Welcome, this is the last talk of the session. My name is Mike Alea from NYU, and we're going to be going over some technical pearls for combined procedures. Disclosures can be found on the websites, and as the gang up here was talking about, these cases can be what we call like the perfect storm, where meniscus, cartilage, ligamentous insufficiency, et cetera, tibial slope, so we have to really be prepared to know how to do all these procedures in a facile way, whether it be combining cartilage and meniscus, ligament, et cetera. So these are tricky patients, these are tricky cases, and as much as we all are up here trying to talk about the things that we need to do for patients, we have to understand that these patients are not really a cookbook. It's not like we just have the check boxes and then we're going to get the optimum result. Every patient is going to be different. Every patient is going to have different needs, different expectations, different issues, whether it be smoking, BMI, are they going to be my patients, which I'm not going to disclose who my patients are in that particular slide compared to Dr. Sherman's, who could easily be seen, but you have to understand what you're dealing with, and if you don't then you're going to be doomed to fail. So look every patient in the eye, figure out who they are, figure out what they want, and then you move from there. And then we talk about how much surgery we want to do on these patients, and there's a lot of stuff that we do. Osteotomy, et cetera, you have to think about patient comorbidities, what kind of employment do they do, how long can they be out of work for, what's their support status, I mean do they have help at home to get them around, do they have access to physical therapy, access to wound management and care, et cetera. So you know again, some of these patients we think we can make better, we can make very much worse. As Armando was talking about, never hesitate to scope first and ask questions later. You know, get as much information as you can, as early as you can, use it, integrate it, make it part of your algorithm. Write your steps on the wall. You know, a lot of these cases are huge, they require a lot of effort as a team. Work with people who know the systems, they know the instrumentation, they know the procedure. So if you've got a case where you've got a fresh rep and you've got a fresh technician who hasn't really done very much of these things, then it's going to be helpful to put your steps on the wall so that everybody knows what the next step is when the surgery is happening. Position positioning and prep is also of critical importance. You know, are you going to use a post versus a leg holder? Do you need to hyperflex the knee for an ACL or are you going to do something like outside in where you don't need to hyperflex? Do you have assistants that are capable and qualified? I mean if you're sitting there with a fresh intern and you've got this five hour case, you might want to rethink how you're going to manage things. Where's your x-ray going to come in from? Is it going to come in from the contralateral side or the ipsilateral side? What's going to make your life easiest? Are you going to use a tourniquet? Seth was saying that he doesn't use a tourniquet for a lot of these things and I would agree. I think that these are cases that you want to recognize bleeding quickly and address it quickly. And then the use of TXA, which I do very routinely. I do a ton of multiligament surgery. They all get TXA. I don't have any data to prove it, but I think it works. High tibial osteotomies, DFOs, they all get TXA. Unfortunately, we just finished a control randomized study looking at TTOs at our institution. We found no difference. But considering that TXA is so cheap and so small of a risk profile, I think even though my paper doesn't show any difference, you could still use it and not have to worry about the consequences. And then you have to look at tibial slope as well, which is sort of like the elephant in the room that I think people tend to overlook when we're looking at these complex problems. So considerations for combined procedures, and these are important. Number one, should the aspects of the procedure be staged? You don't have to do it all in one setting. If your help is not really with you, then do you want to do six or seven hours of surgery on a patient? They've got a higher risk of compartment syndrome, higher risk of neurovascular complications, infection rate, et cetera. Be cognizant of that. Know your order of business, what your steps are, what you're doing first, what you're doing second, what can go wrong at each particular part that might throw off the rest of your game plan. Surgical approach, which thankfully for these knee procedures are not particularly difficult in the technical pearls. So we can start with some cartilage restoration with valgus malalignment. I mean, the same would hold true for varus malalignment. This is a case of a 30-year-old female with a failed attempt at a prior OCD repair. You can see the large osteochondral injury on the lateral compartment. You can see that she falls into some slight valgus alignment. So this is a patient that might benefit from a distal femoral osteotomy as well as a cartilage restoration procedure. So in my algorithm, and we're going to be moving a little quickly here. So if you guys want to get a copy of this talk, by all means, just email me. I'm happy to send you this. But does this need to be staged? I don't think so. We can do this in a relatively facile manner in a quick amount of time. But we have to understand what our order of business is. How are you going to address the cartilage with respect to the osteotomy? So osteochondral allografts, like I think Armando was saying, that's sort of like my workhorse for cartilage. If I'm doing an OCA, like a bulk osteochondral allograft with an osteotomy, I will do the OC graft first because that cartilage is resilient. You can move the knee around and flex it and maneuver it however you want and that thing is not going to go anywhere. As compared to a MACE or a surface procedure, where if you do the MACE first and then you start mucking around with the knee, you might displace the MACE, you might have some issues with that. So typically I'll do a MACE last when I have to do any kind of surface restoration like this. This is a surgical approach. Make an extensile approach for any case that you're doing combined because we're not looking here trying to be cute. We're trying to be good. So if making two or three extra inches on that incision is going to make your life easier, then do it. Don't hesitate. We always like to say take what the defense gives you and that really kind of holds true for these kind of surgeries. And then approach obviously is the key for easy access. So this is a combined DFO with a lateral OC graft and you can see we've got a pretty large incision going through the IT band. And then what you can do, you don't have to make a separate incision for the osteochondral allograft. You just hop over the lateral collateral ligament and make your joint arthrotomy right on the other side of the lateral collateral ligament. You put in a few Z retractors and you can get great access to the cartilage on the lateral side. You could easily do your osteotomy plus your OC graft in one incision. Obviously lateral side can be tricky because some of these lesions tend to be a little bit more posterior. So you have to be ready to hyperflex and gain some access to it. But these are cases that can easily be done with one incision and you can get pretty good results from it. Varus malalignment and cartilage, the same rules really apply for me. Osteochondral allograft before osteotomy and osteotomy before MACE. Do an extensile approach and again don't make life hard on yourself. Another combined case that we see often, if we thankfully don't have to add an osteotomy to this, can be some kind of cartilage restoration procedure with meniscus insufficiency. So take this case, a 19-year-old male with a prior subtotal lateral meniscectomy, unstable displaced osteochondral lesion of the lateral femoral condyle. So this is a patient that you're obviously going to want to do some sort of meniscal transplant or meniscal preservation procedure with an osteochondral injury. So again this is only two procedures thankfully, but do the procedures need to be staged? Probably not in this one. Again the order of business, we'll do our meniscus allograft transplantation first and then we'll proceed with our osteochondral allograft. We tend to make a relatively small arthrotomy for the allograft procedure and then we extend it for the cartilage portion of the procedure. Scoping can be difficult if you have a giant incision in front of you. So again that might make your life easier doing the meniscal allograft transplantation first and then proceeding with the osteochondral allograft or the MACE secondary to that. So the medical pearls for this, you're going to want to protect your anterior horn of your meniscus transplant when you're doing these procedures. Again if you have to hyperflex the knee, the anterior horn can be at risk for this. So you know you don't want to muck up with all the work that you did. So be very careful and very cognizant of it and then you can obviously get a relatively good outcome with that. Different case, 17 year old female. When you start adding malalignment into this problem, like the terrible triad of joint preservation is malalignment, meniscus deficiency, and cartilage damage. So you can have a 17 year old female, prior subtotal lateral meniscectomy, lateral femoral condyle grade 4 lesion, valgus malalignment, the terrible triad. This is a procedure that you can stage easily and in my book I don't see any problem with staging this. You can do your osteotomy first and then come back and do the other stuff later. But if you want to do it all at the same time, what we would recommend is doing the meniscal allograft first, typically using a bone, like a bridge and slot technique because you know you don't want to do a meniscus allograft, have some sutures down there and then cut right through your sutures when you're doing your osteotomy. So you have to realize what your technical pitfalls could be with these particular cases. So we'll do our meniscus allograft first, then do our resilient osteochondral allograft, then do our osteotomy after that. So again like I said, it's probably better to use bridge and slots and no tunnels for these kind of cases. You do need to crank on the leg for a meniscus allograft, so if you're doing it at the same time, do the meniscus allograft first because you don't want to crank on a fresh osteotomy because you could just fracture right through there. And any cell-based cartilage procedure, and again the same thing holds for me, I don't know if it does for you guys, but anything cell-based we're pretty much doing last. Surgical approach, again, you know start small and then extend as needed. And again this is just a, you know, this is one of those cases where you do all three in one time. This patient received a distal femoral osteotomy with a meniscus allograft and a relatively large second-generation ACI. Then we start talking about ACL insufficiency with malalignment, again something that we're going to encounter very significantly. This is a 27-year-old male, prior subtotal medial meniscectomy, medial compartment DJD, varus malalignment, the question of whether or not you want to add a meniscus transplant to this kind of patient is up to the, in the eye of the beholder, it's user-dependent. Should these procedures be staged, honestly I don't think there's a need to. You know your implants, you know the pitfalls of each implant, you should be able to do it all at one time. What we typically do, we do our intra-articular work first when we're doing ACLs with osteotomies. You can drill your femoral tunnel, then once you've drilled your femoral tunnel you can do the HTO, fix it, and then do the tibial tunnel last. You want to know where your plate is going to sit and how you're going to drill your tibial tunnel, so be very cognizant of where that plate is going to sit, respective of your tunnel, respective of your osteotomy. We make a standard HTO incision for this, you got your basic scope portals, it's not going to be a very difficult approach. Like again, going back to what Seth said, I do all the intra-articular work off of tourniquet. Save the tourniquet if you need it for the osteotomy portion where you could have some bleeding, but let the tourniquet down before you close because if you encounter bleeding you want to realize it before you close the wound. That way you can get a good closure and not have to worry about the development of a massive hematoma, infections, etc. The other thing I would caution everybody to know is what the tibial length you're going to need is for the ACLs, so when we start doing these osteotomies you might change the respective length of the tibial tunnel of the ACL, so if you're doing an all-inside technique or if you're doing traditional, just have that thought in the back of your head that you're going to need to get the appropriate tibial tunnel. And again, knowing your implants is important. I mean, going back to this slide, and I use both, I use locking plates and I use inset plates. You know, for a locking plate you want to make sure that you have enough room outside of the hardware that you can get a good tibial tunnel in, or if you want to use an inset plate like this you can actually use one of the holes for the screws to make your tibial tunnel and just put a cortical fixation device at the end of it. This is a different case, this is a 22-year-old male with a prior subtotal medial meniscectomy. This is ACL and medial meniscal insufficiency, so now you're doing ACL with meniscus transplant at the same time. Again, no need to really stage this, you can do them all at the same time, but for this kind of case we'll use bone plugs instead of a bridge and slot technique because if you're doing your bridge and slot technique and then you drill your tibial tunnel on the ACL you can compromise the meniscus transplant that you just made, so we'll typically use bone plugs for this or you can use an all-soft tissue meniscus transplant, which is certainly gaining traction as well. Our order of business, we'll first start with our intra-articular work, we'll drill our femoral tunnel, then what we'll do is we'll do our posterior meniscus root tunnel, pass and seat the bone plug, pass the meniscus sutures, drill the tibial tunnel after that for the ACL, and then fix your anterior horn of your meniscus allograft last and tie your sutures and then you do the tibial side of the ACL. So it's a lot of work on this, I mean these are cases you have to know every step right on the board just so everybody's prepared. Something that hasn't been said today is pie crust the MCL for these cases, do it early, do it often. If you don't have experience pie crusting the MCL, it's very easy. For me, you can go anywhere you want, for me I'm going right off the tibial aspect of the joint line, a few poke holes posterior medially with some valgus and you can get an easy five millimeters opening on that side without destroying the entire integrity of the medial side of the knee. So you know this is a case where you can see we've opened up the medial side of the knee, this is a meniscus transplant with an ACL, we use these retrograde reaming devices to pass our bone plug through there, see it's very simple to get that, then we pass our meniscus plug through there, subsequently pass a bunch of our sutures, we won't tie our sutures until the end because you do want to have anterior and posterior fixation on your meniscus telegraph before you start tying those sutures down, then we'll do our ACL after that. And then we start talking about issues with sagittal malalignment. So tibial slope is critically important when you're looking at instability and this is a great case, this is a 23 year old NYU student who failed three prior ACLs and they were all done well, but her tibial slope had never really been assessed. Her slope in this case was about 16 degrees, so this is a case that we wanted to do an anterior closing wedge osteotomy with the revision ACL. So you could easily do an anterior closing wedge osteotomy in these kind of cases, you can pop off the tubercle and then put it back on at the end of the case if you want to keep your patellar height what it is, but you can otherwise risk ALTA for this because you're actually loosening the extensor mechanism. You don't want to do these procedures in cases where the patients already have a significant amount of retrovotum because you will increase that retrovotum and increase their risk of popping the ACL again, or at least if you're going to do an ACL at the same time. So this is a case that we did an anterior closing wedge osteotomy, fixed it with these three compressive staples, and then put a new ACL in there afterwards and ultimately the patient's gone on to do very well. We got about a 10 degree correction there. This patient did not have coronal malalignment, so we didn't need to do a biplanar osteotomy, but always be cognizant of this. This is a different patient who had a PCL injury as well as sagittal malalignment because he had pretty much a negative slope. This is a patient who was 16 years old. He had an anterior fiseal bar presumably from some sort of tibial tubercle fracture. He came to me from a different country. It's one of the joys of being at NYU is we see a lot of pathology from a lot of different places in the world. This patient had a negative tibial slope. He probably had about 30 millimeters of posterior translation. It was extremely significant. This is a patient that would benefit greatly from a slope changing osteotomy. Again this patient wasn't in significant coronal malalignment, so we didn't have to do a biplanar cut, but again this is a case where you want to pop off your tibial tubercle. You can do an anterior opening wedge osteotomy right through that. Then pop your tubercle back down at the end to preserve your patellar height. You can get an x-ray before and after to make sure your patella is still in line with Blumensatz so you're not changing the patellar height too significantly. When you're done, if you're doing these kind of procedures, what's really critical is after you finish your osteotomy you should stress the knee again, whether it be for the ACL or the PCL because a lot of times you won't even need to do the PCL or the ACL. The osteotomy will do the work for you. In this particular case we got about 15 millimeters of translation corrected from that, but it was still pretty significant. We made the decision, okay, we're going to put a PCL in on top of that. We changed the slope significantly, did a PCL as well. This is fresh out. I don't have any clinical updates for you. I literally did this case a few weeks ago, but I'm sure the patient's going to do fabulous. The discussion that you have to have is that all these patients have various lesions and you have to have a thought process for all of them. Your thought process is not going to be the same for every single case, but the thought process is the hardest part of these cases. Technically, they're not very, very difficult. We know that we can get these patients better. Like Armando and Rachel and Seth were saying, it's hard to make a 90 into a 100. It's a lot easier to make a 40 into an 85, and the patients tend to be really, really happy. Know who you're operating on, know why we're doing the surgeries, and you can get very good results. Carefully think through the procedural steps, choose the best approaches, execute your plan, be the quote-unquote hero. Something that I think is very important, and I love having partners that are extremely helpful, I scrub in on my partner's surgeries, my partner's scrubbing on my surgeries. Never ever hesitate to get an extra set of hands with hard cases with tons of steps. There's no joy in trying to do a surgery for seven hours yourself and then watching it fail or watching a serious complication. But what you do get joy out of is turning a five-hour case into a two-hour case with an optimum result. For us, some of my partners and I, we do all these hard cases together because we all have the same operative days. Just do it together, you have some fun, and you bang it out. Never hesitate to have some buddies help you or vice versa, because if you are doing this with an intern or a PA who doesn't know anything about what your steps are, that's going to be a tough case. You do these cases with someone who knows the steps inside and out, who's thinking the same things as you the entire case, and you're going to have a better outcome, better result, and more fun doing it. With that, I say thank you to all.

combined procedures

orthopedic surgery

patient needs

preoperative planning

teamwork