All right, so in keeping with this lovely experience, it is quite cathartic actually. So this is a 30-year-old male recreational basketball player. He had an ACL, hamstring autograft, postrolateral meniscectomy 16 years prior. I did not do that one. It was obviously done quite well. Four to five years post-op, he started to have some instability, doesn't really recall any trauma, but for a few years he was doing well and then it doesn't feel like it was right. And then had continued rotational events, lateral joint line pain, impact activities. Range of motion was normal. He had a 2B Lachman, 2-plus pivot. He had tenors palpation laterally, 1-plus effusion, SANE score was 60. I will say it was a combination I probed him deeply regarding, is this pain or is this instability? And he said it was absolutely both. So here is pre-op images, 30-year-old guy, Aaron. Yeah, so, you know, clearly has some post-meniscectomy arthritis in the lateral compartment that's now led to some valgus, you know, acquired malalignment. So this is one where, you know, you're looking at a big surgery. If he's failed appropriate non-operative management, we have to correct the alignment. You probably have to add a meniscus. We get more information on the MRI and then revision ACL. Anyone do have other thoughts, Armando or Justin? Same for me. Same. Okay. And do you all do this? Well, let's go to the MRI before we get into that. Okay, so here is MR images. Armando, just change your thoughts. No, I mean, I think that the things that are going through my head right now, obviously that lateral compartment is compromised, you know, as is typical. It's all posterior where predominantly lateral meniscus looks pretty diminutive, extruded peripheral osteophytes. I may not be thinking articular cartilage restoration in this patient. I'm probably going to offload him. My gut looking at that hypoplastic lateral femoral condyle and joint line obliquities that it's going to be femoral. I would want to do some deformity analysis. But as that thought enters my mind, it's like, I need to revise the ACL too. And I think that doing an ACL reconstruction with a DFO is a little bit challenging. So and I'm an opening wedge kind of guy. So I would probably think about staging this or doing a closing wedge medially just because that's a lot of burden on that lateral femoral condyle. So those are the thoughts that are going through my head as you begin to present this case. So deformity analysis, lateral proximal tibial angle was 82, medial proximal or lateral distal femoral angle 82, medial proximal tibial angle was 87. Yeah, so it's a femoral deformity, right? So in my hands, this would be a lateral opening wedge DFO and a staged ACL. Like I would probably bone graft just because I think that would have a conflict with my femoral tunnel. I think I'm just not as experienced with a medial closing wedge. It'd be very reasonable to do that. So you can allow them to bear weight and you would take the burden off the lateral femoral condyle. And you can do it in one stage. But for me, it would be lateral opening wedge DFO staged revision ACL. Yeah. So you could do either side of the femur. Your lateral plate tends to sit anterior. So I've done many ACLs after, you know, lateral opening wedge DFO and you're posterior with your ACL femoral tunnel to your plate. So either medial closing wedge, avoid the lateral, you know, real estate altogether or lateral opening would be reasonable. Do you do them same stage? You know, this one, I probably would do them as two separate surgeries. One is I would want to make sure he has meniscus deficiency. I would want to look at the cartilage, you know, would he benefit from an osteochondral allograft, lateral femoral condyle, all that information you can get at the time of the osteotomy. Justin, any additional? For me, I would be medial closing wedge and ACL. And I would not do, you know, plan the meniscus or anything cartilage at that first stage. And then that would be what I would come back for if needed after the osteotomy. Okay. So here is scope pictures. You see a very pretty medial compartment that didn't really line up. And then the lateral at that center, when you can ignore it, just the middle condyle looking good. And then the lateral side is as already described, posterior wear, as you would expect, pretty severe. The meniscus looked not great for obvious reasons. So what we expect to see is exactly what happened. So my plan, do this in one stage, be the hero, did an ACL, revised his ACL using the same tunnels, which were reasonable, with a BTB autograft, and then medial closing wedge osteotomy. So I put my pins in, and this was sort of how I typically do it. I've changed it, and we'll go to that in a little bit. But this was my game plan. And then I'm starting to put my plate on. I put my distal screws in, and I'm really happy with my alignment and very proud of myself. This case is going great. And then I zoom in, and then I see that hinge fracture. So I recognized it this time, and not happily recognized it this time. And then at this point, he's starting to break out, and it had some stability. But then my game plan was, I'm checking realignment. I have my plate, and I'm like, oh, maybe this is going to be OK. And then it starts to rotate and slide. So it wasn't just a little hinge fracture at that point. So it completely cracked out and was now rotationally and translationally unstable. That's a tumble fix you have in there too, right? Yep. Yeah, it's a pretty robust plate. What's that? It's a pretty robust plate. It should be able to tolerate. So something's going on. So the proximal screws weren't in. Oh, I got it. OK? I put the plate on. I closed it down. I put my distal screws in first. And then we were looking at the x-ray. This had happened before I put those screws in, to be candid. But the proximal screws were not in. And then it starts to slide. So at this point, what would you all do? I mean, hinge fractures on the femur are way more challenging than hinge fractures on the tibia, in my opinion. Because it's a much bigger bone. The distraction forces are much higher. They tend to get a flexion deformity as the hamstrings pull it down. So it's a very unstable situation you've got going on here. As opposed to a hinge fracture in the tibia, which sometimes your plate can tolerate it, you can leave it alone, or you put a little staple or a little two-hole plate. So I would probably, I mean, you've got a tumble fix. A tumble fix, in theory, should be able to withstand the forces of a hinge fracture. I would finalize my fixation, get reduction, and come back and fight the good fight another day in terms of doing the revision ACL. Okay. So do you open, well, the ACL's done. Oh, the ACL's done. So that's your screw from your new ACL. That's my screw. Yeah. So I'll show you. If you go back, see that button up there? Yeah. Oh, I got it. That button was the previous hamstring. Got it. Got it. So the ACL's done. Yep. Yep. So we're down that road. I'm trying to understand your fracture pattern, what you're dealing with. So it's distracted and rotated. Okay. Aaron? Anything? Do you go laterally? Yeah. I mean, if you recognize that hinge fracture intraoperatively, you have to do something on the distal femur. You know, proximal tibia is inherently stable. You have all the collateral ligaments. You have the fib joint. The distal femur, you know, the rotational forces going through it from the hip all the way down to the distal femur are incredible. So if you recognize a hinge fracture, you absolutely have to treat it. So I would make a lateral incision. You could put a small plate. You could put a couple staples. You know, whatever you felt comfortable with, you know, getting that reduction. The hard part here is, you know, the question is your femoral fixation, you know, distracting that fracture at all, you know, is there any malreduction on the medial side? You just have to kind of assess all of those things before adding your plate laterally or staples. Well, this is why we do these, because I'm learning as we go here. Because actually, in Travis, I just showed you mine the other day, where Interop did a closing wedge with an ACL and had a hinge fracture, but it was stable. Like it was easy to bring together, no rotation, nothing. I just threw my TomaFix on, and I walked out of there feeling pretty good about myself. So now I'm scared by Aaron and thinking if I should have done more. And then a side comment, you know, what I'll do, Travis, in fear of this happening, is I'll take a little two millimeter pin before I throw the plate on and just put two little poke holes into the medial cortex so that if I become rotationally unstable, at least I have a little map of how to get back to what was there before I messed it up. So I love that comment. One of the biggest issues is the rotational instability here. It doesn't really happen as much on the tibia, but the femur it does. So the two pins, those pins you see here, they're actually four pins. So two anterior and two posterior, and that's how I do my osteotomies to make sure that they're appropriately aligned. Those allow me also to make sure that I can line them up if this had ever happened. So at least I planned for something horrible to happen, and when it did, I had that to lean into. Do you always go bicortical? Do you always go all the way through with those guide pins? No. Not anymore, anyway. So there are a number of retrospective changes that I've made, that being one of them, actually. So what Armando's talking about is seeing those lovely pins all the way out. I thought at the time, this is going to be great. It's going to lightly weaken that cortex and going to help me. Not a good idea, actually. So we'll get to the nitty gritty of this. So this was my game plan. So at this point, I basically lined it up. I closed reduced it. I did not go laterally. Closed reduced it and shot a K-wire across it. I actually opened it back up initially to allow it, because when I closed it would distract effectively, sort of like a seesaw effect. So I opened it up and shot a K-wire percutaneously from proximal to distal, and then closed over the K-wire, allowing the K-wire to become the hinge to get where I wanted to be, and then plated it at that time. So you can see the plate sitting way off the bone, which is not where you want it to sit. But I did not want to do anything other than that. Now Armando talked about the tomofix being an extremely strong plate. It is. I would agree with Aaron. It would definitely be biomechanically more appropriate to put a plate on there. But I didn't at the time. Maybe I should have. I don't know. But this is his final alignment, which I was happy with that. I did not love the plate sitting off the bone that far, but that was just how it needed to be. So here's him three months. This is the beauty of closing wedge osteotomies. They heal, and they have incredible structural stability, actually. And this is him seven months post-op. So he healed it. As you can see, the plate is out, because he hated it. Usually you don't have to take medial closing wedge plates out, but this one sat so far off the bone that he did not like that. So it healed up well. He did fine. It ended okay. But I talked to him about it, and I told him what happened. I explained why the plate's not in the zip code of his bone, and he understood that. So that was what happened here. A few points now. So he's doing great. I actually operated on his other knee and fixed his other ACL, not with an osteotomy. He was not super excited about doing that again. He didn't need it anyway. But he's doing okay. So here are my thoughts. Interestingly, so we published on this a little while back after this, and you can see now the pins are not perforating the lateral cortex. I've distalized them somewhat, actually. So those previous pins, as you saw, were a little more proximal. Not surprisingly, the more proximal you get, the more cortical you get, and the less plastic the lateral side becomes. So moving your pins down allows that hinge fracture to happen less frequently. The other thing is I've since revised it, even from this paper. So I'll widen my pins so they don't converge so soon, actually. So one of the biggest issues and one of the mistakes I made in this case was to put my pins so they touched laterally. So if you think about this, and I should have known this, but if your pins touch laterally, you actually don't take away bone with the saw, because the pins stop your saw from getting over. And they stop it sooner than actually taking the bone away laterally you need to, to close. So you effectively have a little wedge of bone that you're trying to compress. You're not hinging on the lateral side. You're compressing that bone, and it effectively books open the lateral cortex. So I've now opened up those pins so they don't actually get that close. There's about one to two millimeters of distance between those pins, and I watch my saw come in to make sure I'm removing an adequate enough bone laterally to hinge on. So as far as distal complications, Armando talked about doing lateral opening wedge. Those can have, those lovely things can have it happen too. You can get arthrofibrosis, painful hardware, hardware failure, nonunion. You can get cortical fractures, hinges, etc. It doesn't matter which side you do it on, to be honest with you, Aaron mentioned you can go either side. I completely agree with that. I do both. But if you need to do a lateral opening for limb length deficiencies or something of that nature, completely fine to do it. It's more comfortable for you. Totally fine. We looked at this, did a systematic review and looked at survivorship. Frankly, they're the same. People talk about lateral opening wedge. Even last night at my alumni function, like lateral opening wedge, I'll go to nonunion. That's not true. In fact, nonunion rates are pretty similar between the two, even though you'd think it would. As far as hinge fractures, turns out it wasn't just me trying for this solution. Others have too. An ounce of prevention is a pound of cure. This group actually published the hinge point and found a similar situation, which is if you drop it down in the inferior margin of the metaphyseal flare, you can reduce your hinge fracture rate. They had a union achieved in all patients. They also did this little maneuver, which I thought was pretty amazing. They put it in before, before actually closing. They shoot this pin from distal to proximal and then bend over the pin and pull the pin out after putting the plate on. I thought that was pretty neat. They actually prevent the problem, and if they do have a problem, they don't have to fix the problem because it's sitting on the pin anyway. This is what they do in every single one of their medial closing wedge osteotomies. Shoot that pin and then close it down, which I may start doing, honestly. I haven't done it yet, but in preparing this talk, I found that interesting. That's my lovely experience. I will tell you, hinge fractures will happen. The goal is to recognize them intraoperatively. If you do, you can fix them. I may go laterally in the future, but I might start shooting that pin. I don't know. I'll have to think about that. Two technical points. One is, Olivier described that as the golden pin, and I use that on every single osteotomy now. You can place it prophylactically, whether you're doing the tibia, medial, lateral, femoral, medial, lateral, and it really does prevent that hinge fracture. The second thing I've done on distal femorals is making a biplanar osteotomy, not a biplanar correction, but actually making an anterior phalangeal bone because then rotationally it's solid, even if you do get a hinge fracture. Those are two things that are quite simple that you can do to try to improve so this doesn't happen. Additionally, that phalange allows you to stay low and avoid the trochlea because that's always a concern as you get lower is that you're coming across and you're coming right above the top of the trochlea, so if you do a biplanar cut, you can avoid that. You get better surface area for healing, but I do a biplanar cut too. The only thing I would say on a biplanar cut, so I had one intraoperative complication, so if you make the biplanar cut, you just have to make that phalange longer than is going to be your correction. So for closing wedge, it doesn't matter, but if you geometrically make that anterior phalange the exact same height as you're going to open it, then the defect will fall in and you'll have a completely unstable distal femur, so I found that out the hard way intraoperatively, so just make sure that phalange is long enough, longer than your opening wedge. Wonderful. Any questions from the audience? All right, wonderful. Well, I think we'll cut it there. We had a couple more, but we're right up against it, so I wanted to thank our panelists for laying out their sins for everybody to share and appreciate your participation and attention. Thanks.

surgeon

case study

ACL surgery

complications

osteotomy