you guys are describing. I think there's indications for different techniques. And I think hopefully you'll hear from this morning is that we have different techniques for different indications. And you just need to be facile with all these different techniques. So I'm gonna be talking about DFOs and double levels. Okay, so no matter what we're doing here, the general indications for neo-osteotomy remain the same. And this is just a very simple diagram really covering the majority of what we do for when we're doing alignment corrections. And I think that's really been talked about a lot already. I think one thing I talked a little bit about this yesterday is this sort of whole concept of orthopedic dogma. And I think we hear an awful lot of this is that if you have a varus knee, you should be correcting it on the tibia. If it's a valgus knee, you should correct it on the femur. And of course, we're moving away from this now and thinking more along the lines of doing a deformity analysis. And some of these new systems where we can actually measure out all these different angles and determine where our deformity is and then correct that deformity in the appropriate level, I think is a very, very important thing to go through. And with some of the more advanced computer-assisted programs, we can actually do the osteotomy digitally and you can see how that affects our joint, okay? So with our preoperative planning, we look at the type of pathology, the site of the pathology. We measure our angles. We can look at our long leg alignment. We determine where the deformity is and then we're gonna work out how to correct it. And this slide is just a little bit crazy, but all it really shows is that you've got lots and lots of different options to correct different types of deformities through closing wedge, opening wedge, anterior. We can go in the femur, we can go in the tibia. And so lots and lots of different options, okay? But I don't need you to go through that in detail. Okay, what I do look for is trying to achieve balance in the knee. I want to look at the medial proximal tibial angle and there's been lots of discussion about this when dealing with, particularly in the varus knee, when we're looking at joint line obliquity. And if you look at these two radiographs, you've got an MPTA of 92 degrees on the left-hand side and then on the right-hand side, you've got that significant increase in joint line obliquity. And the question is, does that cause problems? And there's been lots of discussion about this probably in the last number of years, where really we know from finite element analysis work that by increasing our joint line obliquity, it increases shear forces across the articular surface. So that could be a problem. I think that's more of a problem certainly when dealing with ligamentous laxity, so looking at instability cases. The big question, is it a problem in the OA patients? And there is differing literature. This study, for example, suggests no difference in cartilage between patients with increased joint line obliquity versus normal, okay? And this, or is this, sorry, that study actually showed that the patient-reported outcomes were worse with increased joint line obliquity, whereas this study suggested that there were no differences. So the clinical outcome scores, we have to be aware of and we have to think about it. So my general rule when dealing with joint line obliquity, if I see a mechanical axis that's outside of the joint, so it's not even in the joint itself, I will look at doing a potential double-level osteotomy. I'm going to do my deformity analysis and work out where the correction should be. If I can just do a simple tibial correction, that would result in an NPTA of less than 93 degrees, probably do a single-level correction. If I find it's more than 93 degrees, I'm certainly thinking about doing a double-level correction so we don't have to do it on every single case. So I'm just going to show you some cases that I'm going to be doing, looking primarily at distal femoral osteotomy and then double-level osteotomy. So this is a 22-year-old. This is a guy who had a KD3M knee dislocation following a bike accident, and essentially he was in, this just shows stress views on his medial side, so these are valgus stress views. We did the deformity analysis, and his deformity is primarily in his femur. He has valgus, he's in his femur. I'm concerned if I do an MCL reconstruction in this scenario and leave him in this degree of valgus, that that will stretch out, that will be a problem. So in this scenario, we planned out the osteotomy, and I did a DFO, so I did a medial closing wedge, a distal femoral osteotomy. I staged this, so I did actually the PCL and the MCL in the first stage, and then six weeks later, went back and did the distal femoral osteotomy and the ACL in the same sitting, and he's still doing extremely well. That's a number of years out now. So when we think about distal femoral osteotomies, we have options. The lateral opening has probably been the workhorse, certainly in North America. It's an easy approach. You do one cut. You can obviously do a biplanar cut. I'm not talking about biplanar corrections. You can do two cuts. And then we have stable locking implants. But most of the data that we've looked at certainly suggests we get a lot of hardware issues, particularly with the IT band. Most patients require plate removal, and there's always that concern of loss of correction. My favorite approach now is to do a medial closing wedge, distal femoral varus osteotomy. We get really good soft tissue coverage over the plate. It's a very stable fixation. We get early range of motion, early weight bearing. Pain seems to be less of a problem. We can get these patients going much more quickly. I do these as an outpatient in our ambulatory care center. The approach can be slightly more challenging, but I'm gonna show you a video of that. And certainly with closing wedges, generally it's a little bit less able to dial in the correction. But there are a number of techniques we can even use to do that, where we can adjust as we go. So here's the technique. It's actually a really lovely dissection. It's one of my favorite procedures to do. So it's a longitudinal incision in the distal femur. We're doing a subvastus approach. So you just go through the VMO fascia and then lift the muscle up. We're then going posteriorly. We're taking the intermuscular septum off the posterior aspect of the distal femur. We get those vessels there that we must cauterize, otherwise we're gonna end up with a lot of bleeding. You can do this with tourniquet control or without tourniquet. It really depends on your own preference. I've got a blunt Hohmann retractor placed posteriorly. And then I'm just planning out the millimeter of correction. I use breakaway pins, just means it keeps it away from where I'm actually trying to work. I plan a biplanar correction and that means basically a cut in the sagittal plane and that gives us really lovely stability. It stops us from the knee from actually going into deflection or extension and also controls some of the rotation. We can then take the wedge out with an oscillating saw. The retractor is posteriorly throughout. So there's very little risk to the neurovascular structures because I've got that retractor in at the back. And then we just basically pass the osteotome across to the lateral side. I know how long the correction is or sorry, the osteotomy length is because we've measured that. And then I can take the wedge out and the wedge just comes out in one go, comes out like that every single time. Right? Every single time. Gonna love, you're gonna love videos. Now you see there, I also use the kerosene rangeur. So with the spinal surgeons, you can use the kerosene just along the back of the posterior cortex. That'll just nibble that cortex away. It's a very nice way to make sure that you've got adequate bone removal. I'm placing the osteotome right across here. I'm just doing an osteoclases. So perforating the lateral hinge and then it just closes down nice and easily. And once it's closed down, we're gonna fix it with a locking plate. Okay, so that's our, I don't think I need to show you too much more of that. That is really just very straightforward. We put a couple of locking screws distally and then a compression screw just proximal to the osteotomy site and we get a very nice stable correction. Okay, so the evidence for various osteotomies, most of the literature, there's a lot of medial closing. The medial closing technique has definitely evolved and where some of the older literature would have been using blade plates. The survivorship of distal femoral osteotomies tends to not be quite as good as high tibial osteotomies, but I do think that is changing as our techniques are improving. The biggest problem seems to be hardware removal, but as I said, that seems to be less of a problem now with using medial closing wedge. Now, we've already talked about the issues with joint line obliquity and of course that means deformity can be on two levels. So this is an example of a case with a 34-year-old female. She had bilateral valgus alignment. She'd actually had a really significant recent weight loss, so she got her weight down, but she was complaining of the deformity, but also symptoms from a lateral compartment. Okay, so here you can see there's a mechanical axis, not even inside the joint. I'm already thinking this will potentially be a double level case. So we did a medial closing on the femur and a lateral opening on the tibia. I actually operated on her cousin a couple of weeks ago and did a medial closing on the tibia instead. So we did a very similar procedure, but just did a medial closing on the tibia. So lots of different options to achieve a straight leg. So again, pearl is the mechanical axis outside of the knee. Think double level correction. This is a very interesting girl, so that's skeletal dysplasia, very short stature. Again, bilateral lateral knee pain. In this scenario, yes, I'm doing a double level, but I changed up the solution just because I wanted to try and give her a little bit more leg length. And so in this scenario, I did an opening on the femur and then a closing on the tibia. So lots of different options just to really try and achieve nice straight legs, and she's doing extremely well. This is an interesting case, and we had a 43-year-old migrant worker with a knee dislocation. So this is a KD3L, so lateral side completely out. And you can see on the left-hand side here, you can see that he's in significant varus. So this is an acute case, but certainly for Mike and Mike, I'd be extremely concerned here about doing a three-ligament reconstruction when someone with significant varus in this scenario. So I did some planning. I looked at just purely a tibial correction, and the tibial correction just increased his joint line obliquity to a degree that I wouldn't be comfortable with, primarily because I was gonna have to come back later to do a three-ligament reconstruction. So I wanted to really maintain his joint line. So for this scenario, planned out a double-level osteotomy, and that was basically a femoral correction and a tibial correction to try and achieve better balance across the knee. Now, the other thing we gotta think about, of course, is the axial plane, and we could have a whole instructional course just purely looking at torsional abnormalities. This is a 17-year-old girl with patellofemoral maltracking and anterior knee pain. She'd been to see multiple surgeons, all told her that she was a bit crazy, and really she has just a significant torsional abnormality, and you can see that just on a clinical examination during the Staheli rotational profile. And so when we do CT scanning, we can see that she's got significant femoral torsion as well as tibial torsion based on the Waddletch technique for measurements. And so in this scenario, doing a double-level correction, I've done it both in the distal femur and the proximal tibia, and you can see here on the left-hand side and the top left-hand corner, I actually put in Steinmann pins to start with and then apply an external fixator. So I've got my pins. I can put my pins in at the degree of correction that I wish, apply the external fixator, do my osteotomy cut, and then loosen off the external fixator and then bring the pins parallel. So it's a very nice, controlled way of getting a torsional correction, and then reapply the external fixator. There's no stress in the OR. Everybody's happy. I apply a plate and then move on to the next level. And so she's now had her contralateral side done as well and is doing extremely well. Now, this is actually just post-operatively just on the left-hand side, and you can see the difference in terms of her tubercle sulcus angle. She's now got a patella that's sitting much more anteriorly in the tubercle in a much better position. So take-home points, I think deformity analysis. Really, if you take nothing else from today is look at your X-rays, perform a deformity analysis, and really understand where your deformities are and correct that in an appropriate manner. We've got lots and lots of different options, closing techniques, opening techniques. We wanna try and avoid excessive joint line obliquity. You don't have to have it absolutely perfect. I don't think that the literature really supports that you need absolute perfect parallel joint line, but you've gotta be thinking about it. And as I said, there's an exception to every rule, so just use good clinical judgment and common sense. And just a shout-out to Pete Fowler, who really is a legend of osteotomy and one of our great mentors. So thank you very much for your attention. Thank you. Thanks, Al. That was great. Al, like me, is like a transplant from Europe to North America. Now, you went right above the border. I went below it. So maybe we can just kind of osteotomize it right in the middle somehow and bend it. But so you take these nice post-operative lung cassettes. Do you do that routinely? You know, it's a nice way following up your patients. And, you know, we talk a lot, like when we do cases, I usually bounce it off this group right here, send a text, what would you do? And going to a double level initially scares you a bit more. I just did this on a patient who is also a friend, you know, and I mean, you know, the femur side really bothered him for a longer time. Did you ever regret going by both levels? No, I don't think I've regretted it. I mean, when we looked at our complication data, and if you look at hinge fracture, if you look at tibial, you know, the tibial corrections, our biggest risk of having a hinge fracture is for a large correction. So anything over 11 millimeters, you significantly increase your risk of having a hinge fracture. So in many ways, whilst you're doing two cuts, doing two approaches, actually, if you can do then two smaller corrections, you may well reduce your risk of complication. I don't think any of us want everybody leaving today thinking, oh, you've got to do more and more double level corrections. That's not the message. But the message has to be that if it's appropriate to do it, then think about it. Look at the deformity, plan your analysis. And then I think that there is definitely a rule for it. But the majority of cases that we do are not double level corrections. And Neil, correct? I mean, these are relatively rare, right? Absolutely. And I think it's easier on the soft tissues, too. You know, doing, you know, you said yesterday, a 20 degree wedge, that's not, you know, that medial side is not balanced. It's, so, I mean, you are doing a deforming operation. We want to do a reforming operation. Yes, I agree. And let me just follow up on one question. You mentioned that hinge fracture. And if it's a small hinge, you know, little fissure, if you will, not displaced, and you have a nice big construct on the other side, it's probably fine. When do you go to like a hinge pin? Do you ever put it in prophylactically? I don't use a hinge pin. And I don't use that sort of golden screw technique. I worry that actually it causes too much stiffness on that hinge and actually might make it more difficult for me to open up. So I tend not to do that. I think where I'm showing you those medial closing wedge distal femoral osteotomies, because the fixation is on the medial side, you've got a tension construct on the lateral side. If you get a hinge fracture in that scenario, that's actually a pretty unstable construct. So I've got a very low threshold just to pop a staple in across the hinge. That's a really easy thing to do. It's a very small incision, quick staple, and it'll help you sleep at night. So, you know, be aware of the issue with hinge fracture, but just treat it. It's not a big deal. Nice. Question. I've been guilty of ignoring joint line obliquity my entire career. What's your upper limit of increase in joint line obliquity that you'll tolerate or accept before going to two level? I would say that originally when I first started, I would totally ignore it as well. And I'm much more, you know, I think about it an awful lot more now. And as I said, it's probably 93 degrees is reasonable. You could probably push it up to 95 degrees. And certainly one of my partners, Bob Giffin, who's got a much greater experience in series of osteotomies than I have, and he never does double level osteotomies. He's got a huge number of cases with significant increase in joint line obliquity. And a lot of those patients do well. They've published their 10 year outcomes. So I think it's something to think about, but I'm not sure that the clinical data really supports the concept as yet. But like anything, you know, we're always trying to improve our outcomes. These, you know, we've done very well. It's the classic orthopedic sort of 80 to 85%, good to excellent results, right? Well, how do we get to that 90 to 95%? Maybe doing these cases where you can really preserve the joint line, we can make our cases, our results a little bit better. We're always gonna be trying to just push the bar. And I think the obliquity is one thing, but the soft tissue, you know, if you're going two centimeters of an opening on one bone, I mean, there's a lot of stretch that happens. So I'd be careful. Roland. Just a comment. I mean, this is a big advantage when you use a tomofix plate, because if you really break the hinge, you use a compression screw. And I never actually went to the opposite side, to the lateral side, basically, to stabilize. It's not necessary. So when you compress, then you have a really stable situation. Of course, then you have to keep the patient for a while, non-weight bearing, yes, for maybe six weeks, but not longer, because due to the compression, you have quite early, actually, on the hinge side, healing, actually, of the bone. I'm just coming back. People sometimes really may avoid starting with a biplanar osteotomy, especially on the femur, which is a big advantage. It's not very difficult. And if you break the hinge on the femur side, you really struggle to get the rotation right. So, but if you have a biplanar osteotomy, you always have a landmark. Anterior, you can put a while through, even if you break the screw, and you still can do the correction. So that's very, very helpful, especially when you do the osteotomy there. If I, yeah. Hinge management on the tibia and the femur are different. You can get away a lot more with a tomofix on the tibia. On the femur, because of the lever arm, you know, if you have, I'm much more aggressive about overtreating the femur, to Al's point, than the tibia, I ignore all the time with a tomofix. But they're different. If I can, can I just make a little quick comment to that regarding hinge fractures? Just one comment. Just one comment. All right, you know, we talk about hinge fractures all the time, and concern about hinge fractures. I often see propagation to the lateral cortex from fluoroscopy, right? It's not an unstable construct. The simple rule of thumb is that when you do your opening, if you see translation, okay? So when you've opened a medial opening wedge, you see translation. That is an unstable construct, okay? So all you do is take your instruments out, see if it reduces, and it's fine. As Roland says, put your tomofix on, if you get compression, you're fine. If you have significant translation, particularly if it's gone distally or up into the joint, I do think a lot more about maybe doing some fixation. But with a tomofix, you don't have to worry about it. If you use something like an iBalance or something that's maybe not as structurally stable, another one would be like a non-locking pudu plate, which some people still use, which is kind of crazy. But then you have to be much more concerned and do some added fixation. I wanna show you a few cases, but before I do, I would like to ask David and Stefano and Roland to give us some tips and tricks. The osteotomy that I mostly do is the person that has the failed ACL, the person that has a meniscus transplant coming, a cartilage procedure, and you just add the osteotomy, and it's just a logical step that every patient will simply follow because they're already undergoing a two-hour or whatever procedure, and at six weeks of crutches, it doesn't matter. How do you approach a patient, Roland, when you have a meniscus tear, degenerative meniscus tear, where here in America, we just go and scope, scope, scope, scope, scope, and you don't. You do a media, I mean, a valgus dating osteotomy, which is a very, very hard cell. I have a hard time doing this. What are your tricks, or how does the patient just follow your lead on that? Because you'd probably do, what, 200 osteotomies? No, no, not as many. No, no. You mean if you have a virus deformity and instability? No, a person that has just a degenerative meniscus, and they have like an 80-degree varus or whatever. Yeah, I mean, in this case, I mean, it depends on the age, of course, and activity of the patient. I mean, if I'm talking about age, I'm not talking about numbers. I'm talking about biological age, and in this case, yes, I would probably do the osteotomy, and I even have- How do you convince the patient to do, that this is the correct procedure to do, and that, in fact- No, because you're telling them, you do a biological technique, and then you can tell them, but the other option would be put in union. That's what it means, and I always say, I mean, if I'm considering doing a joint replacement, it's partial or total. That's end stage what we can do. There's nothing else behind, but if you treat naturally or biological, so an osteotomy is great, and even in my area, I have people, because we have a huge running community. I even have done osteotomies, and people are doing running, and they get back to running, actually, so it's a great procedure, and it's very, very powerful. But it's nice to use the word biological. I will take that. Can you give some statement on how do you, you know, that 55-year-old, quite active person, and they have medial overload, and here they want the quick fix. Osteotomy is not a quick fix. No. How do you tell that to the patient? Yeah, but as Roland say, what you remain, if you don't do osteotomy, you just have a uni-knee, and for me to do a uni-knee in a 55-years-old boy is stupid, because... Why? No, because the uni and the total knee are more for more old people, more than 60 patients, 60 years old. I agree. So it depends on the age, and on the biological age of this patient, obviously, but I do even, I did even uni-knee even in a 55-years-old, but the degeneration might be very big. Otherwise, I think it's better in this case to do osteotomy, plus if there is the chance to put in a meniscus. Why? You just do a biological resurfacing. It's a really biological solution, a biological approach to try to avoid the metal. I agree. Any questions that anyone would like to ask? I mean, what is the indication to, you know, do the osteotomy and the meniscus transplantation? Do we do it, and sometimes you do it at the same time. So, I mean, what, yeah, so what is the indication? Not just saying, okay, I do the osteotomy. We'll see how the patient's doing. And then you wait. Yes. Yes, but why you have to give? But this is a problem of life. You have to do, if you have to do an osteotomy and wait how it goes, then you have, after six months, then you coming back and you do a meniscus. So, the patient will not be happy. So, if I have this possibility to do it in one time, in the 14 minutes, why? Why I cannot do it? 14 minutes. 14, 14. Yes, yeah, yeah, 14. One more. Yeah. I wanted to ask you, if you're decreasing slope in the setting of a revision ACL, what's your target goal in terms of slope reduction? What are you, are you going to nine, or are you going to less than nine? You have to overcorrect, like probably all the osteotomies, and my target is between two and five degrees of tidal slope using this method. Yes, yes. Because this will really make your ACL having no constraint at all while you're walking. You have to be careful with the knee that already hyperextends. That's my question. If you have to. Yeah, it's always the question. You're right. When you do that and when you do the reduction, all the time you have a hyperextension. 10, 15 degrees. And it's bad for ACL, of course. So what to do? Two things. The first is when you pass your graft, and when you fix your graft, I fix my graft at 70 degrees flexion. So I over tense my ACL. The second is I put an extension brace right in the ore, locked at zero degrees, and they keep this brace six weeks. Would you adjust your slope correction based on pre-operative retrovital? No, I don't. In fact, I don't care about the retrovital. Even if my patient pre-op has a retrovital. So the brace is for six weeks, 24 hours. They take it out for rehabilitation program, of course. They have no weight bearing three weeks, and partial to full weight bearings between three and six weeks. And then at six weeks, you end up with a patient who is almost like a normal, a classic ACL. And then you move to a ACL protocol. And so you make your knee a little bit stiff, and it goes, frankly, in the revision, in the studies that we have done, we have no hyperextension.

osteotomy procedures

deformity analysis

joint line obliquity

single-level osteotomies

double-level osteotomies

tomofix plate