All right, perfect. Okay, so I'm just going to show you a bunch of cases. And I don't have a ton of complications in here, but I'll tell you some of the issues that I've had. Okay, so this is essentially one thing. First thing I want to bring up is that not all valgus occurs in the distal femur, and you've already heard that from Anil and from Seth. And I think the key here is don't accept dogma. I think from the start of my career, I just always wanted to question the dogma, and there's so much dogma in orthopedics. And I think the osteotomy is no different. So what are we going to do? So this is a guy, he's a 29-year-old medical student, lateral sided pain following a previous meniscectomy when he was a football player. And I'm sure most of you would be thinking when you see these radiographs, okay, you see lateral osteoarthritis. He's collapsing, inflection, and there's Rosenberg views on that lateral side, and I think that's a really important point. Okay, so there's his arthroscopic pictures. He's got post-lateral disease, he's got a subtotal meniscectomy, and he's got that lateral, he's got that valgus alignment. So, you know, I think most of us would suggest traditionally straight-to-DFO. Okay, well actually when you measure him out and actually look at it, and I think this is something that's very, very useful, is to use digital planning. So we're moving away from mechanical axis and thinking more about doing digital planning and doing deformity analysis. So understanding where your deformity is and then correcting at the point of the deformity. And when you look at that, you look at that medial, mechanical medial proximal tibial angle, you can see he's basically, he's got some tibial valga. Okay, so with this case I did a medial closing wedge proximal tibial osteotomy. Now Seth's already talked about some of our series that we did using lateral opening wedge, and certainly lateral openings an option, medial close. Because I've become more comfortable doing more and more closing wedges, I actually prefer to do a medial close. And the reason for that is just it tends to be a little bit more of a stable construct. Patients can weight-bear a little bit more quickly, it's less painful, and you know the concern we always had was what do you do with the MCL? Well I'm much more facile with actually dealing with MCL issues as well. You can see a little anchor in there, so it really doesn't bother me. So this was a proximal tibial correction. What issues did he get eventually? Well he had some hardware irritation, the plate came out at about a year. Not a big deal, this is not a big concern. And certainly if I look across all of our corrections, particularly in the medial opening wedge with Tomafix, 50% have their hardware taken out. So that's an easy quote that you can give, a number that you can give your patients, but it really is not a big deal. I don't really change the weight bearing status after I take the plate out. Okay, case two, osteotomies don't always have to be extra-articular. Okay, and Neil already mentioned one of his cases. So this is the case, he had a Schatzker 6 tibial plateau fracture, fixed by some of my trauma colleagues, double plating, did well, but she obviously got that proximal tibial deformity. And for this case, we did an intra-articular osteotomy. So this is a freehand technique, put a couple of wires in, put a saw in, and then opened it up, got a correction, put a femoral head allograft in, and fixed it with a plate. Okay, so now what happens with this? Well it's an intra-articular correction, it's a big operation. She got a little stiff, she needed a manipulation under anesthetic of three months, but otherwise doing extremely well. Now in terms of actually goal setting for this particular patient, she's never gonna have a normal joint. Okay, so she will probably have some ongoing discomfort. In terms of her deformity and the issues that she was having pre-operatively with dynamic valgus collapse, that has gone. She's walking much, much better. She does have some mild discomfort, but this is a much, much better scenario now for when she comes to do a total joint. Okay, so be aware of increased tibial slopes. This is a case that I operated on the Middle East. And if you just look at, you know, this huge, huge posterior tibial slope, and we get those lateral radiographs, have a look at that lateral standing radiograph with a significant amount of anterior tibial translation. That is a case that I cannot control with doing, even if I use a BTB autograft, could go to the contralateral side, could add in a lateral tenodesis. That is not going to control that amount of deformity. The bony deformity is going to really rule up the day. So we did a double level correction plus a slope reduction. So big case, a lot of, lot of stuff going on, but you've got to think about that slope. So let's talk a little bit about slope. So we know that slope is an issue. You know, we've heard the study from Bob Giffen, who's my partner at Fowler Kennedy, but there's been some really nice work now more recently that's been done, this is done in Vail, looking at both ACL and PCL and the effect that slope has on graft strain. So we know all about slope and the effects that it has on our cruciates. We also, so with ACL injury, there's a significant increase of ACL injury with increased posterior tibial slope. We often think about 12 degrees as being that sort of number, which makes us a bit concerned. And if you look at a young age population, it's even worse. I mean, this is just crazy data, 20% survivorship, okay, with, if you're adolescent, with a slope greater than 12 degrees. So that's not great data that you want to be able to show to your patients. So what are my indications for changing posterior tibial slope? Okay, well, slope reducing. Okay, if we've got a failed ACL reconstruction with increased posterior tibial slope of greater than 12 degrees, okay, so we can measure that out, particularly if I'm seeing anterior subluxation on a lateral weight-bearing view and extension. So that's a real, those are my sort of two key points. You always, patients with fixed flexion deformity, they particularly do very well. If you've got hyperextension, that's a bit of an issue. So be cautious with hyperextension greater than 10 degrees. It's an extension osteotomy. It could make that recurve artem. It will make that recurve artem worse. They could get a hyperextension thrust. Okay, slope increasing for failed PCLs, post-relaxal coronary reconstructions, and chronic hyperextension thrusts. These are great, great indications. I would say that the slope increasing osteotomies, patients do much better than the slope decreasing because you're actually treating their symptoms. A lot of the time with a slope decreasing osteotomy, you're really treating risk. You're trying to reduce the risk of a re-injury of their ACL. With slope increasing, they're presenting with a problem associated with that increased or that decreased slope. If you increase it, it changes their whole knee kinematics and improves things. Okay, so what about, so when it comes to this, we do preoperative planning. We look at a sagittal plane correction. The lateral view, weight bearing is really important. And there's the general point of view is just, is to think about one millimeter of correction equaling one degree. It's a bit basic, but if you want to go to the PSI, you're going to get a much, much better, more accurate correction. But I would argue that we don't really know exactly where we need to correct to, in which case then you can just do something that is of a reasonable degree. Okay, so this is a bit of a busy number of slides, but it just sort of gives you an idea of my thought process when I'm thinking about patients with increased tibial slope. It's got normal coronal plane or you've got coronal plane malalignment. So let's start with a normal coronal plane. If I'm doing an ACL reconstruction and I only need a small correction, I do a super-tubicle anterior closing wedge proximal tibial osteotomy. So I'm going to leave the tubicle intact. I'm not going to take it off. If I'm doing a staged ACL reconstruction and or a large correction, so a correction greater than eight millimeters, I'm taking the tibial tubicle off. It's a much easier correction for me. If you've got coronal plane malalignment, either varus or valgus, then we've got to think about how much correction can you do simultaneously. We talk about biplanar corrections, but really they're uniplanar. It's just a vector of the two planes, right? So essentially, if it's less than five degrees, I can do an asymmetric anterior closing wedge with a tibial tubicle osteotomy. I can take a little bit of extra bone out of one side to change the correction. If it's greater than a five degree correction, then I'm going to do an anterolateral closing wedge proximal tibial osteotomy. On the valgus side of things, same again. If it's less than five degrees, can do asymmetric close. If it's greater than five degrees, probably going to have to go double level, correct like that case I showed. I'm going to basically do the anterior closing wedge in the tibia and then a valgus correction on the femur. Okay, so here's just a surgical technique, which is for an anterior closing wedge osteotomy with a tibial tubicle. So basically we're going to go on the lateral side first. I'm going to take down the tibialis anterior. Anything that you're doing with osteotomies, you just want to be safe. You want to protect your soft tissues. You want to protect your neurovascular structures at the back. Here we're going just through the PES. Okay, so it can actually, and then so release the PES and then I'm elevating the MCL. So now I can put retractors laterally, medially, everything's nice and safe. Okay, we're then going to dissect out the, the tibial tubicle. Okay, and then we'll do a tibial tubicle osteotomy. And that tibial tubicle osteotomy is done in a trapezoidal wedge manner. Okay, so I can actually get right down into cancellous bone. I don't want the flat shingle. I want a big chunk of cancellous bone because that's going to be nice and easy for it to heal. So this is a super easy TTO. Just going to quickly just pop the saw in. You can see I'm using the scissor just retracting behind the patella tendon just to really give me nice exposure. And so the saw is just working its way in there and then we're just going to pop it out. Let's see if we can speed this up a little bit. There it goes, an osteotome going in there. Okay, and then it just pops out. Okay, and you can see that the shape of that is a big chunk of bone. So it's nice cancellous bone for healing. Okay, so next thing up, I'm going to put in a couple of K wires. Okay, and those K wires are going to determine my level of correction. Aiming for a hinge point at the most distal part of the PCL fossa. Okay, I want to be up at that level in that tafseal bone. Again, trying to avoid complications. The more distal you are, the more you're going into cortical bone, higher risk of the hinge popping at the back. Okay, so we're putting in parallel K wires. I'm going to start with a saw. You can see the retractors are medial and lateral, so everything's nice and safe. Okay, and this is no different than putting a saw in from anterior to posterior when you're doing a proximal tibial cut doing a total knee. So this is all basic stuff that most of us as orthopedic surgeons are very, very comfortable doing. Okay, so we're just bringing the cut in, then we're just going to take that wedge out. And you can see with the tibial tubicle out of the way, it's much easier. Okay, we've got really good visualization. We can just take that little bit of bone out, and then I'm taking a K wire, and I'm just going to drill the posterior cortex, just creating like a postage stamp. Okay, if you remember what those things are. And it's just so you're perforating the cortex. It just frees it up, makes it nice and flexible, and we get a nice, easy correction. Okay, once that's done, you can either fix with a plate. You can choose whatever fixation device you like. I've used staples here. Again, that's a stepped staple, so it's just nice and simple to do. I'm drilling the far core, the distal tine, so I can get compression across it. So put the staples in, and then I'm going to use the plate as a biological fixation. You notice here I'm just checking hyperextension. Okay, so I've got the correction. Then I can just whittle away some of the bone so it fits into the defect nicely. I'm going to fix that with a couple of screws. Now you see I have to take some of the bone off distally. I've changed the position of the metaphyseal bone, so I want to make sure that I haven't changed patella height. And then just using AO technique, I'm going to lag the tubicle together with a couple of screws. No washers. I really don't want to have any... I want to have good compression, and I don't want to have any issues with hardware. You can use... These are just using 4.5 millimeter screws. You can obviously use three or four other screws, like the 3.5 screws as well. Here's something that we use an awful lot of. That's local infiltration, so it's a mixture of catorlac morphine and rapivacaine. We do that routinely for all osteotomies. I'm giving a gram of tranexamic acid at induction, and obviously antibiotic prophylaxis. Okay, so you can do this super tubicle as well, so you can leave the tubicle intact. This is really helpful if you're doing this with ACL reconstruction. Okay, and I'm going to buzz this on, so I want to make sure Armando's got plenty of time to give his talk. So we'll move on a bit. All right, but so just there's an option there. This is just a little bit more challenging to do, because the tibial tubicle is right in your way. You've got to work around your patella tendon. Okay, but I'll often do that as a biplane cut, not a biplane correction here. Okay, and you have to take a little bit of wedge bone out from the undersurface of the patella of the tubicle, so that when you close it down, it doesn't act as a buttress. Okay, so considerations, and Neil's already covered this, in terms of actually what you're looking for with the hinge axis. So we can think about where you place that hinge, and that's certainly where PSI really comes in to help you do multiple corrections. Lots of results, mostly from studies from Europe, regarding anterior closing wedge osteotomy. Small case series, they generally do okay. Okay, but these are complex patient selection. This is our data, so myself and Volker Mosel put our data together. We're in the process of trying to publish this. We've actually got 23 patients now, when we combined with some of my colleagues in Banff, and essentially we can do very well at changing the slope angle. We can certainly improve anterior tibial translation, but a lot of the time the patient reported outcome scores are not that great, because we're actually working with patients who have had a second or third failed ACL reconstruction. Okay, when we're looking at a sloping coronal plane, I already mentioned this. This is a scenario where I want to reduce slope, but also change the coronal. The most effective way for me to do that is an anterolateral closing wedge, rather than a medial opening wedge. I think you get a much greater correction doing a closing wedge technique, but be aware that everything doesn't have to be opening. Everything doesn't have to be closing. We use different options, different procedures for different indications. Okay, so that was just in terms of reduced tibial slope. Now here's an absolute doozer of a complication. This is a young girl who presented with ACL-PCL post-lateral coroner. She had hyperextension recurvatum, generalized ligamentous laxity. I did a three ligament reconstruction. That all stretched out, so I did a revision ACL-PCL post-lateral coroner with allografts. She did well for a while, but then unfortunately continued to stretch out, ended up with hyperextension thrust. Coronal plane was pretty good. ACL was okay, but her PCL was really just failing her. So she got a flat slope. You can see just here in the OR, you can see her PCL stretched out. She's got hyperextension. And so for this case, I did a opening wedge, took the tubicle off. So exactly the same as I showed in the video, tubicle off, do a cut. But in this scenario, just opening, putting a femoral head allograft in, and then putting the tubicle back on as a biological fixation. And I really didn't want to run into any problems with this young girl, so I put a plate on as well. It may have been overkill with her fixation, but it got rid of her thrust. You can see the significant increase in her posterior tibial slope. That is on purpose. Got rid of her posterior translation and got rid of her hyperextension thrust. So thinking about slope increasing, it's exactly the same thought process. How much you need to correct and thinking about coronal plane as well. So in summary, realignment osteotomy, it's vital, vital for us to use this. It has the ability to achieve coronal, sagittal, and axial balance and the complex needs. My first go-to procedure when I have complex pathology. And there are lots and lots of techniques that you can utilize. And with that, just to acknowledge Pete Fowler, who's the godfather of osteotomy, certainly in Canada and worldwide. And he taught us a lot of these techniques. So thank you very much for your attention. Thanks. So is there any questions for Al while we get Armando's slides up here? Question? In the lateral osteotomies, do you always take down the proximal tib-fib joint? Or how do you decide what to do with it when it needs to be mobilized? So for lateral opening wedges, you can often just release the soft tissue of the proximal tib-fib joint. As you continue to release, because you're relieving small corrections in the lateral opening, it's usually sufficient. For a closing wedge, I routinely now do a fibular neck osteotomy. I do it in a oblique fashion, so when I make the cut, as I close it down, the bone just slides. And I find that very straightforward. It's a bit nerve-wracking. You've got to dissect all the way around the neck to check the comfort of nerves. But if you've done enough cases on the lateral side, you can push lots of corners in. You can also do distal. You can, yeah. That's if you're afraid of that. That's almost a separate thing. So for the closed, for the opening ones, then you leave the tib-fib joint intact, which is cut just below the nerve, essentially. So for the opening wedge? For the closing wedge, yeah. So you leave the joint intact, just do distal on the neck. A little small bone on either side. Take a small, like a saw that I've used for a BTV, for example, and just do an oblique cut. If you do a straight cut, you're going to take the wedge and cut it out. And two cuts, a bit more hassle. An oblique cut, just on this side. What about your medial closing wedges? It looks like your fibula wasn't, your tib-fib was intact. Yes, for medial closing wedges, it was. No. No. Because you would think it acts as a strut against you. Agreed. All right, let's go. The nice thing about following Anil is you only have to prepare a five-minute talk. So I think, in the interest of time, we also only told Anil to present complications. The rest of us were, the rest of us decided not to. We're like, tell Anil to bring complications and the rest of us are just going to show our home runs. So I think if there is a summary to this talk, and I think it's been reinforced by all the speakers, is understand where your level of deformity is. And I also think a concept that I continue to work with and battle through is what's occurring to the joint line as you affect it on the femur or the tibia. We spent a lot of time, and Anil captured it perfectly. Five years ago, there were no ICLs and osteotomies, and now everything's about tibial slope and its effect on ACL rupture, ACL failure. We don't really talk a lot about the slope on the coronal plane, right? What's that joint line obliquity doing? And as osteotomy gains further acceptance, I think you have to challenge the dogma, as Al said, about, you know, varus is always on the tibia, valgus is always on the femur, and understand the deformity better. So if there is a theme of this whole ICL is do a good assessment of where the deformity is.

orthopedic surgeons

osteotomy procedures

medial closing wedge proximal tibial osteotomy

tibial slope

preoperative planning