Thank you Volker, thank you to be with all these great speakers. So let's speaking about lateral closing wedge that is, as Volker says, is really the old fashioned technique. So these are my disclosures. So the 8 goals, the HTO goals is to unload the affected compartment, stabilize the joint, decrease pain, protect the meniscus and delay TKA as much as you can. And if multi-planar correction you should do in all planes. So the amount of correction is important. If you do under-correction you have a poor outcome and you have recurrence of deformity. You should shift the mechanical axis. When you have a post-meniscectomy syndrome I normally go for zero axis. Can I have treating OA cases? Maybe I don't reach Fujikawa plate but normally I go about 50-55% of the width of the tibial plate. So there is also important to see that this type of procedure has been really decreasing over the years and there is an increase of opening wedge IT bilosteotomy. So definitely we saw more and more less of this type of surgery that I think is really in fact effective and I still use it sometimes even if I have now a national grant about opening wedge IT bilosteotomy. So I am forced to do opening wedge. So there is no really consensus but this meta-analysis that shows 9 studies with more than 600 patients no significant difference in pain and survival rates and there is unable to point out which technique is superior. So we are really similar in results. And for me there are different surgical indications. You have to think about the amount of correction that you need and also to the length discrepancy of the leg lengthening discrepancy that maybe you can choose one or the other one according to the lesion. So the osteotomy I think it depends on correction required, arthritis stage, ligamentous instability, preoperative leg length, weight, age activity level of the patient and tibial or femoral torsion and lastly surgeon preference. So you see when I do combined surgery I prefer to do closing wedge because I have more space to put my tibial hinge. And also we need to consider that if you do an opening wedge you normally have an increase of lengthening of the leg of more than 7 mm almost and closing wedge you normally have a decrease of lengthening of 4 mm. But what I can say from my experience right now I saw more patients that they do an opening wedge they complain a little bit about the leg lengthening respect to closing wedge but I have no any complaint about this leg discrepancy. And clinical examination is the key so to assess the alignment in all the three plane you have to observe the gait, detect the far thrust if there is one, evaluate ROM and flexion contractor, examine patellofemoral joint and check stability and obtain an MRI in order to see if there is a good indication or not. I normally do this because in our end we prefer to use closing wedge when you don't have to do a high correction because I think in this way you reduce the risk to have a problem when you will do a totally after the ward and for big correction we normally go for opening wedge. So the closing wedge has I think some advantages, you have lower hardware related problems, you don't have to remove the plate as it happens on the opening wedge, you have no bone graft, you have autologous bone to bone healing so you have a faster recovery and for me it's easier to combine with additional procedure. And these are the results of a closing wedge IT Velosteotomy made by Olivier and in 2020 and you see that even at 20 years follow up you can have a very good results reaching about 80% of good results. So the contras are the peroneal nerve injuries, this is the only risk factor of this type of surgery and you can have disruption of the proximal syndesmosis of tibiofibular joint, difficult subsequent TKA as I say, you have a bone stock loss and you can pay attention to the breakage of medial cortical hinge. So this is my procedure, it's quite easy, simple, this is one of the part that is more important is to release the nerve and you have to check the nerve and cut the annulus fibrosus that goes from posterior to the anterior tibial fossa and then you deperiostate the joint and then you put some retractor to protect your vessels and then you put two pin, the key wire, the first one is normally parallel to the joint line and you have really you go close to the metaphyseal part to have a better correction and the second pin I normally go perpendicular, I start perpendicular and then I go to reach the position. So in that case you check and you do a correction of the joint to reach the correction. You see this was not a big correction, then you have to do a second cut on the top to have a maintaining of the length of the patella tendon and then you remove everything, you do this cut of the anterior part and then you remove and then what you do with the fibula, I normally do the same amount of resection of the fibular head, in this case the fibular head bone is very soft so you can eat with the ronger and I normally put protection with the finger of the nerve that is very close to this area. So this is the only tricky point of this type of surgery and then at the end you go with the scalpel to reach and to maintain the fossa and you can really arrive to the protection and maybe you can even cut the bone but you have to maintain the periosteal on the medial side. Then you close and I normally use this type of staple that is a crackle staple, it is from Smith and Nephew but normally it is on the trauma part so it is normally, even Smith and Nephew doesn't know if they have this type of staple, I don't know why but and then you are finished so it is very simple, very quite easy surgery, you just have not to do a second incision on the fibula to go inferiorly and then at the end you have a nice correction and you see and I normally have a nice opening of the medial part of the joint on this way. So this is my results of the series that we just evaluated just recently, we didn't publish yet. We have 51 patients with 6 bilateral, preoperative Kelger-Lawrence 2.6, age of surgery 46, target correction was neutral alignment so at more than 10 years follow-up, survivalship is 84%, we have only 8 cases that convert to TKA, 1 UKA and 2 revision HCO, no OA progression this is important so at the follow-up you have Kelger-Lawrence 2.8 and VAS activity was 3.1 and Lyson score 79.5 and especially it is important to see the alignment, you see that the alignment you just have slight 3 degree varus at the long-term follow-up and you can see the joint-like congruence angle that is important is just 2 degree so it is really correcting. So I think at the end I think this is a less performance than in the past compared to opening wedge. My first choice is in correction under 55 of varus and combined procedure, this is my choice because I think I can have a really very easy access to all the medial part of the knee and good to excellent clinical outcome and high survivalship at long-term follow-up. Just be careful to avoid the nerve and you have to have some tricky things to avoid this. Thank you and I invite everybody to Bologna and to Milano. Very nice, this is really a beautiful procedure especially the way you showed it, again make it look very easy. It is a little bit of a forgotten procedure because we go so much to the medial opening wedge and you can probably potentially be slightly more accurate that way but then this procedure will allow you much more your ACLs, your tunnel placement, etc. Can you tell us when you have a case, when you do the HTO for varus, you have an ACL too and you would like to correct the slope just a few degrees, is it easier to go on the lateral closing or on the medial opening, what is your opinion or what is the amount you think you can achieve? When you do a closing wedge of steotomy you normally decrease the slope a little bit automatically so you have not to, if you have an ACL and I normally do sometimes, I do meniscus transplants, ACL and osteotomy all together in one time and in this case I really protect with the closing wedge the ACL because you have a decreasing of the slope automatically during the closing wedge and I don't know, I haven't done yet the deflection osteotomy of David. I think it could be nice to do, especially in revision case, I think I will do starting on the revision case to do, I don't think I will do in a primary case. How about the other three panelists in this scenario, you go medial opening wedge to correct, you showed a case, Anil, where you were able to correct seven degrees I believe, that seems a lot to me, in my hands I have a hard time with the medial opening wedge to get that many degrees of slope, how do you do that? Before I met David, I was always doing opening wedge and I have done about maybe 25 and it's hard to do but you have to destabilize your posterior lateral hinge but we showed on paper that you can get about five degrees. I had got seven at times but it's technically demanding, where with the closing wedge you can get like ten degrees, so I mean, but I don't, if they are avarice to me and they have a slope problem, you can certainly get five degrees up, you know, you just have to take your time and if your PSA died, you can really put your hinge where you want it to be. Also, it depends on also… Opening wedge slope correction, because then you're talking about, I mean, remind us of that case the other day where he did a pure sagittal and a femoral osteotomy, so then you have two, you know, a double level wedge, I don't necessarily think you always have to do, so you shouldn't throw out that thing. Also, it depends on how you put the blade of the saw, so if you just open up a little bit anteriorly, so you just incline a little bit the saw blade when you do the cut and you can correction automatically. When I think about PSI, you know, this is really, the nice thing is, you will be able to exactly place your hinge where you need it to be able to change that slope. When I look at your procedure, I'm thinking how much would it slow you down to do PSI, do you… I know that, I can tell you one thing, I have now a protocol with a company in England that I did the opening wedge osteotomy with personalized jig and really personalized plate and I do with this company a closing wedge, the jig, cutting jig and also really planning of the osteotomy to have a correction for the closing wedge. And in this you can have a better control of the even of the deflection of the osteotomy. Very nice. I'd like to talk about the triple varus knee for a minute. So if you have a scenario where your PCL is out, your corner is out, whether it's a revision case or whatever it might be, and there's a varus, obviously you assess it with a gait analysis, you see the varus thrust, you know that a post-adult corner alone is not going to work there. Are you concerned in a scenario where in this case maybe the peroneal nerve is already somewhat compromised to go on a lateral closing, would you go medial opening, does it matter? Is there, you know, that fear of the peroneal nerve change anything? In this case probably you can do the medial joint opening, but if you want to do closing you have just to pay attention because the nerve is important to really release these annulus fibrosus and also sometimes you have to check when you do with the ronger the cutting of the fibula at the same level, you have to pay attention that it doesn't move when you are closing the tube plane to be not a movement of the fibula part. So sometimes what I found in one case is I check at the x-ray and you have to check if the fibula is really complying with the same amount of the two parts. If you have a motion of this fibula part posteriorly, then you can have a problem. I think that's a great point, it's a very important point because you can obviously either dislocate the proximal tibia joint, you can go lower, you can use a saw, so this technique of using the same amount of cut on both the fibula and the tibia at the same level I think is an important thing you need to respect. Closing wedges to me is a very good option, it's an option. You have some indication for opening wedge, you have some indication for closing wedge. And the problem with the closing wedge is that there are no nerves. Don't be afraid about the nerves. Yes, you have to look at this. This is our work, this is our profession. I normally go with the blade just touching the nerve. And you have no problem with that. Don't be afraid about the nerve when doing an artery or scalp surgery. Yeah, absolutely. I mean you expose the nerve on every case, it's the same whether you work on the medial elbow or on the lateral knee. So, very good key points. Any questions from the audience? Please. In a case of chronic posterolateral harm, in a patient who has native varus, say 3 degrees, how would you think of handling that with osteotomy? Would you go lateral closing wedge or medial? With the posterolateral, normally I do opening, ITBL opening. For me, I can do both in a normal way. So, for me it doesn't matter, it depends on the case. Really, I choose depending on the case. And I have to do now a lot of cases with the opening wedge because I have a national grant of this and I... So, this is a perfect indication for the closing wedge. The posterolateral action. Because you can feel the pressure. Very good. So, how would you determine how much correction you would go for if the patients, say, contralateral say they're in 3, 4 degrees of varus. What is your goal to achieve in terms of correction? Neutral. Don't go over correction in this case. You've got a possibility to jump out from conversion. Yes. I mean, the most simple way of looking at it is just a lot of gapping. So, you've got 4 millimeters of gapping on the logical part and then you're effectively 2 millimeters on the other side. You take the 2 millimeters off of your correction. So, the most important thing is you have to take that into consideration. Because if you don't and then you just apply your osteoarthritis as normal, you'll get over to a neutral position and then you'll fall over into a more overcorrected position. Instability patients, 8 in varus. Yes. I totally agree. So... Yeah, that's one of my first disasters and cases on that list that I usually give to the fellows at the end of the fellowship year, the 10 cases I wish I'd never done. And one of them is an overcorrected revision ACL where I went strictly into a slight valgus position. Hated it. Hated it. Went all crazy on it. So, what you see, you know, this little ACL is really... I mean, I love it. So, this is... I've done it every year now for the last, I think, 6 or 7 years with you guys and I learn every time. You realize that who you're talking to here is a knee surgeon, not necessarily a sports medicine surgeon, not necessarily an arthroplasty surgeon, but a knee surgeon. And I think this is key. So, one of the elephants in the room is obviously what happens to the TKA later. Would you, you know, is there... Would you rather revise a lateral closing or a medial opening to a total knee? It depends on the case, but both they can go to do a total knee. If you do in a closing wedge, if you have a high correction and when you have the step of the plate that is quite big, when you have a big correction, the amount of destruction of the tibial axis is really high. And in this case, you can have some problems. So, you need to do a prosthesis that you can have a sort of medialization or lateralization of the press fit. Offset, right? Yes, offset. Any other pearls from you? You do total knees quite a bit. No, I don't do total knees, but... No? I mean, I have to know about it. And I have listened to my brother when he revises it. What you have to also think about is your soft tissue envelope. What can be understood about incisions, right? A lateral incision and then you have to make another medial incision. You know, his incision is beautiful for your exposure, but it's not, it's a little bit more and you have to make a new incision immediately. So, for the most part, opening wedge osteotomy is single stage total knee. Closing wedge osteotomy, just because infection is so bad, I usually take that plate out first and then let the wound calm down and then they come back and do a total knee. So, I actually, my dad is pretty clear that an opening wedge is superior to conversion than a closing wedge. Yes, it's easier. Yes, definitely it's easier. You're restoring bone, offset, incision. Well, if you make your, if your start point for a closing wedge is more distant and then you do a biplane cut, so you go behind the tubercle, you can drop the level of your osteotomy, you don't get a cortical mismatch and you don't change the offset process. Yes. That, and you realize that his biplane cut on the closing wedge is not any of the historical closing wedge osteotomy. No. That's a huge difference to historical. And the correction you can get is much less. Yeah. Very good. Yes, please. Can the panel talk about the bone substitute options for opening wedge procedures? Yeah, very good. You know, I was just going to say we didn't talk much about bone grafts. I'm glad you just brought it up. I saw one x-ray. Neil, maybe you can comment. And obviously on the latter closing, no, but. No. Yeah, first of all, well, one thing, if you ever do a level osteotomy, you get a free one. But the other thing I'd say, I always use Connor Evans Wedges, Soto Knee Mac. And I've never had a problem since then. Every time I've tried to use, and I've also now started using Ceramint. I'm a consultant for them too. It's a very good product that really forms bones. There's a lot of basic science data about that. On your. If you fade bone, it doesn't turn into bone. On your medial opening wedge, at what number of correct, how many millimeters of correction before you even put bone graft? Or do you put bone graft on everywhere? There's a hole there. I want to fill the hole because, also I want to fill the hole because of bleeding. So I want to fill that hole because I don't want. To have a bleeding. Yeah, yeah. So it's not just for the bone, it's also tamponading the interosseous blood. Some tibias bleed more than others. Obviously, postoperative management is a huge deal. When I talk to my European colleagues, well, it's not such a big deal. But then my patients start swelling up, come to my office without crutches. I'm just not sure where the disconnect is. Do you agree that filling in a void that you created just for the bleeding part is a good idea? How about Alan, David? So, at eight millimeters or lower, I didn't put anything in. And the, I mean, bone doctors are doing plus medial opening wedge, osteology for years, with no bone grafting. And I don't think you'd roll in these. No, I prefer it, really, I don't use bone grafting. So you don't need it. When I first started doing it, medial opening wedge, I didn't use bone graft. But it took longer for the, for the, to heal in. If you used a 20% plus, for example, 50% of our class had to come in. So now you're looking at a really fast, very, very fast thing to heal up. So eight millimeters or more on bone graft. And it's holograph chips. Very easy, very simple, cheap. Yes. I still like substitutes. Horrible. Don't use them. No. Substitute them. MTF, it's an MTF con, a legend. It's actually a pre-converted way. I'm thinking, so, and those are certainly BMAC. Cerumen is the one that I've been playing with. It's injectable based. And, but, for the most part, all my delayed unions have always been historically with fake bone. So that's. Yeah, I mean, we use a lot of allograft in Pittsburgh. I can tell you that, you know, every once in a while I have the patient who doesn't want an allograft, whether it's in a ligament case or in an HTO case. So iliac crest, I think, is the original gold standard. But, you know, I agree with the eight millimeters is what my threshold is. Yes. Can you talk to us real brief about the post-operative management? How many days is that patient in the hospital? How many weeks are they on crutches? Normally. Do you brace? Normally, after the second day, they go home, normally. And they stay with crutches for three weeks. And they start with partial weight bearing with a brace. That's it. And this is similar for opening and closing wedge. And the pain management, what are you doing? Are you injecting anything after the procedure? And or what is the pain management? You do some injection. But normally, this type of patient, they don't feel so much pain after third day, fourth day. They can go without any pain control. No opioid like in here. Yeah. I actually think a single level osteoarthritis is less painful than a BPD. I think, you know, taking your attention, I think there's more pain than a single level osteoarthritis. Good. I just wanted to put this slide up to show like a very young Anil and David. That is fantastic.

lateral closing wedge technique

high tibial osteotomy

alignment correction

opening wedge HTO

pain reduction

joint stabilization