David Dejour from Lyon, and David will show you a beautiful technique, so pay good attention to how to do the slope correction. How, when did you, like here, Anil just mentioned, eight years ago there was absolutely nothing on osteotomy. Now we have competing osteotomy courses. Last year we had a big life surgery and all this. When did you start correcting the slope in the ACL people? 1991. Nice. But you have seen the son of a very famous guy. You see another son from a very famous surgeon, and my father started that in 1991. And we published, but in French, in 1998. So it started a long time ago, but for sure we improved many things in that field. So why should we worry about the steep post-artibial slope? Because bony morphology in ACL deficiency is definitely very, very important and fundamental. Because you have the notch, the notch could be narrow, you have the congruency between the femur and the tibia, but the slope is definitely one of the biggest risk factors for an ACL tear. Why you can rupture your ACL? You have some extrinsic factors for sure, but you have some intrinsic factors. And I will really focus on them, and especially on the tibial slope, and you will see how tibial slope is important. So when you ask for standard X-rays, what do you look at? Of course you look at the second fracture, you will look at the patella height, the trochlear dysplasia, but also the tibial slope and the static anterior tibial translation. Because while you are walking, you will put, if your slope is important, you will put some stress on your ACL, and you will have a static anterior tibial translation. So this is something very, very important to look at. So wake bearing, sagittal X-rays are really fundamental. How to measure the slope? You have different type of measurement. You can use whatever you want, but you need also to precise which type of measurement you are using, because the values are totally different from one technique to another one. We use the proximal anatomical axis using the 10 or the 15 proximal centimeter of the tibial shaft, and it has been mentioned and proved that it's the most reliable technique that you can use, better than taking a long axis X-ray. The normal value is 9 degrees, and this is the first step to look at the slope. Then you can also look at the slope on the MRI, because the MRI will show you what we call the soft tissue tibial slope, because the meniscus, those wedges, could be removed before, and could increase the functional tibial slope. So it's interesting to look at, but frankly the values are not so precise, and there is a high dispersion in terms of measuring the tibial slope on the MRI, because the cuts are pretty short. So this is a primary intrinsic factor for ACL rupture. We have many studies showing that the threshold is something about 12 degrees. So intrinsic factors plus acquired factors, I mean the meniscus, will increase the autostatic translation when you walk, and it will increase the strain and the tension in your ACL. So there are some shear forces, and you have some compression component, and then shear forces, and then this could stretch and rupture your ACL graft. I'm speaking mostly about revision ACL, because your graft is not so strong at the beginning, and if you allow the full weight bearing on a person who has a high slope, you will stretch the person, your graft, and probably you will end up with a graft failure by fatigue. It's not a biologic failure, it's a biologic failure because the mechanic was wrong, and the mechanic was not very performant for this knee. So, for example, this lady, she re-ruptured her ACL eight months after surgery, while she was coming back on the field. Why? Because she had a 14 degrees tibial slope, and while she was walking, she was stretching her ACL graft. So if you go on the literature, you will see that the slope increased mostly all the different parameters in the biomechanic of the knee, increased the pivot shift, increased all what you are measuring when you face an ACL. So we did two studies about slope and meniscus and the static anterior tibial translation, and definitely we have seen that the threshold was about five millimeters, and when you do your ACL graft with the same rehab protocol, at that time we were allowing the full weight bearing after surgery, but you see that you will not change, the ACL graft will not change this anterior tibial translation. So, for sure, what is important is the bone, and the bone is also fundamental. So, what to do so? When you face an ACL tear, now you have to evaluate it in detail, for sure, the history of trauma, amount of instability, x-rays, MRI, et cetera, but it's also, and it's very important to look at the environment of your ACL, and especially the tibial sole. So the treatment planning is also to repair your ACL, of course, whatever the technique that you are using. The associated procedures, for sure, are very important, but the osteotomies is part of the treatment. So take your ruler, take your goniometer, and measure all the different parameters. This will allow you to protect your graft and protect your patient. Osteotomy and ACL, and it comes also from the vet literature, and it's very important because the dogs, and the big dogs, rupture their ACL, not because they are playing soccer or football, it's because they stretch the ACL, and they have ACL rupture by fatigue. So the treatment of an ACL in dogs is the deflection osteotomy since 1992. So they started just after us. So the sequences. First, when you do a revision ACL, you do your placement, you do your meniscus management, then you do the tibial osteotomy, one stage. And while you have done your osteotomy, then you pass the graft and you fix your graft. So one stage surgery is always better than two stages surgery. So this is the way to do the deflection osteotomy. First, while you do the skin incision, you have to expose quite a little bit, and yes, you need to open the knee, and to expose exactly the upper part of your femur. You take your graft, and then you take the landmark of the pterotendon insertion. I don't like to do a TT osteotomy. It increases the problem, so avoid that. Then you release deep MCL and the deep fascia. And when you are used to do total knee arthroplasty, you know that you will not create any laxity doing that, and you have to go very, very posterior. So don't be afraid of releasing the deep MCL and the fascia lata, because you will have the best exposure of your proximal tibia. So when you have done that, you see perfectly your upper part of your tibia, and then you will position some key wires just to reach one centimeter below the posterior part of your tibia. This is a goal, and so you will not damage the PCL, of course, and that's important. So you put one key wire each side, and then you will position the second key wire, which will give you the amount of osteotomy that you will do. We use the one millimeter, one degree. It's a rule which works perfectly. And when you will do your cut, you will cut below the upper key wire, so you will never go in the joint. It's very protective. And the second, you will be above the second key wire, so you will reach perfectly the posterior part of your tibia. It's very important to use a fluoroscopy to position your key wires. This is the key, actually, to prevent any problem in terms of the posterior inch. So while you have done that, you go all around your cortical. You have to go slowly. It's not an easy surgery, but don't be afraid about the nerve. Don't be afraid about the vessels on the posterior part, because your key wire will protect you, and you know that you will not go to posterior. Then you do your second cut, and you will end up with two wedges. It's good to go a little bit biplanar, and to cut just behind your pectoral tendon, because it's not well exposed part. So then, you see, it's moving. So the inch is perfect. So if the inch is good, you take your wedges, middle and lateral side, and then you will be able probably to close the osteotomy. You see, this is a revision ACL, and you will, at that time, you can remove also the metallic screw, which was here at that time. So easy to do. Don't waste time by removing the hardware before. You do it when you have done your osteotomy. Well, so easy. Then you push, and you close the osteotomy, and you see it fits perfectly. Maybe because of this video, but it goes easily. And then two staples. You don't need to use a big plate or things like that. Not necessary. It's very, very stable, and the posterior inch is highly stable. So two staples are okay to fix your osteotomy. You use your fluoroscopy tool to check the amount of rejection that you have done. It's very important to check because sometimes you undercorrect. Most of the time, we undercorrect, so you have to be aware of that. So when it's done, you put one staple on the middle side, another one on the lateral side, and your surgery is done. Then you pass your graft, and most of the time, you have to redrill a little bit the tibial tunnel because the tibial tunnel is always on the osteotomy level. So not a problem. You go mostly with your hand. It's better. And then you pass your graft, and you fix it. So this is the deflection osteotomy. Some results. We published in 2015 a midterm study. We published recently a 7 to 15 years follow-up. Definitely, we had no re-rupture, no new surgeries, no meniscus injury. I would say that this surgery really stopped the natural history of your ACL. So it's highly, highly protective. Of course, you have a little bit of arthritis, but finally, not so much. So the deflection osteotomy is the best way to correct your graft. And to stop the natural history of your ACL tear. And you have seen before that the slope is very important, and when you do a closing wedge, usually you reduce the slope. When you do an opening wedge osteotomy, you have a higher risk of increasing the slope, so you have to be very careful of the slope when you do a correction on the axial alignment. See you in Milan 2024. Thank you. It's another one of these videos that when you watch it, it's like, okay, that's great, let me go home and do it. I can tell you when David showed me this a few years ago, and again, you know, I was wiped off the stage over at the W Society at the last, I don't know, six years ago meeting. Like, why would you correct the slope? That's a dog operation. The first time I went back to Pittsburgh, I did this procedure. It looks so easy, but the real estate, you have about two centimeters from the joint line to the patella tendon insertion. And of course, Freddy sent all his fellows in the room, you know, one, like, no, no, don't do that. Don't send everyone to watch me fail on this. I've done it since. I do take the tubercle off because it's easier for me. You said you don't want that, and I understand it, because there's an ununion risk, there's unnecessary risks. Do you do this in second ACL failures, or have you done it in primary ACLs when the slope is really crazy? Several steps. We started to do that in a second re-rupture ACL, so the first study. And the results were so encouraging that now I do that very often in the first re-rupture. Anytime you have a slope more than 12, anytime your static anterior translation is something like 10 millimeters, because I know that I will face a failure. And we will publish soon a new study about that with a higher number of patients. So, for sure, when I have a young sports guy with a slope of 13 millimeters, 13 degrees or 14 degrees, I say, wow, I will do a normal ACL and I will probably see him again in two years. So I feel guilty. And sometimes I do primary few, but maybe this is the next step. And maybe we will do like in dogs. We will do only osteotomies. And can you clarify for everyone, when you say static anterior translation, can you tell everyone how you actually measure that? Because I don't know that many of you are doing telos X-rays on ACLs. Is that what you do? So we do telos, so dynamic X-rays, comparative side to side, and we measure the anterior tibial translation like you do on a KT1000 or other devices. But we also always do lateral X-ray, true sagittal, weight bearing, 20 degrees flexion, and the fluoroscopy to have the two core lines aligned. And then we measure the anterior tibial translation, tibia from femur. And this is what I was talking about, the five millimeter threshold, is something important to allow your patient to have full weight bearing, partial weight bearing, or no weight bearing. Because if you have anterior tibial translation more than five millimeter, frankly, you stress your ACL graph. So I do not allow the weight bearing immediately. Thank you so much, David. All right, Al Getgood is next. Oh, you have a question? Yes. Yeah, go ahead. That was a great talk. You made it look really easy. How do you manage the patellar tendon insertion tibial tubercle? You made it look really easy without doing an osteotomy of the tibial tubercle. Did you undercut it and just kind of work around it with the ronger? Yeah. You have seen on the technique, so I go medial lateral, and then I do like a B-planar osteotomy. Because you are right, just behind your patellar tendon you don't see too much. Sometimes when you try to close the osteotomy, you cannot. But you cannot because you still have some bone behind. So with a ronger, you go behind and you can close your osteotomy. But frankly, adding a TT osteotomy to that surgery, it's taking some risk. Don't do it. And actually, I'm just going to ask real quick. I'm going to ask Roland Becker. So David goes above the tubercle. I go through the tubercle. I just find it easier. Maybe I go back to your technique when I graduate another 10 years of learning. You go distal to the tubercle? How? Why? I mean, it's different. You mean not slope correction. You mean if I do an open medial osteotomy? So we did it above the tubercle, but that's what I said yesterday. Actually, we changed it, and now we go below because it's increased stability. And this even allows me to ask whether the patient can actually put weight on very early after three weeks. I start very early. When you go below and you go closer to the diaphysis, are you worried about healing potential since you're more away from the metaphysis now or no problem? No, because it's a bioplanar osteotomy. So the osteotomy, basically, which I'm doing is still at the same level. But the second cut, basically, is going not above. It's going down. And there's just enough strength. So I'm not worried about this. Great. Thank you.

slope correction

ACL surgery

ACL tears

tibial slope

deflection osteotomy