you a few cases just to kind of pick everyone's brain and to discuss about it. This is a girl who is a bit syndromic, had a stroke early in life and this is basically a neuropathic sort of valgus. She is very high-functioning and is in working life and basically not quite independent but high-functioning. Now for the young people in the room you know you wonder I mean the valgus has nothing to do with that slope you know but because she is neuropathic and after stroke she keeps falling and falling onto her tubercle you see there is no tubercle because she keeps smashing it so it arrested and therefore she had a reverse slope. So 12 degree you know minus slope and valgus was about also about in that order 12 degrees. What will you guys do? Will you tackle this all at once and I should also preface this by saying that they came to me and wanted me to do it but they saw your partner and our friend you know Rodsbrook who's a brilliant surgeon and who does illeser off surgery but they were turned off by the fact that you know for a few months you have this external frame on you which is probably the slicker way to correct all of these you just plug it in and go and dial. So what do you do here Al? So first up clinical examination I'm going to do a rotational profile because they can often be torsional abnormalities here. Yeah. Second thing very complex deformity so I'm going to get a CT scan I'm going to measure all of that I think the more information that you have in these scenarios the better. I'm going to presume just looking at her x-rays but it's a bit of a presumption that she's got femoral valgus and that she's obviously got that slow problem so I'm going to double level. I would most likely do a medial closing wedge in the distal femur, an anterior opening wedge and the proximal tibia. It looks like she's got tibial valga as well so we may have to look at possibly trying to correct that as well so this is a really important one for doing deformity analysis. To do the anterior opening wedge I take the tubercle off much easier you can then do the correction graft it with a femoral head put the tubercle back on use that as a biological plate fixation you can fix it with a plate or staples and then yes I do everything in one go but then take the rehab very very slowly but that's all bearing in mind I don't have the full deformity analysis. Right so on a CT scanogram this is only within a few degrees what's your threshold when do you go through the femur and do a derotational osteotomy on top of your valgus correction? Wow now we're getting really complicated so you can do so we've just done a systematic review looking at what the sort of the threshold would be and so first off you've got to understand what technique you're using to measure because they all give you different different numbers which is really confusing so use one technique and then stick with it I use the waddle edge technique and I usually use it by 25 degrees of femoral torsion a femoral internal torsion and then about 30 degrees of tibial external torsion but then that obviously you have to think about what they're presenting with is this is anterior knee pain versus patella instability it's lots of things to think about if you're trying to correct a multi-planar deformity you can do it through a single cut but then you change the obliquity of your cut but I think we're probably getting into a little bit more of it you know when you actually do that rotational correction then it'll correct both the axial plane on the coronal plane right so it gets pretty it gets pretty complicated then you go more than 10 degrees in rotation and get really into like very tricky fields now would you go and actually think about it is a rough and yeah she does have versional abnormalities you're creating two unstable osteotomies you're creating a floating knee so I would really be hesitant I mean Al's got more cojones than I do but I would certainly use a frame here or I mean you know you know or a lengthening nail I do it a lot with with Austin Rob but I think it's if you have another plane that's that you know because you have you just that's it's a floating knee that's that's complicated so David talking about the goal for your slope I do agree that when we're talking ACL you're talking high slope correcting it seven is normal I agree with over correcting so I kind of follow your lead there and I usually shoot between two and five now here you a minus 12 I've done this procedure twice and lost the hinge in the back twice got away with it twice what how many degrees will you correct that slope I will go back to an a slope of two to two to five because you cannot reach the nine the nine degrees a normal value and on the anterior covetous to me you have to do a TT or so to me it's mandatory if you do not that it's almost impossible and you will end up with a patellar inferior so it's on that case mandatory and then you put an allograft in the front or whichever structural graft closing the tubercle back onto it that all good enough for the fixation or do you add like I did this big plate no here again I use only two staples and two screws for the TT yeah yeah we lost that hinge she was flexed for quite some time but in the end got away with it and liked it just a question about that case maybe I'll you can answer you decide to do on the middle on the lateral side for the femur if you go if you are if it's a big surgery is that much is a little bit better to go on the medial side for boning healing so I usually go on the medial side because the healing is better in her case the leg length discrepancy I wanted to go and open her so she isn't she had already like a two centimeter discrepancy I mean this is this is as you can imagine you know somebody that that that walks like this and hyper extends with it right so and so therefore I went lateral I don't like lateral at all because most of the time I have to take that plate out yeah and they're often yeah it causes a lot well you get an increased tension on the lateral side within the IT band so I think it's a it's a good option here to try and increase leg length but the medial side certainly more stable and less painful so this is a this is a actually a very good friend so I never like operating on friends and I haven't done it yet I want to ask your opinion on this but there's somebody who saved my life four years ago now he wants me to save his knee so he's you know 55 is very very active masters level swimmer but also hiking and about 20 some years ago I had the medial menisectomy and was fine with that for many years but now he can't really walk without pain he can even swim without pain he has this medial overload loss of medial cartilage on both sides meniscus is extruded and there's only a remnant and we have about a five degree varus unilateral Stefano give me your magic this is the case that we discussed yes before so I think in this case you should do a smite the osteotomy valgus osteotomy closing wedge in this case and then you do a meniscus transplant if you want to have in a 55 year old without cartilage in your hands that's a cartilage in this case is a little bit too maybe it depends on what he does because what he wants to do this guy because the problem is what they want from your knee so he's a surgeon not orthopedic but he's a surgeon in the operating room every day. He wants to hike, he wants to go biking and to be in the OR without pain yes I mean he has he doesn't have unrealistic demands. In this case for me there is the right indication for doing that what you would do David yeah would you do a unit? I don't know but if he wants to go fast in OR the unit is probably a good option because he has an ECM, he has no deformities. I would say that it's probably one of one of the best indication for a unicompartmentally orthopedic. I still think it's never a good idea to put a union when on your weight-bearing x-ray you still have a joint space so his it will take a long time for his bone his bone has not I called scleroticized enough to take an implant so he will in five years I agree love a uni when that compartment completely collapses but his knee is still in a blister with the bone maridema it's not a callus I never put a union until it's a callus of the of the medial tibial plateau to support it. I'm sorry I didn't include the PA flexion weight-bearing but he has a relatively nice joint space this is a weight-bearing lateral. Just ask for a shoes x-ray because on this patient he might have a bone on bone but an osteotomy is of course a very good option especially if he's active but if he wants to go back fast to work you know we all know that it takes three months four months sometimes and we do a physical work so he's like he's like work patient and on this it's fun that you are doing closing wedge osteotomies on small deformities and opening in big deformities I do totally the opposite so my deformity I do an opening wedge osteotomy not to have a big bone on the medial side not to over tension my medial compartment and when I have a big deformities I do a closing wedge osteotomy which is so good. No this this is good in so right now he has a brace I'm sorry for this case I don't have an answer yet this I'm asking you and then maybe next course next year I'll show you what I did right now he has a brace so he can hopefully come back and I know in Germany we used to do a lot of the lateral shoe lift like what what what do you do it because it has really an effect you know on the loading of the knee as well so slightly insoles where you elevate the lateral part of the foot yeah that's the first what I'm doing and there are some studies have shown actually the effect is quite similar than doing the brace test so in this case I mean I I would consider probably you need to be honest and I would do an embrace test first see how it goes and because that's this for sure that's an intra-articular deformity so and normally that what you're not really able to address with osteotomy you guys are all not helpful you know uni media opening and closing and and I can tell you in Berlin he never did an injection ever ever ever here in Pittsburgh I do an injection right and left right and left he does not have any effect of the injection at all because it's this bone it's not the joint so I'm gonna do a media opening wedge osteotomy and at the time you have this shitty little meniscus remnant I don't know that I want to put a transplant in will you send centralized the meniscus in this case no okay why not you could he's osteoarthritis this is an osteoarthritic knee so for me this is an osteotomy I don't do you knees I would I could refer him to my one of my colleagues to do you know I can guarantee you they would not do it because they hate you knees in London Ontario so I will do I will do an osteotomy here but I would not add in any biology I wouldn't do a transplant I wouldn't try and centralize just because of the disease in his joint he will do great one second with an HTO he will do great and he will absolutely love you for doing an HTO for him but it's gonna be tough so don't send him to Leon don't send him to Brandenburg just do the operation he'll be fantastic you guys will be best friends give me one more so I need to ask you Ichi so Koga described the centralization for exactly this now we've taken centralization and do like root repairs like Aaron Critch showed yesterday and be doing this for the meniscus transplant but this is the patient that he described it for do you do centralization and in Japan on on on these types of patients that's it okay so send them to Kobe there's one other point is that thank you I always think you have to respect the final operation which is a replacement I would definitely do an osteotomy here but I would not do anything in the joint I stay extra articular you don't want to and you know if I put tunnels and put suture if I did a meniscus transplant or any fake cartilage here you're just you just yeah you're just violating the joint that doesn't need to be violated you know I would just offload this knee or inject them forever until he gets a uni but you know that the overemphasis of doing intra articular work you're just exposing a need to infection hardware suture gunk which is just I would just do an osteotomy you wouldn't even scope him no yeah because you know what you'll see there if I have a good MRI no yeah no I agree I agree I any questions from the floor because this is the case you see all the time okay so maybe one more case I guess you can all sort of guess what we're doing here so but this is a 23 year old that's actually a pretty smart kid so he drove all the way down from Erie because it's easier to drive south than take the ferry boat and go north which is where you are so and he had two allograft ACLs done he's 23 and he had an allograft and it failed I'm sure all of you when you see an allograft failure and you know the tunnels maybe whatever they are gonna go to a different graph but no they did another allograft and he's smart enough to ask the question you know why why does it keep failing is it because it's allograft I'm like yeah but I mean you know and but he also has this right so it would be a very much of a knee-jerk reflects to say all right they did two allograft ACLs right they put it a little bit anterior a little bit high you know whatever have you let me just do or quadriceps or whatever autographed but then you have this slope of 14 degrees not the highest slope I've ever seen but I don't want to ask David because we know what David would do right absolutely in one stage so can I just so do you one stage or two stage I mean when I was in do you all I mean everybody unanimously we're working on the slope here yes all of you you have to you know slope is still a big that he just gave you his post-operative protocol that's a it's not it's it's it's not a benign procedure and you always have to think I mean to do two allografts on an athlete under 25 years old to me is malpractice it's just so it's really hard to you know if the kid had a BTB or you know it's so you have to put that in the equation he had a two inferior graphs and had no attempt at mystical preservation so I'm not saying I wouldn't address the slope you know you're saying a 3b Lachman so that you know you know yeah so so that's that's what's probably you know his exam is gonna drive me but when I have an inferior graft a 14 degree slope you know I may try to cheat but but that's one of the factors you have to always consider the problem I have is not only the slope it's also that the tibia is interior now I don't take these stress x-rays but even without a loaded x-ray your tibia is interior how you're gonna but you don't need it it's not a stress x-ray you can just have the patient weight bearing with a lateral view and you will see anterior tibial translation and I'm presuming that's not a weight bearing view is that a weight-bearing view doesn't look like it so my bets are there's more translation if you're seeing a Lachman like that your whole envelope soft tissue envelope is all stretched out this is a chronic problem so whilst I agree with you putting in a better graft will help you can't then just think that you can depend upon that graft because this knee is perched so we need to do something bony I care about the physical exam and whether it's a physical exam you're doing or it's your dynamic physical exam on an x-ray that you know don't I can put a line anywhere I want to put it you know so whenever I want to do an osteotomy I make it 15 or 16 slope and whenever I don't I make it 12 no so I'm gonna open a whole another can of worms Stefano will you do you know you do the over-the-top technique then you avoid these half in half out tunnels and then you go with the graft all the way down back to the tibia Gertie's tubercle and do your lateral plasty will that be effective in somebody who has a 14 degree slope I probably should take in consideration to do my technique but also deflection of the other meals okay okay this case yes okay but okay so I mean we're kind of running out of time this is what we ended up doing you see this ACL was obviously completely busted a little bit partial medium and a sectomy there too so what we ended up doing is a slope correction we lifted up the tubercle and then did about a seven degree correction so we didn't over reduce them too much and then I know you're saying this is malpractice but I did another allograft because I like the over-the-top technique and the Achilles allograft we've just recently done a nice outcome study on this we have a really low failure rate with this but the idea with the over-the-top position is you cannot malplace the femoral tunnel because obviously you're not doing a femoral tunnel you're very very anatomic and so that that is what we ended up doing and the slope correction now if I hadn't done the slope correction I would never do another allograft but so this is this is what ended up happening so okay I mean it is it is absolutely anatomic it really is and you can you can get away with doing a single stage here because you're using an over-the-top I would do the same in many in many instances and the tibial tunnel for me is the thing that's probably going to drive whether I do this as a two stage or a one stage if the tibial tunnel is good then I'm going to do both at the same time if the tibial tunnels bad I would do the osteotomy bone graft the tibial tunnel and come back in a second stage ACL and so this is another beauty of the Achilles allograft I don't want to make this an allograft talk but you can change the direction of your bone block on the calcaneus and put the bone block such that the tendon enters anteriorly and so a slightly posterior tunnel can still be quite anatomic so anyway I mean we can probably keep talking and talking about lateral procedures allografts autographs I think this was a great course I really appreciate all of you coming thank you please put in an evaluation and then we do it again next year thank you

neuropathic valgus

stroke

falling

osteotomy

external frames

treatment strategies