go Fujisawa on him and go and give him one valgus knee and one slight varus knee. He wouldn't really like tolerate that. So you can only go about five degrees and go to neutral and shouldn't go any further. Anyway, I think the osteotomy would have been the more powerful procedure here. So very cool. Any questions? Any questions? Daniel, hit me. Tell me how bad this is. How disappointed you are. This is great. I would have done the same. I actually had a question on a different topic, but just to wrap up on this, I think my reasons for doing a uni here would be, I think it's Anil or Dr. Zafnini, to note no tarsal deformity. It's all in the joint and he has low activity demands. And, you know, the survivorship, I won't say robotic, but just because we're better at doing unis now, we're really high. So, you know, 98% survivorship at five years and over 95 at 10 years. So I think you did the right thing. But the bone loss thing, I agree with. It's a given. But my whole, before you go, my whole argument of if you understand why Mako has changed the uni landscape is because they took an operation that was extremely difficult to do because it's limited exposure. And it was, unis were only performed well in certain centers with skilled hands. If you look at the Oxford experience, at HSS was a disaster. Because if you're 99.9% in Oxford, it wasn't 99.9% everywhere else. And then a few centers got good at it. Mako made it an average surgeon operation. And that's my whole argument of PSI. Because these guys don't need PSI. But- It's a level of the playing field. That's why guys like me and you who do 20 unis a year have a good case every time. So that's my point of osteotomy, is the robot made, make unis an average surgeon operation. I think PSI can make osteotomy an average surgeon's operation. My question was for Dr. Dujour. A great talk, I really enjoyed it. Thank you very much. So I wanted to ask you about the scenario in which you have a patient with a failed ACL high slope, but they also have a varus knee. Sometimes even they have medial meniscal deficiency. But they're coming to you with instability. They don't have medial pain. So in that scenario, where you're going to do a sagittal correction, do you need to worry about that coronal plane deformity? Do you need to address it? And in the cases where you feel you need to address it, what tips do you have to address that coronal plane deformity as well with the slope? Because as you said, it's quite hard. Dan, I'll ask you one question. Is the varus asymmetric or symmetric? It's- The other knee. Symmetric varus. So is it- But now the patients come back, they've had two failed ACLs, they've got medial meniscal deficiency as well. You're going back to address their instability, but what do you do about that coronal plane deformity? They're even getting some wear there, but you ask them about medial pain, they say, no, no medial pain. The first thing is that you need to target your surgery. And if you target the ACL reconstruction and the ACL laxity, you will focus mostly on the slope and you have to reduce the slope. And it's very tough to change both slopes and the coronal plane. You can do it more easily with a PSI, as you said exactly, but when you are talking about that, your target was the coronal plane, not the sagittal. So this is the best question. The other thing is that when you do a deflection osteotomy, the risk is to increase a little bit the varus because of the exposure. And we have shown that recently that if you do an error, it's about a one degree error in varus. So probably when you put your key wires, you may plan to correct a little bit the varus, but you cannot change too much the coronal plane, I feel. So the goal would be definitely not to increase the varus in that setting. But if he has some meniscus, if he has no more meniscus, or if the medial compartment is not really beautiful, yes, try to correct also the coronal plane. By what is maybe a bigger gap. Yes, exactly, yeah. So you do like a closing word just told him. Good. So I have a case, which is the third case on this topic, but I want to show you this next case. So if you recall. I'll make it a totally vulgar place. If you recall, right, you're a bit worried doing an osteotomy in somebody that has a compartment like this. So let's go a step further on how shitty compartments can get. And I'm sorry, this is the only slide I have for pre-op. So if you want additional images, I'm just gonna tell you what they show. But this is a 45 year old, about the worst host of a patient that you can imagine. Previous drug abuser on Suboxone. Very nice guy with severe, severe knee pain for many, many years. And what's probably worse, horrible range of motion. Now he does have extension, but he really only has about 110 degrees, which okay is your functional range of motion, but it's not great. Now he has a 14 degree varus with main part of the deformity being in the tibia. And he has a horrible looking patella as well, but no symptoms there. At least not as much. And he did have some relief with an unloader brace, right? So that's usually my first step. I check that out. People usually come back and say, you know what, I hate that brace, but it works, right? If they really give it a try. And I tell them, it's like a new pair of glasses, right? You get these transition glasses, you won't wear them the whole day on the first day. And so neither will you do that with the unloader brace. So what are you guys gonna do here? So, and don't tell me you leave him alone. You did this now for two years. And there you go first. Just a question. Yeah. Mr. Walker, you speak about patellofemoral arthritis, but you don't have axial view? No. 30 degrees flexion? No, no, no trochanterostomy. Oh, so sad. You should ask about that. I also, I'm sorry that I don't have the Schuss view, but he has pretty bad joint space collapse at 45 degrees of flexion. There's basically no more joint space. But he has definitely a trochanterodysplasia. Yeah, I'm not sure. I mean, I have the same patient, not that severe, but he was an investment banker, not a drug dealer or a drug abuser. And I did an opening wedge osteotomy, a bad osteotomy, and I increased his slope. And he loves his knees, had it for 20 years now. So this to me, I love chronic PCLs with various, it's the easiest osteotomy to fix. Now, whether you want to tackle this subject is a different story. I'd refer him to Canada. Yeah, I would too. It's pretty close to us. The thing is, what you're saying there, opening wedge osteotomy, that's the first thing I'm jumping into, thinking about increasing his slope. My only concern is his range of motion is zero to 110. If you do an increased slope, you're going to run the risk of getting a fixed flexion deformity. And I've done that on a patient. He absolutely hated it. And it was an early failure and an early conversion to a total knee. So just be very careful about getting a fixed flexion deformity. Yes, there are a lot of no-no's here. And Stefano, is this too much arthritis for you to consider a joint preservation? No, for me, 45 years old, I would do an osteotomy in that case, trying to pay attention to, maybe you can increase the slope a little bit, but to avoid the, but as Alan say, you can have a risk because zero, 110 is not so big a range of motion. But, and for the patella femora, I wouldn't do, I wouldn't touch in that way. Maybe later, in 10 years later, you do a patella femora prosthesis. Yeah, I mean, David, I have even the, my fellow is the keenest in osteotomy now in a couple of years. I don't know if they're here, but he's like, oh my God, I wouldn't do it. So, what do you do? I will definitely move to an osteotomy. We all know that the patella femoral joint is not so important in terms of osteotomies. I would be concerned about the amount of deformity, 14 degrees of various, it's a lot. If you do a closing wedge osteotomy, no worry about that. If you do an opening wedge, are you doing a double level osteotomy? Mr. I am not, I am not, because a lot of his deformity, I think, is because of soft tissue laxity on his lateral side, and also some intra-articular. So you just got to, you got to plan it very carefully. And, you know, I would most likely be doing just the tibial correction, what I'm looking at, but I would, I'd need to do some angles. Okay. And if he's 45, well, he doesn't sound like a great host. So, you know, doing a double level might be a little bit more of a challenge. Stefano, if I do a lateral closing wedge on him, 14 degree deformity, probably roughly a centimeter and a half of a closing wedge, what do I do with the hinge on the medial side? Is that at risk? Does it matter if it pops open? No, it's not a big risk. You have to pay attention to the fibula that you have to remove because it become quite a big, Yes. defect that you have to remove if you do a closing wedge. But in this case, probably I would go for a opening wedge. But if you did, so when you do do big corrections on the lateral side and you deal with the fibula, how do you deal with the fibula? Do you pop the tib-fib or do you break it distally? No, I don't break distally. I always do at the level of the osteotomy of the tibia and I go with the ronger, making my finger on the nerve, so removing the placement. And you do that for all, even small corrections? Yes. Even for small corrections? Do you pop the tibia? All correction, yes. And you saw the video, that was real time. You feel for the nervous nerve. Al, do you go, so you said you do, or do not go double level on this? I mean, this is one I need to put into a planning software and just see what sort of size of correction that we're dealing with, taking into consideration is JLCA. And people talk about, if you do a double level, that's two operations, there's two cuts, higher risk of complication. They tend to be two smaller corrections. We know that the risk of hinge fracture is gonna be higher when you have a larger correction. So if you're doing more than 10 millimeter correction, your risk of having a hinge problem is bigger. So actually doing a lateral closing on the femur and a medial opening on the tibia with small corrections is actually very well tolerated. And I tend to find it actually works very, very well. So again, just goes back to your deformity analysis and try and get a software program that works for you. And you'll find that you'll be able to address these more challenging problems a lot more easily. The other interesting thing about this case is just looking at his reverse slope. It's a thing, if you do enough PCLs and start looking at your slope with your failed PCLs, now some of that's where, but a lot of that was him. He was never born with 15 degrees of slope. This guy had a flat knee his whole life. Yes. And Anil, I mean, you use PSI on every one of your patients, certainly on this one. Yeah, I mean, look, if it's truly a protoplasm issue and this guy really wants a joint preserving, I'd be much more inclined to do a smaller opening wedge badly, increases slope as much as I can, and then do a closing wedge on the femur. Take the bone from the femur, stick into the tibia. I mean, I apologize, I don't have all this software here, but that was the first time I used PSI. And I have to say, I really enjoyed that because all you needed to do is, you drill your pins, you drill your holes before the plate even goes on. I mean, it's very fast. Now, what is nice about the double level is, sounds like David disagrees. You disagree? I totally agree with you. Yes, David disagrees with me. I said that on this patient, I would have done a closing wedge or still to me because I know that I can correct the amount of correction that I want with an opening wedge or still to me. It was the purpose of my question. You did a double level because it was too much. The thing about the double level is, you have less risk of a hinge fracture, right? You have smaller corrections on each bone. Now, I think we did eight on the tibia and six on the femur or something like this just to make sure that you have no joint line obliquity. But I think that that works really well. And oftentimes you shy away from it. In this tibial cut, you use bone graft or not? So yeah, I do use some allograft I usually put in. So it's America, we have allograft. I use it a lot. I don't use any of the putties. I just don't like it, but yes. In fact, from the closing wedge on the femur, I moved that to the tibia and then added a little extra. And you see, I did not bother with the slope because I was just too worried about the range of motion. And he's not an instability patient. He was that instability patient 20 years ago, but not anymore. The knee is roughly too stiff. Okay, questions, anyone for this? Then I think we have time for one more case. So we'll do this case and we're talking slope and we're talking varus. It's a very tricky subject. I wanna hear from the panel, your tricks how to do this. So first of all, this is a patient that comes in. He's very athletic. He's currently a junior, I believe, football and track and field. And you have to make a decision. Are you going to be a sports medicine doctor right now? Or are you going to be a joint preservation doctor? And I leave that up to you, but you have to make it clear to them. If you go down this path of osteotomy and grafting and meniscus and cartilage, there may not be such a great return to sport. And maybe they shouldn't. You can also talk with the patient and say, hey, look, we're gonna get you through your college career and then you come back after. And then we make a joint preservation. Anyway, this is a joint preservation case. That's what we decided together with him and his family. ACL tear about four years prior, BTB done a year later, re-injury, and has a failed ACL, has good range of motion. Very importantly, he actually has pain and is tender over the medial joint line. And he does have a eight degree varus. And he has a 15, no, 12 degree of a tibial slope, big pivot shift, pretty tough case. So do you want to start again, Anil? Do you- Well, the one thing I'd point out here, that's what I was, this question I asked Daniel was, this is not symmetric varus, this is asymmetric varus. That's correct. So if it was three degrees, if he had constitutional varus on both sides and didn't have a meniscectomy, I would ignore it. But this one, you could see his meal compartment, he had a meniscectomy, it's asymmetric varus, and you see his joint is 50% reduced on his affected knee. So I would affect both planes. This is one I would use the templating system and I would either do a pure sagittal osteotomy trying to correct both, or I would try to do, because he's young and he's got good bone, a standard opening wedge with a PSI with a very small anterolateral hinge, because his correction has to be big enough. If I have to get eight, nine, 10, coronal crates correction, I can get six millimeters of slope correction. If it was a four degree coronal plane correction, I cannot get six, seven degrees of slope correction. This is the one that's like right in the middle and I would have to play with both techniques. But to you in this particular case, is it more important that he's, like you correcting the varus more or the slope more? Because you have to, well, you're gonna hear from the masters if you have to, but in my mind, you have to sacrifice one for the other or you do two stages. What's more important in this case? Well, you could do both, but theoretically, to Dr. Dujour's point, you gotta kind of pick one that you're focusing on. So which one are you focusing on? I don't know, I'm gonna let Al, he's smarter than me. Al? I'm gonna focus on a slope, but I can address slope on his coronal plane through anterolateral closing wedge. It's a very powerful procedure. It does look like he's got some varus in his femur as well, so I'd measure that out. You could, if you really wanted to go all in, you could do slope correction on the tibia and then do valgaism with a thermal osteotomy, lateral closing wedge, but I'd prefer to do it all through the tibia if I can. Have you ever done two osteotomies on the same bone on the tibia? So a closing wedge below the tubercle and then an opening wedge right above it for the varus? Not at the same time, but I've done it in staged fashion. You know, doing multiple osteotomies in the same bone, soft tissue issues, it's not good. Defanon, can you handle the slope with the lateral closing wedge? I think so. You can maybe reduce of two or three degree and in this case maybe it's enough and you combine with the ACR reconstruction. And David, I ask you the exact question, but opposite. Can you affect the varus enough? I know you already said that, but you do a deflection osteotomy here? Yes, probably. This is exactly the patient you were talking about. Just the question is you're coming for an instability or for pain? Yes, he's coming mostly for an instability. He's 21 years old. He has a ACR rupture. The tunnels are not too bad. He has a static anti-artificial translation, which is probably high. No arthritis on the shoes position x-ray. So the goal is to redo an ACL to correct the reason of his rare rupture, which was the slope. And then if you want to change a little bit the varus, you can, but the goal is definitely the slope and the ACL. I have sort of an algorithm that I think if you do an asymmetric closing wedge, I think you can correct about four degrees in the coronal plane. That's a very ballpark figure. He's at eight degrees, and that's why I think I would go more to an anterolateral closing wedge rather than a direct anterior closing wedge. But the asymmetry, you can definitely correct about- No, but if the varus is a sports guy, he's 21 years old, you need to preserve his varus deformity constitutional, because if you move this guy to a normal or valgus, it's over for him. Definitely don't want to go to valgus. It will never go back on itself. That's a new compartment, correct? Yes, it is. Yeah, so I think you can't do a pure sagittal osteotomy for that, because you need to get six to seven degrees of a correction. So, I mean, I struggle with this, and this is a patient I don't see all the time, but I've seen that patient since. I mean, that type of patient since. I did two stages here. I did go and did a medial opening wedge, and I was trying to affect as much of the slope as I could, which I didn't do a fantastic job on this. He still has a pretty high slope. So that's something I've, in the past, gone in, done an osteotomy, and then after three months, did a second osteotomy. But to me, more important was the medial joint, and it was at risk. So he had the medial opening wedge, he had the revision ACL, and we did go back and then gave him a meniscus transplant and an osteochondral. So it's a pretty heavy procedure, but hopefully something for the long term. So with that, I'm gonna say thanks so much to this panel. I'm sad this is probably the last time we do this here because it's a three-year term. So maybe give us some really good evaluations and say we must have these guys back. It's so amazing. Please, to be honest, say what you wish to change. Maybe it should be a round table or whatever it is, and then I will make sure to bring these guys back. So thank you, all four of you, so much. I love this course. I've learned a lot over these years. So thanks, everyone. Thank you.

knee osteotomy

orthopedic surgeons

medial opening wedge osteotomy

tibial slope

ACL tears

deflection osteotomy

distal femoral osteotomy

lateral opening wedge

medial closing wedge

high tibial osteotomy

case discussions

surgical techniques