I think, because that's the thing, because I think if you do your correction off the anatomic axis, you'll create problems with the mechanical axis. If you do correction off the mechanical axis, you'll create problems with your anatomic axis, which ultimately will change your mechanical axis. Which makes it a lot of fun, because there's a lot more to understand. We can, we should be. I think everybody's just running to the bathroom. I might run to the bathroom. I'll do a bathroom break, and then I'll get started. No. You see him? You see him? Yes. That's him. We're all over here. And guys. OK. Hello. We begin the session of Tibber Slope and Ligament. We have two talks and four base case. The first talk, Alan, will talk about when to address the Tibber Slope, my approach. All right, perfect. Thanks, Rodrigo. OK. So we're getting into sort of the slope session. And I'm just going to put together a few slides. There's going to be a little bit of repetition. But that means I can blast through some slides quickly so we can get on to the case discussion. So with that, some disclosures, none of which are relevant for this particular talk. So I'm going to talk about some really simple biomechanics, some indications, surgical tips and tricks, and then some case examples. So really, when you're talking about slope, we're looking and thinking about life in the sagittal plane and what happens in the sagittal plane. And of course, with our center of mass, particularly in this patient who's got hyperextension recurvotum, we want to think about what's going on with the associated ground reaction force, which is anterior to the center of rotation of the knee, which is going to create an extension moment. And that's counteracted by the posterior soft tissues. And Rob's already shown a case earlier on with biceps off. And so certainly, Frank Noyes has done a study recently looking at posterior capsule and its role in controlling hyperextension. So in this scenario, we've got an increased extension moment that can be due to a lax posterior capsule, reduced posterior tibial slope, creating hyperextension recurvotum and a recurvotum thrust. In my experience, these are relatively uncommon. But when you do see them, they're very, very symptomatic. So with tibial slope, with a PCL, certainly Andy's done some great work when he's working with Rob and Val, showing the effect of a reduced tibial slope and the impact on the increase in forces on the PCL. And of course, we've known for a long period of time the impact of increasing tibial slope on the ACL graft forces. And again, this study that Andy did, again, showing this linear relationship between increasing tibial slope and increasing force on the ACL. And what's happening with the effect of increasing tibial slope, that in the stance phase, the axial load moves the tibia anteriorly. So here's an example of a medial opening wedge HTO that's increased the posterior tibial slope. So a bit of a problem. So the slope's increased. You get some increased anterior tibial translation. And so during that stance phase, the tibia wants to slide forward and increases load on the ACL. And this has been identified a number of years ago. So that study from Mark Sherman, but really showing that increased risk of ACL injury with increased tibial slope. And 12 degrees has really been highlighted as being that sort of cutoff number that we maybe should be thinking about when thinking about slope correction. So associated with increased risk of ACL injury and then ACL re-injury. If you combine that with young age, this is, I mean, it's pretty devastating. If you look at the 20-year outcomes in adolescents with a 12-degree slope or greater, you're down to 20% survivorship. So clearly this is a major problem. So what are my indications for a slope-changing proximal tibial osteotomy? Well, slope-reducing. It's for the failed ACL reconstruction with increased posterior tibial slope of greater than 12 degrees. Okay, but I'm also looking for anterior subluxation on a lateral weight-bearing view and extension. And so if you've got a patient who's got maybe 10 to 15 millimeters of anterior tibial translation with an 11 millimeter proximal tibial slope, just because it doesn't hit 12 doesn't mean to say I'm not going to do a slope reduction. So you have to take all of these factors into consideration. And particularly helpful with the multiply operated on patient presenting with fixed flexion deformity, it can be an absolute win to be able to reduce the slope and increase their extension and get their gait performing better. Now, of course, you need to be cautious with patients with hyperextension recurvatum. You can still do it in that patient population, but you might need to do something with the posterior soft tissues. And in the primary ACL reconstruction, you probably aren't going to pull the trigger initially on a slope reduction. I have done it in some primary ACLs, but they're often in the chronic scenario where you have much more posterolateral posteromedial wear, and you're really thinking about trying to offload posteriorly and also give the soft tissue graft a chance. Slope increasing osteotomies, again, PCL postolateral coronary reconstruction with patients particularly with a chronic hyperextension thrust. And one thing I would say between the two, most of the time I find patients that present with reduced slope and hyperextension and osteotomy is treating their symptoms. It's a very, very effective operation that makes them feel better immediately. Whereas with a slope reducing osteotomy, it tends to be treating risk and risk of re-injury, which is a different conversation to have with your patients. Preoperative planning, sagittal plane correction, so lateral view of full extension weight bearing. This is really, really important to be looking at this, and you can see that you can measure slope as well as your anterior tibial translation. One thing to think about is that you can get a full tibia, so a full length tibia, lateral view, monopodal stance. Most of the studies that have identified 12 degrees as being the cutoff for pulling a trigger on a slope reduction are based on short films. If you do a long leg film, Rob's done a study that shows that those numbers tend to be higher, so the measurement of slope tends to be higher, therefore you can't apply your 12 degrees. So I often will use the short film to keep it consistent. And then a correction, Rob already talked about this, as being one millimeter to one degree. I don't think you actually need to be that accurate, because whilst at the end of the day you're trying to achieve something between six to eight degrees of a tibial slope, one thing you gotta consider is your hyperextension. So maybe we'll back off a little bit if someone already has hyperextension. So you're really trying to get some degree of correction. But we can talk about that during the session. So this is just sort of an algorithm that I work through, and this is not really evidence-based at all, but it's just sort of a way of thinking in the clinic. And so the first thing to think is, yes, you've got increased tibial slope, probably anterior tibial translation. What's the coronal plane look like? If I'm doing an ACL reconstruction, and I wanna do that in a single sitting with a small correction, so less than eight millimeters of correction, then I can proceed with a supertubicle anterior closing wedge proximal tibial osteotomy. If I'm staging my ACL, particularly if I'm doing a larger correction, I'm gonna do it with a tibial tubicle osteotomy, and we're gonna see some demonstrations later on talking about how to do that. Then you get into the slightly more complex scenarios where you maybe wanna affect a coronal plane correction as well. So if it's in varus, then with an asymmetric closing wedge, you can probably get away with maybe correcting up to about five degrees, maybe even not as much as that. These are tough corrections. And so an asymmetric closing wedge with a TTO, certainly if I'm doing asymmetric closing, I'm doing a TTO. And then if I want a greater varus correction, then I'm gonna do an anterolateral closing wedge proximal tibial osteotomy. And the valgus knee, again, smaller corrections in the coronal plane. I can do it asymmetrically, but if I'm doing bigger corrections, I'm probably gonna have to go to a double level. So an anterior closing wedge on the tibia and then a varus, and then the coronal plane correction on the femur. So those are guidelines. They're not set in stone, but it's just certainly some way of actually breaking it down and trying to work through it. So here's an example of a 27-year-old male. He's had three failed ACL reconstructions. He's got significant degenerative disease, instability, pain. You can see on his lateral weight-bearing stance radiograph, increased tibial slope, anterior tibial translation. He's in varus. So for this scenario, I did an anterior closing wedge, but with an asymmetric close, so taking more bone out of the lateral side. That means I can close down the slope and affect also his coronal plane. And he's just post-operative radiographs with a plate on that lateral side to really try and close that down. And you can see just, this is about three months post-operatively, and you can see now the tibia is sitting much better underneath the femur. I haven't done the ACL reconstruction at the same time. I'm hopeful he won't need an ACL reconstruction because to be honest, he was a disaster when I got in there. 24-year-old, again, multiple failed ACL reconstructions, soft tissue followed by patella tendon, 14-degree slope, neutral coronal plane. So in this scenario, it's really a relatively straightforward correction. Just want to do an anterior closing wedge. He wants a reconstruction and ACL done at the same time. So this is where I do a super-tubicle osteotomy. So I'm going above the tubicle. I'm doing a back cut on the tubicle. So this essentially gives me a little bit more real estate on the proximal metaphysis to allow me to do matibial tunnel, and then do the revision ACL with a quad tendon and an LET at the same sitting. And so this is him then. This is him about, I think it was about six months out. Okay, and this is just where you're looking at the super-tubicle biplanar cut. So you've got this on the left-hand side. You can see the orientation of the cut in the sagittal plane. And you have to take a little bit of, a little wafer of bone out just behind the tubicle. Otherwise, the tubicle will buttress against the metaphysis and prevent you from closing it down. Okay, this is a much more complicated case, but again, some ways of thinking about it. So multiple failed ACL reconstructions. He's got significant issues. He's got a bit of hyper, sorry, he's got a fixed flexion deformity on the right compared to the left-hand side. This is a case that operated on the Middle East. Significant anterior translation. And so big issue, again, some degenerative disease. Medial compartment is failing. He's got medial meniscus deficiency. Failed ACL reconstruction, neutral coronal plane. There's 17-degree slope on his single weight-bearing lateral view of his tibia. Eight millimeters of anterior tibial translation. I'll just buzz through this pretty quickly. His MRI showed that he had that medial meniscus deficiency. So lots of problems going on there. He had a lateral root tear. And so this was a, he wanted to do this all in one stage. So we did an anterior closing wedge osteotomy, super-tubicle in nature so we can aggressively rehab. Did a meniscus transplant as well as a lateral root repair. So lots going on in this knee, but a very complex problem to deal with. So a lot of considerations. Went to add a TTO. So large corrections and asymmetric corrections. How much are you trying to correct? Well, what are you aiming for? And how much hyperextension is already present are important thoughts. And then thinking about hinge axis, I think Neil probably talked about it in the last session, but whether you can control that. And I think when you're really getting into multi-planar corrections, this is where maybe PSI could be very, very helpful. But don't forget, anterolateral closing wedge, proximal tibial osteotomies, they're very helpful. You can really affect slope quite nicely. You can change coronal plane. So I'll just give you an example, 19-year-old female. Okay, so she had a failed ACL reconstruction as a hamstring tendon autograft, increased slope, came to her revision. She's medial meniscus deficient. And so in the first stage, we did an anterolateral closing wedge HTO, reduced her slope, corrected her coronal plane. In the second stage, revision ACL with a meniscus transplant. So lots of, there are a number of studies now that have really highlighted the results of anterior closing wedge. A couple of studies from France. This is some of our own work, along with Volcker in Pittsburgh. And really the thing I wanted to bring to your attention, most of these are second and third revision ACLs. And actually the IKDC scores are not that great, really is indicative of, it's a very challenging patient population. If you look at this German study where they've done the slope reduction in the first revision, the results seem to be much better. So certainly we should be thinking about this and maybe having it, maybe further up our algorithm rather than waiting. So slope increasing osteotomy, I'm gonna run through this very quickly. So normal coronal plane was their direct anterior opening wedge. And then thinking again about the varus and valgus, again, you can do an asymmetric opening. And I'll just give you a very quick example. So 23 year old female, this was a failed ACL PCL post-lateral corner. I'd revised her multi-leg surgery. She came back in with a hyperextension thrust, her grafts had stretched out, normal coronal plane, fairly flat slope, hyperextension recurvatum. And so I just did an anterior opening wedge correction, put a allograft wedge, and then took her tubicle off and fixed the tubicle top and bottom and then fixed with an extra plate just to give her a bit more stability. And that got rid of her hyperextension thrust and she was very happy with the results. The take home, so tibial slope, we know the biomechanical issues, is a powerful tool in achieving sizable balance. Okay, it's often not possible just with soft tissue reconstructions alone. And there are a number of procedures available to you to try and address these patients. They are challenging cases, but hopefully over the course of tomorrow, you can try some of these and you've got some real experts in the room that'll help you work your way through it. Thanks very much for your attention. Thank you. Thank you, Alan, and we begin with the case base. The first case is Stiebel, Slob and ACL. Andrew, please. Al's a lot smarter than me and has gotten that cool accent, so I'll talk more slowly and try to eat up the time here. I think he did a nice job, obviously a nice job, he's an expert on it, but giving us an understanding of why we're thinking about osteotomy with ACLs. So in my talk I'll talk about diagnosis and imaging a little bit, move on to biomechanics and clinical evidence, as Al just did, and then talk about a couple of cases. So in imaging you ought to look at your posterior slope, it's been said already today, get the same x-rays every time so you know how to measure it and you're consistent on it. Normal is 7 to 9. You can look at individually medial and lateral, you can look at this with MRI, but using a basic lateral knee radiograph works well. And this is just an oversimplification, but I think we can all think of it visually when you're trying to consider the issue with posterior slope and what it does to an ACL-deficient knee. You can imagine just a block sliding on the inclined plane and the femur is going to roll back or slide back on the tibia. And again, oversimplification, but I think if you see the exaggerated view you understand this a little bit better. Biomechanics has already been outlined. Annie Bernardson, who's in the room, looked at this with Rob LaProd, and there's a linear increase in graft force with increased posterior tibial slope, the most was that full extension. And there's a greater graft force with joint compression. And I think this, again, helps us understand that concept of the reason we have to be evaluating this. With the clinical evidence, I'll just show these two talks. One is, I think you should think of this as a tubercle-on versus a tubercle-off. So the Sondra Guttet article almost 10 years ago looked at a tubercle-off. The de Jure showed a tubercle-on osteotomy, so it's super tubercle. But not a lot of patients. And they're world-leading knee surgeons, and one had five and one had nine, so there's not a lot of data. And again, world-leading knee surgeons, several of them are here, and he just presented this. But this was 2010 to 2020, and they still only had three surgeons and 23 patients. So this is not that common. It's becoming more common, but it's not that common. So this doesn't mean that everyone in the room should go home and start doing slope-reduced osteotomies. You've got to think about it. But again, world-leading knee surgeons, there's only 23 patients in 10 years during the study collection. So just be mindful of that. So this is a brief case, not the one we're going to specifically discuss, but just to help you be a little bit cautious when you're thinking about osteotomies. This is a 15-year-old at Hamstring Allograft ACL. It was revised to a patellar tendon autograft, a well-intentioned attempt to try to address the slope, but through an osteotomy that didn't work. It was placed anteriorly. It was a valgus-producing osteotomy. So now this patient has had two failed ACLs, and now has a valgus malalignment. So you need to think critically about your osteotomy and what you're trying to achieve. So at this point, valgus alignment, one centimeter heel height, grade 3 Lachman, so unstable knee, and valgus laxity. So she had to have a redo osteotomy, hardware removal, slope reducing, take out the valgus, and then a fifth surgery before she was even 20 years old. So make sure you're picking the right osteotomy for these patients. So this is the one we're going to discuss. This is a 25-year-old female, former college basketball player, left knee at age 17, had a hamstring autograft. Fortunately, autograft, not allograft. And then at age 20, had a revision with BTB autograft, and atraumatic onset of instability. And I think that's a key thing, that it didn't fail through some mechanism of trauma, but atraumatic onset. And the patient was trialed in a functional ACL brace and felt better in the brace. So this is just a heel height test. I'd encourage using that. The patient had six centimeter heel height, which is symmetric to the contralateral side. Lockman pivot shift was three plus. There was varus laxity at 30 degrees. And these are the radiographs. So also an MRI and CT. You can see the tunnel osteolysis, a posterior tunnel, and a lateral meniscal root tear. And Rob's shown that in a lot of the revision ACLs he's had in his practice have a lateral meniscal root tear that most likely wasn't treated at the index procedure. So we'll give a chance for the group to discuss this, and we're going to go back to our small table groups. Yep. Wonderful. So we'll transition to that, give some time to discuss it, and then we'll reconvene. Yes. Make the groups again, please. And we discussed five minutes decades. Thank you. I'm just a lay-up-a-lay-up-a-lay-up Okay, Matthew, what do you think, your group? Why us? So we have Mr. Leprade with us, so it was a little bit cheating about what we're going to say. So the global thing is first, bigger sterilizes often implies infectious problems. So because of that, we are very afraid of the single stage, doing everything in a single stage. So we're going to focus first on the main issue, which is obviously a bone issue. So we need to fill the tunnels, actually, the TBR1. We need to correct the slope and potentially gives a slight correction in the virus zone, but it's not mandatory here. So it's basically correcting 12 degrees of slope and fill the tunnel. So we do two stage. We start with that. We do the open, we do anterior closing wedge. During the closing wedge, we graft the tunnel. Then we stage it at when a second step at six months. Okay. What about the hyperstation, Volker? How much hyperextension does she have? About six centimeter heel height. And this is asymmetric, yes? No, this was symmetric. Symmetric? I would probably not worry about it too much. But so I think one question is, you know, do you want to do just an LAT and just don't think about the slope? I think you can. You're just not going to address the problem. But that's something I think all of you ask yourself right now. Can I just do the cheap and dirty eight minute LAT? And I think Armando Vidal, who was mentioned already by Anil earlier, just did a study where they attempted to show, not sure they did it in the best possible way, but then the only way so far, they're the only paper out there. So they did a great job with that, showing that the effect on the ACL is much bigger when you correct the slope rather than you doing a little lumiere. And so I would do, we decided, actually they decided, I stayed out of it. The group decided to do a slope osteotomy. And I would say, to answer your question finally, after so much talk, I would say, if in the end your heel height, Andrew, goes so much higher and you're worried about increased hyperextension, then just fill some of the bone graft that you took out back in and reduce it a little bit down and settle for something less than the 10 millimeter that you might take out here. So if I can say something, for those guys with hyperextension at beginning, we used to put them in PCL brace that avoided last 10 degrees of extension for three weeks. And it's changing a lot the outcomes in terms of what we have in terms of hyperextension. As soon as we start doing PCL brace on those guys, we don't have those issues because I think you have a scarring process of the posterior aspect of the knee. But the beauty here though is that you're, if you come back for a second stage ACL, if they need it, and if they do have hyperextension, you can treat it, all right? So you can address the hyperextension if it becomes a problem. Something different, Seth? You agree? Not much different back here. We're gonna do a two-stage reconstruction. We're gonna do the osteotomy and bone grafting, and then come back for revision ACL and other intraticular work. Interestingly, Christian was talking to us about doing it all in a single stage, taking some of the bone, bone grafting the tunnel, but not doing the ACL. And in his experience, even in these young patients, he hasn't had a problem with having to come back with much regularity for functional instability. I'm still confused what osteotomy people are doing, because the patient's in varus, and has, you said, a lot of varus instability. So are people saying a pure sagittal osteotomy here? It seems like that's what most have said so far, but I think that's a bit of a controversial question. I would plan and execute a biplane osteotomy for this. The nice ventricles, and you'll drift them a little bit into neutral. Right, but she's in a little more than a little bit of varus, and it's a very impressive, you should grade three in full extension. Is that? 30 degrees, I think. Varus. The question was, does the lateral root tear factor in, or influence your desires to put her into more velgus? I think the lateral roots, of course, they have a role for contact mechanics. I think the main thing I'm thinking about with ACLs is for the role for rotatory stability, as Dr. Musal's shown in a study a decade ago, with the role of lateral meniscus for rotational stability. So I think that's a consideration. I think you'd be more worried about putting them into velgus if they had lateral compartment cartilage disease as opposed to lateral root tear. And I think if you two-stage, which is not the worst idea, because like Dr. Amendola said, that will give you the opportunity to find out, you may not need that ACL, but I would fix that root in the first stage, because that doesn't take very long. That's what we said. Probably the root in the first, filling up the tunnels, leaving the ACL. I mean, we expect you at 10 degrees of growth change. We have 10 degrees that gives you an AP translation of more than one centimeter. It's probably way more than the best ligament could ever offer, so. Yeah, right. And the tibial tunnel, you can fill. The femoral tunnel, you don't need to fill because it's too anterior anyway. Yeah. Let's show what was done. So I borrowed this case from an expert, so I'm gonna show what my expert friend did. So stage one, tunnel bone grafting, along with the closing wedge proximate tibial osteotomy. And stage two was a re-revision ACL with contralateral BTB and FCL reconstruction with allograft and lateral root repair at that time. So I think the thought process there was you can, you're gonna be non-weight-bearing for the FCL or at least limited weight-bearing for the FCL, so you could do the lateral root at that point too. And you can weight-bear after the osteotomy. And at the conclusion, the patient felt like the knee was stable. And on objective testing, there was a negative Lachman stable on Varus stress testing, and actually one millimeter tighter on Varus stress testing. And the heel height was a little bit less than before. It was four centimeters versus six centimeters for full flexion. So I think this is certainly controversial because there's a little bit of Varus. It wasn't minimally asymmetric, but a little bit of Varus. So the debate on where your osteotomy has to go, and I think Al is jumping to make a comment, so I'll let him comment. Oh, I was just gonna ask you a question. It's great result, complex surgery, but how do we avoid getting there in the first place? Is there anything that we should be doing? We're all gonna see these types of patients, but hopefully before they've had their third failed ACL reconstruction or whatever it was. Rob, would anything be different? I don't know if you'd... What would you do now if you saw this patient? I think it's a very good question. It's just a matter of, you have to examine the patient and look for everything that you'd have to think about the first time around, because she had a missed lateral meniscus root and she had a missed FCL. So she failed two good grafts the first time around. You can argue that the tunnel wasn't put in the right spot for the femoral side, but the issue is it probably would have worked if the FCL had been addressed and the root had been addressed the first time around. Because once you get past the first surgery, then you have to start thinking more about slope and alignment and all those other issues which address it. And like Anil was saying, we specifically have our therapists don't do any hyperextension for the first six months. And then I think adding the LAT, that's why she ended up with two centimeters less heel height instead of having increased heel height. Because we're kind of paranoid about having increased heel height because recurvative can make an ACL fail too. I have another follow-up question to that, Al and Rob. You think her slope was 18 degrees when she started all this? Or do you think her slope was maybe just slightly bad, maybe 9, 10, 11 degrees? Then she failed her ACL, then she set more anterior, then she bounced down on the posterior cortex and increased her slope and failed again, etc., etc.? I think it's... First off, we get ACL stress x-rays on both sides. So her slope was 16 or 17 on the other side also. So that was her baseline. But I think without the articular cartilage wear, you're probably not gonna have it slide forward any different over time. I don't know if the boning... I guess I know that from ACL research, so I don't know whether or not you see an increased slope over time with increasing failed ACLs. I know that you think they do. But certainly what you do get is with meniscus loss and cartilage loss, you're gonna have an effective increase in your slope. Pete Fowler showed that before. I mean, there's one nice paper I should probably mention in case people haven't seen it, but Lars Engelbrecht, I think, has one paper with a 10-year follow-up of kits treated non-op. Now, it had open physis and the slope changed over time. But there's not much evidence, so it's an open-ended question. And who knows what in the end? Yeah, Volker, I mean, in skeletally mature bone, the bone, the slope will not change unless you have joint space narrowing. No, the posterior medial tibial bone changes as you get joint space narrowing as the failure of the varus knee. But now, you could get soft tissue slope changes, meniscal chondral loss, but there's no way that slope is gonna change unless you have the joint is failed. You're sure about this? You sound so certain, I love it. I know. How about in the Middle East, if you kneel all your life, the slope is bigger there or no? Yeah, yeah, all Indian patients do have that as well. That's it. Correct. Dr. Leprada, I have a question. What about her other knee? She tears her other knee, isolate ACL. She has 16 degrees of slope. What's your index procedure? Right, assuming there's no meniscus work, my index procedure would be a BTB ACL and a LAT. I have another question, and would you opt for a long lateral X-ray even in primary ACLs? Do you think that this should become part of our routine workup, or do you think we don't need that? Obviously, we don't have science on changing. Actually, we support your statement right now. We don't have science that supports changing the slope for primaries, but should we have a radiological workup that helps us out? I think that's a good question. I get bilateral long leg tibias on both sides. We do ACL stress pre and post. The post operative are a lot better than the pre. If they have a lot of pain, they obviously aren't gonna translate as much, but you can see some dramatic increases in anterior tibial translation at time zero, and that helps you to decide if you need to add some augmentation ahead of time, because they'll probably have a three plus pivot when you get them under anesthesia. All right, good discussion. I'm Andy Bernhardsen. I'm the orthopedic surgery department head up here at the Navy Training Center, so I see all the recruits, so anybody who comes on the list through and gets hurt, they come and see me, but we're gonna cover tibial slope in the PCL injured patient, and the role of osteotomy in these types of patients. We'll just close this pertinent presentation. So a little background. If the foundation's not level, the house won't stand, so the Tower of Pisa, everybody's visited that. Obviously, they didn't figure out how to make this thing level before they started building. Tibial slope can greatly vary. As the last discussion alluded to, some of these Saudi patients, and Dr. Charlie Brown has seen some of these folks out of Saudi, and some of these kids have 25, 30 degrees of posterior tibial slope, and that's a growth issue for a lot of them, but can be in the post-traumatic setting and can be negative or markedly increased depending upon the patient. So a flat slope or closer to zero can be protective for ACL patients as we've seen in our prior presentations, but patients at a higher risk of PCL injury. Further patients with a flat slope can have examination findings with PCL deficiency, deficiency in a setting of an intact PCL, so they have more translation. How do we measure tibial slope? I know a lot of the people have touched on this. Do we do a full-length radiograph? Do you do a short radiograph? Do you use a circle method? Do you use 5 to 15 centimeters distal joint line? Whatever method you utilize and whatever's possible within your hospital system, just stick with one method. So I utilize a short x-ray. I know some people use the long-leg x-rays, but again, look at the data, look at where the measurements were conducted for all the papers that are published to decide what method they're using, and use that in your practice. So 5 to 15 centimeters is what I utilize. A flat or decreased posterior tibial slope leads to increased PCL risk and injury. Increased risk of single bundle PCL reconstruction failure has been well-published. So this is a patient that I just saw about two weeks ago who had a tibial tubercle fracture with this very flat slope, and he complains of recurvotum issues. Consider slope in the setting of a PCL injury. Flat slope is a independent risk factor for PCL injury, so it's a study we conducted when I was a fellow looking at flat tibial slope. Basically, how does flat slope occur? You can see it in a ficeal injury contributing to a growth arrest. Sometimes with prior adult trauma, if they had a prior treated tibial plateau fracture and it wasn't well done, you can see this flat slope contributing to PCL injury or this feeling of instability. How flat is flat? Well, what's considered too flat? In our study, we found that PCL injured patients had a average slope of about 5.7 degrees versus our control patients who had closer to nine degrees of posterior tibial slope. So even lower slope in PCL injured patients who had non-contact injuries. Even flatter slopes contributed to non-contact PCL injuries in this study, and about six degrees for contact mechanisms. Flat slope in the setting of PCL failure. So in 2017, they looked at their five and 15 year data from single bundle PCL reconstructions that flat slope led to greater posterior tibial translation and increased surgical failure. We looked at a group of Dr. LaPrade's patients when I was a fellow. We found that our double bundle PCL reconstruction may mitigate the risk factor of flat slope. This was short-term data, two years of follow-up. So we'd have to do a little bit more digging to see if it holds true with the five and 15 years. PCL graft forces and flattening slope. As slope decreases, graft force increases. We looked at both single bundle and double bundle reconstructions in different flexion angles, unloaded and loaded settings, but it all holds true of as tibial slope decreases, the force increases for PCLs. And as you can see, the load is distributed across double bundle and single bundle in the far right-hand graphs. The single bundle reconstructions found most force for loaded grafts as opposed to the double bundle which distributed the load across both bundles. Double bundle PCL may mitigate the risk factors as you can see here. And these are the kneeling stress x-rays multiple months after with minimal change. So you can use an osteotomy to correct for a chronic PCL, just one of my patients who is a 37-year-old Navy SEAL who had a fair amount of media compartment wear as well as varus and he had a grade two kneeling PCL stress x-rays, but not a fully dysfunctional PCL. I trialed him with a brace, I utilized the high tibial osteotomy and I placed my plate anteriorly in an attempt to increase his tibial slope and he was back running at six months without pain. So there is a role for osteotomy for treating chronic PCL deficiency if you can increase their slope. So what's our goal? Well the slope goal for a PCL deficiency is around nine to 10 degrees, but obviously we want to make sure we don't overly increase them. Greater than 12 degrees is the magic number for putting too much force on the ACL. So we want to hit that sweet spot and I know multiple other instructors have alluded to the fact of maybe you don't want to be as precise as getting to that under six degrees for ACLs as you may increase the recurve bottom too much and lead to other problems. So here's our case. This is an anterior opening wedge supratubrical PTO after a failed PCL reconstruction. So this is a patient who had an injury, fell on a flex knee at age 17 and couldn't recall any previous right knee injuries. Had increased heel height, grade three posterior drawer and was indicated by another surgeon for a single bundle PCL reconstruction. So, underwent the reconstruction by another surgeon, non-wipering for six weeks, noted to have immediate return of his grade 3 posterior drawer, unable to return to sport, and that's his post-op x-ray. Four years later, increased heel height 8 centimeters, recurvatum, grade 3 posterior drawer, negative Lachman, stable in varus, and valgus is around 30 degrees. So we measured anterior tibial slope, not posterior tibial slope, of 16 degrees, PCL x-rays with a 22-millimeter side-to-side difference in neutral alignment compared to the neutral alignment in the coronal plane. So we can discuss what we do in this scenario in this setting. Oh, yeah. Yeah. Yeah. Equal limb lengths. Yep. You know, we're getting smarter as dumb sports surgeons and we're getting into like, you know, Dror Paley and Christian Clayland. And so if you do get into that land, you gotta, you know, for this, for me, I gotta know how tall is, you know, what is length. Yeah, no limb length discrepancy in this patient that was a country. Of course not. Yeah, and the scanogram, so. Yeah. But yeah, go discuss it with yourselves while we do this. So the patient failed that first stage PCLR, what would you do? He was 17 at the initial presentation, a few years later, so early 20s, early 20s, young patient. Yeah, young patient. Very young patient. Yeah, I mean, I thought about that, I'm like, eh, open it up, and you don't really go into that. So that's why I stretched out. Yeah. I'd be worried a lot if you kept, like, standing on it. Yeah. If you don't correct it, and you added that. Yeah, okay, so we looked into it and obviously said, well, the slope we're having is extreme. And obviously, this is nothing that you would address with the ligament. And obviously, this is a case for an osteotomy. The question now only is how far can you drive it, how big the hyperextension is. And those cases are routinely cases that I do on a lateral fluoro and then I have a clinical assessment. And I obviously stop with the slope correction when I have a straight limp. So this is rather clinical. Yeah, that's a clinical assessment. And I don't think that this is something that can be really scientifically proven. Because even in, I just told the story just to share for you, there is a sadly unpublished series of 200 PCLs of Andreas Weiler from Berlin. And he was kind of fed up with the fact that he couldn't differentiate what kind of patients, PCL patients he had that would spontaneously heal and what needed surgery. And we know that it's like roughly 50% of the patients that tend to heal and the others don't. And so all of them get PCL jacks and whatsoever orthosis to facilitate the healing and enable the patient to get along without any surgery. So and he retrospectively checked his cohort and the only thing that he found was the tibial slope. And actually he found whenever the cutoff was like eight degrees, all the patients that had more than that actually healed spontaneously and the others didn't. So the question here is how far can we drive it with this patient? And obviously, as I said, this is a clinical assessment. Even if you have 200 cases in your caseload, then probably you have two or three of those. So there is no scientific answer to that, I guess. It's an individual approach here. But that's my take on it. I don't know a case series which is big enough to give me a sufficient answer. I couldn't find anything that was published that really gave me that. I think Andreas published it six months ago in Kesta. And there is a real cutoff. He's saying the cutoff is really zero slope. And he's saying that people with completely neutral slope never healed the PCL. And the one with, let's say, regular slope, 80, 83, or seven degree slopes, they can heal spontaneously so you can let them heal. But then it's not exactly the same case here. So my question was, and it's a question for Chris and the faculty. We discussed with Bob that the question here is, what is going to elongate with 20 millimeter opening? This is the main problem. You create 20 millimeter anterior opening in the tibia. So what will be the problem? And we can discuss that for a long time. But you have nerve, you got patellar tendon, you got MCL, you got LCL. Everything needs to be taken into consideration. Because at a point, you really create an anterior window of two centimeters anteriorly. And those guys can have nerve palsy. They can have stretch MCL or LCL. And another problem, because he was almost born like this. He was not born like this. But it's been 15 years that he's like this. So you need to imagine that you will completely change the gait parameters, the way you work, the way you run. Mr. Moussal? In addition to all this, you can have skin breakdown, because now you're increasing in the front. So you have to be very, very careful. I would treat the skin with my skin incision like I would treat a calcaneus incision. Don't touch it. Don't even look at it. You open this up. Also this patient, some of these patients may be very sad that don't have a tubercle, because it looks so asymmetric to the other side. So if you're already allografting the 20 millimeter defect, think about allografting just a little bit behind the tubercle if you elevate the tubercle to do the procedure. Again, watch the skin. But all those are considerations. So additionally, a couple of little small meniscal injuries, the anterior tubular slope. So this is what we did, opening wedge, bone grafted. So super tubercle osteotomy. And negative posterior drawer. Heel heights were symmetric postoperatively after healing and felt stable. So it's about 15, yeah, 18. 18. Yeah. So we increased it a little bit. So that's the danger you run. That's a home run. And it just says that would 100% get a frame. Yeah. And I think with a lot of those multi-planar deformities or huge corrections, the thought should always enter your mind, should I do a frame potentially for large corrections? And that's a surgeon to surgeon dependent decision. And obviously depending upon culture and access to frames. Andy, what if that patient came to you without having had their PCL reconstructed first time around, what would you have done? I think an osteotomy initially is what, if you identify the bony problem, fix the bony problem first. Because you're setting the table just like we've talked about. If you deal with the problem, don't deal with what you can do from a soft tissue standpoint. If you feel like the bones are malaligned and you miss that, when you just, you know, I'm a PCL surgeon. He's got this big posterior drawer. Well, if you don't take a step back and look at that slope, you're going to miss it. You know, and I think a lot of people until recently, you just kind of, you just ignore the slope. You just, oh, this is okay. I'll just do an ACL. I'm an ACL surgeon. But you have to have the osteotomy toolkit to fix the bony problems. That's the bigger problem. Perfect. Thank you. Andrew, I think that the other point on that is assuming that it wasn't injured. It wasn't injured at all. So, there's absolutely no question that you wouldn't do a PCL reconstruction on a relative in, it's, what you're feeling there in the examination is a reflection of the slope. It's not the PCL being normal. So, you've got an, often they have elongated PCLs. Yeah. So, it's not an acute injury, but it's an additional ACL or PCL. You wouldn't treat a secondary issue with a primary reconstruction. And I think the case that I've presented, it's very similar to the case that I presented from a growth arrest in my talk this morning where the wedge anterior was about 25 millimeters. I think the soft tissue, the nerves, I think, are fine because they're all posterior structures. We didn't really have any issues with the soft tissues there in the metaphyseal correction growth arrest. You can actually, I mean, if there's any MCL laxity in these cases, you can actually sort of, you can readdress the MCL by re-tensioning the MCL by using, keeping the MCL distally attached. So, you can actually sort of re-tension your soft tissue envelope around the knee with this type of reconstruction. Those are all good points. I'd probably see one of these every three months. And now we're starting to see people that didn't have the PCL the first time that failed, so it's a lot easier to treat them because they do remarkably well and they could tell the difference right after surgery. So, this is kind of related to the case that we just had where we're going to now talk about tibial slope and recurve bottom and what to do. And we'll go through this, Matt. Thank you. So, I have, we have, in my town, we have a big problem, which is kite surfing. So, I have the patient that will show you to send me his image of the accident he had in my town like 10 years ago. So, this is what happened to him. In fact, we have a lot of wins. So, the guy is 40 years old, 10 years after this kite surf accident, and he was, of course, fractured and fixed at this time. And this is his X-ray today, so it's a lady, sorry. She's 30, she's 40 today. She had this major, let's say, valgus deformity, you can say. And we were discussing, I was discussing that with my group and I said, when those guys get major slope issues, don't look at the long-ass X-ray if you don't have the lateral views. Because this lady was referred to me for osteotomy because she was young, but 10 surgeons proposed a TKA on that. And in fact, it's, in fact, if you really look to the lateral view, so she's, of course, got 15-degree recuvitum, anterior knee pain, and lateral pain, and valgus thrust when she's walking because she's just like the previous one. She got a major slope, altered slope with a reverse slope. So, for those guys, the main message before getting into the discussion is look at the lateral view when you have this really shitty aspect of complete bone-on-bone, you know, because it's not bone-on-bone. The problem is you see the posterior aspect of the tibia at the same time than the femur. You see something which is an artifact. So of course, she had a plate, she had a fracture, so it's not looking like perfect. But if you really look to this aspect, she had a joint line. Everything is OK. It's just not good, just not at a good position. So this is what she had. She had normal torsion of the femur and the tibia. She had 110 lateral slope, 100 major slope. She got a pretty normal, let's say, tibia with the MPTA 83 and globally a valgus of 15 degree. And she's asking for a solution. Now it's your turn. I return to this one. Thank you. So what do we have? First row. Alan, get good. I think we were, what were we thinking? So it looked like the deformity, it's a post-traumatic deformity, so all through the tibia, correct guys? Didn't look like there was a problem on the femur. She's got an increased anterior slope on the lateral side, which is causing her increased valgus. And so we would do, I personally would take a tubicle off and do an asymmetric opening wedge, open it up more on the lateral side than the medial side, so you're increasing the slope on the lateral side preferentially over the medial side, and then put the tubicle back down. I would use Oligraph, just like Christian said, I would just basically titrate it up, and you can use two laminar spreaders either side, and you can basically just crank it up until you get to a point clinically that you're happy with it. But I also think this would be a good indication for the, when we all agreed, it would be a good indication for PSI. So, question for, exactly, how do you fix it? What is your fixation system? So I do two Oligraphs, thermal and Oligraph wedges, and then I put, I tend to use a plate. You can use staples, I don't love that concept, because I just think as the Oligraph starts to incorporate, you run the risk of it collapsing, so I tend to use a fixed angle locking plate. Something to comment? I don't know. I think it's important to sort of understand the pitches you're looking at. I think a lot of the valgus that we're seeing is apparent, because they've got, and it looks like they had a previous bicone of the fracture, because the slope's been more affected on the lateral than the medial side, because it looks like it's about 15 degrees off on the lateral side, and more like 10 degrees off on the medial side. I think the slope, you'll probably end up correcting a lot of the valgus. What I would do in general principles is use PSI, we'd get a CT scan of the contralateral leg, and we'd have our engineers just plan it to reproduce that, and that will tell us what the wedge needs to be. I suspect because it's been a bicone of the fracture, we won't get the two plateaus exactly perfect, but I don't think it'd be big enough discrepancy to do an intra-articular osteotomy. So I think as Al said, it'll end up being tubercle off, antralateral opening wedge, and you'd be guiding it by the PSI. And obviously taking a look clinically to make sure that your slope correction matches the loss of the hyperextension, abnormal hyperextension he has as well. I just want to stress one thing that David said, because I think some of this valgus is not true valgus, and the one thing, this isn't one of those people you want to actually just look at them, does she look like she's in 15 degrees of valgus or not? And I think that's a very critical point, because sometimes your x-rays with these deformities based can trick you to really look at. Yes, I don't have many other points to make except the long cassette x-ray can have very different values depending where your ankle is placed and if they're internally rotated or not. I would say the 10 degree difference or 7 degree difference between the two slopes, anterior and lateral, is very, very tricky, wondering if any interarticular osteotomy like Chiba could do it. But I think this would be a brilliant case for a Taylor spatial frame, which I'm not familiar with how to use, but then you can just play with that and dial it up until you're happy. This is what we have there, we said progressive correction with a Taylor spatial frame. I think it's an option, so this is what was planned. Our group met, we haven't said anything. So we just wanted to say the same. Are you Swiss or German? Go ahead. Go ahead. So just then I take your question. So this is what we plan. We plan to do an isometric correction, so only three degree of varus correction and asymmetric closing wedge, 24 degree on a point, 28 degree on the other point. We have two plates, we have double cutting guide like this. This is specific for slope changing thing. And we see, you see, we have tons of key wires to protect the zone that should not be cut during the surgery. And now I have a question. And you see that it's, we have, I don't know if we see it here, but you see that what moves the whole thing is 25 degree, 25 millimeter, 22 millimeter. So it would be a tough surgery. You know it. Just a question for the master surgeons here. So if you're doing, if you have any of those big corrections where you're doing an anterior opening wedge osteotomy and you take the tibial tubercle off, do you have any tips on how, where you should place it back then? How do you, how do you figure out where you're supposed to put that tibial tubercle back? I think this is very controversial. We can discuss very, very, very long time even between the faculty here of the influence of anterior closing wedge osteotomy on patellar height. I think there is a very good paper from Adnan there that will come out sooner or later on AGSM saying that it's, it's very, very slight changes, even in very big correction in anterior closing wedges. At the same time, David Dujour just published a paper like two weeks ago saying there was major change. And in fact, you need to realize that first point, we don't have good measurement. The cartilage index, the insole solvati, the Schroeder index, the Blackburn and Peel, all those things are made for patellar height in instable and dysplastic patellar issues. They are not created to analyze the effect of slope. And if you think about it, the landmark of the cartilage index, this one, of course it will change a lot if you change the, if you create an anterior wedge osteotomy, it would change a lot. But will the patellar be influenced by this, the position of this piece of bone? I'm not sure. I don't think so. I think the patellar is influenced by either the position of the, of the tibial tuberosity. And potentially what is really important is not where is the patellar compared to the tibia, but where is the patellar compared to the femur? Because there is not such a thing called the patellar-tibial join. You know, there is no join in between the patellar and the tibia. So what happened in between the tibia and the patellar, nobody cares. What is really important is what happened between the patellar and the femur. So we need to create a good parameter to measure that. The Schroeder index from Stefan Schroeder in Germany is good, but it's deeply influenced by the flexion of the knee. So we don't have a very reliable way to measure that, except maybe one that Christian created five minutes ago. Again. Of course not. Just to give you a technical answer to the question, obviously when you don't want to change anything, then you don't just take the tibial tubercle off as one flat surface, but you have a step-off, either distally or proximally, where you want to have it reassembled at the end of the surgery at the same height, and then you can just lock it there and bring it back to the height it came from. So a practical point, you put it back on the tops. Well, actually, depending on where I want to have it. So either I need a step at the distal side if I want to attach it there, or the proximal side. And the only thing that you need to see is that you probably then have a resection of one millimeter of saw blade thickness, so that you change it by one millimeter, which may not be an issue. And I will give you another option in my live demo, real live demo. So this is real-time surgery here. You have what we've done. It's Christian Clay live surgery, so it's very fast, very easy to do that, to be honest. Nothing to complain with this kind of surgery. The hinge protective key wire, very important here to avoid to cut the popliteus artery. You open your graft, your plate, job done. I'm kidding. It took me two hours. But you see here, so two cutting guides that create two plate positions that allow you to really control your asymmetric opening. Because at a point, everybody says, yeah, I'm doing allograft here, allograft here is very well-fixed position, whatever it is. In fact, it's very tough to create an asymmetric cutting plane. So you need to be, even if you do a perfect line, you need to be perpendicular to the mechanical axis of the tibia, otherwise you probably shift a little bit, you can create rotation based on that. So this PSI thing, there is several companies designing that. You saw one by David, one by Anil, one by me here. Don't focus too much on the origin of the thing. It will help you to drive this kind of surgery. And I think this is all. Thank you. Matthew, can I just make a point too? I think you said at the very start that 10 people had recommended knee replacement. Yeah. And, I mean, I do knee replacement, but just, I think for those in the room who do knee replacement, firstly, this wouldn't be an easy knee replacement because it would be very difficult to balance because of the bony deformity. And so this operation has achieved two things for this patient. It's made them better, it's deferred the knee replacement, and it's made the subsequent knee replacement a lot easier. So another benefit of doing an osteotomy rather than just assuming you should go to a knee replacement because it looks too hard. It's impossible to create a real easy TKA in the initial scenario. You will cut everything, everything, to have a nice cut. And I think, and you see, this is the only procedure I know that will create cartilage. There was no joint space. Now there is one. Thank you. Thank you, Matt. I think one other thing to think about is that when you're doing osteotomies, you have to have a good x-ray tech, and I think that point is brought out. So I meet with my x-ray techs every two or three months. I save the bad x-rays and go through. So they don't send a Rosenberg to me unless it's a pure, straight Rosenberg. The same thing with the lateral x-rays. They have to have the femoral condyles overlapping because they know I'm not going to accept them. But if you have a large group of people that are taking the x-ray for you, you're going to end up with bad information because when I have a patient with an increased intebral slope, they'll come and tell me, hey, I can't get a Rosenberg for this reason. It's good that they recognize it. So try to work with your x-ray techs on that, too. So we're going to make things really confusing right now. We're not talking about increased slope or decreased slope. We're going to talk about chronic ACL and PCLs and biplanar corrections. So Neil, answer the question. So first of all, I want to thank the discussion, Al, Dr. LaPrade, and Elizabeth for inviting us here. So many things that come out, so many pearls here, it reminds me of when Dr. Burke was our chief of PEDS. He would say, they've been shooting x-rays for 157 years at HSS and they still can't get it right. I mean, it's just the amount of times I would say one of my biggest mistakes with osteotomy is what the Volcker saying is not realizing I had a bad x-ray and not learning rotation the hard way, learning where the feet stand the hard way. And we have an EOS machine. They can screw up an EOS machine where the feet are there. I don't know how they do that, but whatever. We screw up things, too. So I want to talk about chronic ACL and post-reliable corner, not PCL, because that, I don't know how to do a biplanar with an ACL and a PCL. I don't know how we do that unless we do an intraticular osteotomy. Only Matt could elevate mid-plateau front and then depress the back. That's just a different thing. So this is a thing I've worked on for years, and I want to show you more of a talk of my evolution of this problem. So this problem is kind of a varus knee with a sloppy lateral side. So here's a question my group asked me multiple times. Can we reproduce slope with an opening-wedge high-table osteotomy? And then how do I manipulate my lateral hinge? How do I, you know, and Matthew talked about this before, how do I template my joint convergence angle? What's my ideal goal of correction? And then we'll get to some cases. So this is a paper we did years ago, and this was actually from Dr. Warren, one of my mentors. He said to me, he's like, Aneel, whenever I have an ACL deficiency, I did a lateral closing-wedge, and I never had to do the ACL. He goes, go in a lab and prove a reason why. And so we went in the lab and we showed that, you know, when you do a closing-wedge, because of the bone that you're taking out, you can take a lot of slope out. And I still use, it's one of my best indications for low-demand people to do a closing-wedge to dampen slope. An opening-wedge, you know, I was, we reproduced, we can get four to five degrees. Now, I'm not saying you can't get more, but it's just a much technically harder thing to do. So I always tell, you know, our guys, the answer is yes, but it's hard. It's hard to dampen a lot of slope, and you have to just understand that. But you definitely can do it. And you know, what's, how do you do that, right? You have to really understand, you know, your gap, and your gap in the back has to be not a one to two, but a one to three, or really a four to zero, right? If you really, you know, you really want to have, you see there, that ruler's there, that anterior cortex is literally touching each other. And that's something that's, it's really hard to do. There are a lot of tricks, and you really have to understand how do you get that ratio. It's understanding your anterior, understanding your hinge axis, right? So it's not just the position of your hinge, it's the axis of the hinge. So we did a paper using some CT technology, and we basically figured out that really the only way to control or to dampen slope is to do a small anterior lateral hinge, which makes your osteotomy, by definition, more unstable, right? Here's the thing where people, you know, you always want to understand, if you're going to break someone's leg, you got to make sure you can heal someone's leg. So one thing we haven't heard a lot about is, you know, non-union, delayed union, and that's always, you know, that's our dirty laundry. Where there's a lot of arthroplasty dirty laundry, that's our dirty laundry. Because when an osteotomy does go bad, it can go bad, so that's always in the back of my brain. So here's another paper we did, and it says, you know, how do I really manipulate my hinge axis? So principle number one, you can reduce slope with an anterior opening wedge. It's technically difficult, you have to understand your gaps, you need a very small anterior lateral hinge, and that anterior lateral hinge can affect your healing. Issue number two, we showed, doing a CT paper, that an ideal hinge axis is about, you know, 90, it's actually 102 degrees, whatever, it's that black line, but it's, you know, pretty consistent to what you think. But the more interesting thing is, if I want to manipulate slope, I have to create really, really extreme hinge axes, okay, we understand. Issue two, it's really hard to manipulate slope with small coronal corrections. That is a principle that you need to just bury in your head. If you're saying, oh, I'm going to damp it, I'm going to do an opening wedge, I'm going to take 70 degrees of slope, and I'm doing a four degree correction, it's impossible. So if you look here, as your tibial correction gets bigger, your hinge axis can get more, less extreme. It could be extreme, but less extreme. So just understand principle number two, the only way you can really dampen slope, if you want to have a coronal, you need a coronal correction to drive that slope. And that's where using CT virtual osteotomies will help you understand that second principle. Principle number three, we talked about this before, this is something, you know, we know that when you have a high joint lacerating angle axis, your risk for overcorrection, and you're also at risk of patients not liking you, decreased PROMs. So how do you deal with this? If you ever have difficulty sleeping at night, read this paper that Christian and Matthew wrote. It's a phenomenal paper, and it's better than Ambien. But basically, it goes through all the literature, and I would just say, if you want to know the answer to this question, ask Matthew or Christian, but really the answer is, you take a couple degrees out, all right? Take the complex symbol. But there are a lot of different predictive models, and it's basically, it's soft tissue balancing from a total joint perspective 101. How you understand that you don't, my dad would always say that a total knee is not a bony operation, it's a soft tissue operation. And if you always just look at your coronal axis and then cut the bone, you'll be in trouble. You have to examine the knee and figure out what's the soft tissue balancing of the knee. We know that better than total joint surgeons, so that's something that we have to understand when we're doing alignment surgery, understand those principles you learned with arthroplasty. Last but not least, what's my, you know, what's the ideal correction? We've talked about this a lot. You know, I'm a lateral tibial spine guy. When I'm dealing with something with a loose posterolateral corner, I think we've touched on this. I'm going to go a little bit more closer to lateral spine. I'm doing a non-op, older patient. If I do everything all together, I will be less into valgus if I'm doing the posterolateral corner reconstruction. And then, you know, how much slope I want to get out, you know, if I want to, you know, I want to get, you know, a few degrees out. That's always my goal is a few degrees for those bioplanar corrections. So here's a case, 20-year-old male, morbidly abused construction worker, had ACL as well as a posterolateral corner, fibular-based. He had, you know, it was like two or three years ago, persistent pain and instability. He had a varus thrust, a little bit of hyperextension, he had a positive Lachman, positive anterior joint, PCL exam is normal. He had some varus instability at zero and at 30 degrees, a little bit of increased PLRI at 30, nothing at 90, valgus side was negative. Slope wasn't horrible. Here's another thing I want to say, not every patient has abnormal slope. It's not, we don't just do slope anymore, right? I mean, that's still, we're talking about the rare scenarios. LDFA wasn't bad, his joint-line axis wasn't bad here, but this is not a stress X-ray. And his LDFA and MTPTA is as you see here. So here you can see his MRI. You can see on the MRI scan though, he's in, while he's lying down, he's gapping, right? That's always, you know, as I said, I can't get an X-ray at HSS. So my poor man's X-ray is understanding how, you know, we get an MRI in 30 seconds at HSS. It's kind of weird. You can see the gapping on his lateral side. So you know he's got lateral insufficiency and he has some ACL insufficiency. So what do we do? So. We're kind of running behind time. Okay. I wonder whether or not we just basically. Just just run through. Yeah. All right. So in this case, I did an ACL revision with a hamstring autograph. I did a curl and sagittal slope reducing osteotomy. On this guy, because he was so big, I did a PISA revision, tibia and fibular base. I added a staple here because I did a tibial tunnel and the only time I've ever done this, I always put staples just to kind of protect myself. And he, and I put him into a little bit more valgus. He was a big guy and he did very well. So I have a couple more cases. Should we just. Yeah. Yeah. Well. Okay. Fine. Let's do the second case. So this is a patient and this is, you know, the way I kind of made this talk is how I evolved my technique. This was a 37 year old. This is a classic patient that had a BTB in 2016, failed, had an ACL revision with an allograft a year later, failed, had an ACL revision with an allograft and ALL a year later. Okay. This is like, happens all the time now in the States. You know, big anterior door, big lockman, some varus instability, valgus is fine. Varus thrust. Not horrible slope, five degrees of varus, amputee, joint line, not so bad. So in this one, all I did here, this one I used a PSA guide, I template, I try to get seven degrees of slope out. This is one where you really want to touch that anterior cortex. The patient did very well. I never did her ACL. I overcorrected her because I tried to get all of her slope out. And this is how I learned the evolution of that question. One last patient, 20 year old kid, suffered knee dislocation, lost a follow-up. He had an MRI when he had his knee dislocation and now he's got persistent knee pain instability. Again, positive, you know, ACL stuff, varus is out, positive dial. He's in six degrees of varus, MPTA, but he's got a little bit more of a joint line. And this one I did, you can see that was his injury film, mistreated. He actually interestingly had kind of entrapped in his medial meniscus. I did an ACL with hamstring, released the medial meniscus, did a body CAD, and I only tried to hear correct about three or four degrees, and I did a postular corner at the same time, fibular based, and this is kind of how we do it. So my point is is that I think you can, let me just get to, you can do bioplanar osteotomy. I think PSI really helps you to afford you to get small anterolateral hinges, but you have to be careful about how much slope you really want to do. Understanding that current correction doesn't need to go to Future Southwest Point. You got to look at your gel LCA. You can do this in one or two stages. I do that based on the patient, you know, whether they can take the hit. Using protoplasm matters, and you know, obviously, usually if I am doing this, I'm doing more of a fibular based. If I do a tib-fib based, I will protect it with some lateral hardware. Thank you very much. So I think I'm the moderator for the next session. We're just going to go through, right? So now I'm going to invite, Dr. Leprade is doing another surgical demo. He's doing a PTO with a TTO. Do we have the feed? Yes? All right. I was just going to say, I have to do a conference, so I'll post it, and I'll have a PDF for it, so I can have it. Right. You're doing a video, not live. Gotcha. Yeah. Oh, this is endless, too. Yes. This is how I think of myself. That's what I'm saying. OK. So Andy Bernhardsen and I are working on this forever So we've been asked to present on a tibial tubercle osteotomy, closing wedge osteotomy. And obviously, there's three different types, and they've been described. We can do a super tubercle, where we do the closing wedge osteotomy above the tubercle. We can do it through the tubercle, or we can do it infratubercle. So we're going to be going with a tibial tubercle osteotomy. Indications for this can vary. It can be with patients where you're worried about their patellar height with significant patella alta, and you want to make sure that you don't increase the amount of proximal migration of the patella, where you can move the tibial tubercle distal. Also, in cases where there is an increase in a wedge, David DeJure has just shown us that up to 20 millimeters, looking at their patients where they calculated what the patellar height would be, and whether you'd have sufficient ability to have good fixation of staples, at least 15 millimeters approximately. You can go up to 20 millimeters. So the indications for a tibial tubercle osteotomy may be somewhat limited for most of us. But also, when you're first starting out, it's not a bad thing to do, because then you can see things easily. So different ways to look at doing one of these, and we'll try to go through those. So Andy's kind enough to get the knee ready. We like to make an anterior incision, expose the extensor mechanism. The important thing is to totally expose around the patellar tendon, because you're going to have to make a cut. Maybe it's not as important as a super tubercle, but we want to make sure we remove all the adhesions. Almost all these patients have failed an ACL reconstruction. A lot of them have already had a BTP graft harvested. So there's going to be a lot of adhesions. So you want to make sure you get as far close to the attachment site of where the patellar tendon would be on the tibial tubercle, just so when you make your closing wedge osteotomy, your more distal cut is in a good location. You don't drift proximally, because that can happen if you don't do a good exposure here. The other thing is you'd want to make sure that you clean along your proximal medial tibia, all the way down to your medial collateral ligament, which Andy has shown here. So we want to clean off sufficiently. And then we end up doing a release to a little bit of an extent along here and putting a retractor under the MCL, so we can see. And then laterally, we do the same thing. It's important to expose the anterior compartment not too much, but just enough so you can see the edges. And then you can elevate up under Gertie's tubercle and elevate up the iliotibial band, all the way to the corner where you're going to have your proximal tib-fib joint. So you've got all the proximal tibia exposed in terms of what you'd be trying to expose for your closing wedge osteotomy. So we'll do a little bit of a TTO here. I'll hold it for you, Andy. Any questions, Anil? No, do you, what's your angle of your TTO right now? And do you ever do a step cut, as Christian talked about? That's a good question. I know, like, David Desjardins, I'm sure Liza's in that camp, where you're not just looking at a flat TTO. Stop there for a second. So instead of going flat all the way across, you can come down at an angle on the side here to make sure that you have a trough to be able to move it and distalize it. So that's an option that, is that the question that you were trying to? Yeah, exactly. So you're thinking of the, as you talked about, a distalization, but even potentially intramuralization. So you're affecting a lot of deformity at one time. So I think the big question is, and it was already mentioned that there's not an answer to it, do you take out a piece of bone on your tibia if you're worried about patella alta with a big closing wedge, or if the patella is sitting up high? And that's something we'd have to discuss possibly with our experts here, but I think it's something that has to be considered as a potential option there. So you can get this piece out. You can see we've created a little bit of a wedge there. So it gives you really good exposure. If you haven't done a closing wedge, this is one way to look at it. Just little pearls about doing a closing wedge osteotomy, you're going to make sure that you've got enough bone along the edge here so you don't go down into the anterior compartment too much. So you want to make sure that your osteotomy has sufficient bone laterally. If you're changing with an asymmetric cut like we've been talking about, you want to make sure that you've got good exposure and make sure that your cut is uniform. And especially if you do a super tubercle osteotomy, you want to make sure that the bone is taken out so when you close things down, you don't have a big wedge that's still in there that gets in the way so you can't close down your osteotomy all the way. So we're going to put some pins in. X-ray is ready. So optimally, we're taking a wedge out, right? And we've supposedly calculated how much we want to take out. Is there a ruler here? Oh, we got one on the marker. What's the smallest correction you would do? Probably somebody that's failed several ACL reconstructions with a 14 slope, I'd be looking at decreasing that. I know that some of the work of David and Bertrand has talked about 12 or 13, but I haven't. In those cases, I'm mainly looking at doing a LET rather than looking at a closing wedge. It's hard enough in Minnesota to get people to agree to a closing wedge osteotomy. So when it's a big dog knee, it's a lot easier to try to get them to do that. So I'm going to place in my pins, making sure that I have enough lateral bone. Probably not there. And I want to be perpendicular to the tibia, trying to hit the posterior cortex. And then you can measure in terms of how much you'd want to cut out here. So remember, we talked about one millimeter is one degree of correction. I guess I'd kill him even though I have a ruler. No, electron. There's not one on here. So I'm going to assume that's one centimeter. OK, another guide pin. So optimally, we'd be getting x-rays. We'd be trying to have the angle come down and hit the posterior cortex. That looks like it's too long. Roughly in that position, let's just get an x-ray. Let me just while we get an x-ray. Let me ask the room, is anyone doing infertubercle slope decreasing osteotomy? In France, they are. That looks too tight. But let's see what we got. Where's the x-ray? That's our preview. That is not my knee. That's not ours. Nope. We're out. Pushing. Right there. I can't see it from here. Pushing a little bit. Where is it? Yeah, here. This table's floating. Oh, the table's floating. It's cortical bone. It's not secure. It's hard cortical bone. There we go. All right, try that. There we go. That's too calculated. That looks like my first attempt with a fellow. Yeah. Let's do it here, Andy. Yeah, I would think maybe use the fluoro. Yeah, I'll take that. That's probably too tight. But you know, the advantage there, though, is that you're not worried about any tubercle problems. So there is a lot of theoretical advantages of doing infratubercle. 100%. It's a cortical osteotomy. X-ray. So can you see that OK? That looks great. So that's what we're angling for. So we do the same thing on the other side. And then we get those in. It's a lot easier to put the second ones in because, hopefully, your trajectory is in the right spot. Swing both pins over. So we're going to put our second one in, trying to make sure that it's perpendicular to the tibial shaft. Bob, how many of these are you doing a year? And how has that changed in the last five years? That looks too far in. These are shorter pins. Oh, never mind. Sorry, I just had a heart attack thinking that the artery was gone, but the pin's a lot shorter on this side. So I'm probably doing, at most, two a month. And compared to 2017, 18, when I think Americans started figuring out slope was a big problem, I'm doing a lot more. So you can see the X-ray there. So I'm happy with that position of the guide pins because, ultimately, the guide pins are just there for us to cut the cortex. OK, let's go back here. Any questions? I'm sure Matthew wants to say something. Go ahead and type that down. Yeah, so this is the question that we get all the time. And I ask you that on the other knee. But Matthew wants to ask the same question I asked you once before. So a patient that you presented had two failed ACLs and a native slope of 16. She tears her other knee. You're still not doing a primary slope-reducing osteotomy with an ACL. Let's change this one first. We're having my fellow of seven years ago redo things here. No, I don't think that we have enough good information. Hopefully, with people like Alan going to the Middle East and seeing people with the high slopes and doing ACLs, we can collect some data and have some more information about that. But I'm not aware of any data that shows that a primary slope-reducing osteotomy in somebody with a slope that's like 15 or 16 is going to make a difference. Walt Lowe has presented some data where he has a series of 40 high-level football players in Houston where he's on primary slope-producing osteotomies with an ACL. Has he published that? It's not published yet. So that's good, but we obviously need to go through peer review. I don't know what the right answer is. Well, I think when you have a thought leader in osteotomy saying that it's still not proven, it's a very powerful and appropriate response. So Bob, one question for you. You have a patient that had three ACL ruptures. You do a slope-change osteotomy. This guy returned back to play, torn his other knee ACLs. What would you do? That was his case. He still said no. L-E-T. He said L-E-T. He said this. That was the case he presented. At least he's consistent. We've asked him four times. I still haven't changed my mind. What would you change? The winning team, then? What was the question? Sorry, the saw blade was going. Why do you change the winning team if the slope-change osteotomy was the final point of the left knee? Well, it's because all of these ACLs coming in had a shit job the first time. So I can't assume that if I do it correctly that I have to worry about them failing. That's the problem, is that almost every single one of these multiple revisions had ramps that weren't treated, roots that weren't treated. The ACLs were put in the wrong spot. They missed other ligaments. So I think if you do it right the first time, it's not as much of an issue. That's why I have a hard time just jumping into that, because I think if you do it right the first time, you don't have to worry about your slope as much. No, I think that's a very important teaching point, is that before you critically evaluate what operation you're doing, you have to critically evaluate why that first operation failed, especially if it's your operation. I think it's the same mentality that we were worried about for a while, is that you do an ALL on every single patient, but you're not necessarily fixing the roots, and you're fixing the ramps, and all those things. It's like the slope is probably going to decrease the slope on the ACL, but is it over-treating the patient? That's the question. I don't know if we have a good answer for that. And in your experience, how are your patients doing? Because Volker and Al's, their series, as he said, they don't think they're doing that well because of the multiply-operated needs. So I would agree ours aren't doing as good. I think we've looked at our series. Can you pop that off? Yeah. We've looked at our series, and our IKDC scores are in the mid-80s, so they're not in the 90s like primary ACLs. And I think yours were in the high 70s, Alan, so it's pretty similar. I don't think there's that much of a difference there. They're not doing like primaries, but their needs are stable. I don't think there's any doubt about that. I haven't seen one in referral or in anything in literature where the closing-wedge osteotomy series patients have had any failures. Bertrand's and Alan's and David's, they were all successful at having the ACL revision work. We had three failures. Sorry. You just ruined the talk I have with patients. So, Mathieu, what's your indication for a primary closing-wedge? Never. I mean, I agree with Bob. I would never do that because we don't know. I think osteotomy is such a game-changer in terms of gait parameters, in terms of able to land and able to run, able to return back to sports. I really want to see Walter Lodato published. I know it's not so many patients, but he's one of the rare guys that operate professional athletes with slope-changing osteotomy. But to be honest, we have a combined series with Chris here. It's accepted. It will be published in AGS Sampson later. There is 68 cases. It will be the greatest series with functional scores. They do bad. All the patients do bad. They do bad at the beginning. They do bad at the end. Reason being that all have a major meniscictomy on the road. Most of them, they start having ACL problem at 16. They are 28. I mean, the problem is potentially we treat them too late, but I'm too afraid to start. Not today. Maybe in five years. I don't know. Ned has a comment. Dr. Amidala. It's really nice hearing everybody speak about slope-changing osteotomies. You know, I've been going on for a long time. You can hear it. Yeah, I can hear it. But I think if you have a very high slope over 20 degrees and you've done a slope correction on the other side because of failed ACL and you want to get a new ACL on the other side, I think you should consider doing a slope correction. I've had one case of a 15-year-old that had a 29-degree slope on one side towards ACL, and I did it primarily. And then I did a prophylactic slope correction on the other side and he never injured it. I think it is a risk, and I think we should consider doing something. That's going out there. Exactly. That's a whole different level. Well, that's just like looking at the anterior slope on the PCLs too, right? I mean, when you're getting over 20 degrees, it's like 0.1% of the population in terms of what the demographics say. So you can't disagree with what Ned is saying. It's just that the problem is most of the patients that we're going to see that have increased slope are going to be 14 to 17 or 18. So those are the ones that, you know, do we have the answer to that yet? I don't know that we have the answer to it. Anyways, I submitted that as a case report to Bruce Ryder, and he refused it. I do think, though, if the patient tore his ACL and had three or four surgeries in the other knee, it's not a hard sell to be like, look, let's just go to what solved your problem. So if we're going to start with primary slope-reducing osteotomy, that's the patient which is, I'd say, a fair place to start if they tore their ACL. Not prophylactically, but if they tore their ACL. So, Dr. LaPrada, what are your pearls to close this wedge down? Most of the time I'm doing super tubercle, but this is a lot easier. The pearls are super tubercle. Make sure you clear out everything just above the tubal tubercle because if these little bone wedges are still present, when you try to close it down, you're going to see a gap there, and usually it's because you haven't totally cleaned out. And the other thing is use your lateral x-rays. Take a small curette. You want to make sure it's a triangle and not a rectangle when you take the bone out, but feel all the way to the back cortex. We don't have a curette right now, but I'm feeling to the back, and you'll feel that little scrape in the back. And you just want to make sure that you've cleaned it out. And then the other two things is you want to take a ronger or an acetone and get your posterior medial corner and get your posterior lateral corner because if you don't get around the corners, you're not going to be able to close it down. So that's the whole key. A lot of these break. This one didn't break. But you just want to make sure that you're able to close it down and not have a gap because you've possibly left either the posterior lateral corner or posterior medial corner or there's just a bone hinge you haven't recognized under the patellar tendon. So if they break, you get a crack, does that change your weight-bearing? Well, I keep them non-weight-bearing anyway, so no, it doesn't change the weight-bearing. And we looked at our group of, I think it's about 25 that we looked at them, and about half of them on the postoperative x-ray did have a fracture and their slope didn't change over time. So with my rather conservative protocol, it doesn't change the slope if you break the posterior cortex. And does it change your fixation methods? No, it's still two or three staples. So we got a few more minutes, one more minute left. Do you have any closing pearls for you to throw your staples in? We don't have staples, but I don't want to tell any more pearls because I'm probably stealing all of Volker's thunder with what I've been saying. He's over there throwing darts at me, so I'll turn it over to Volker now so we can talk about it. We're going to first go to Mathieu Olivier, and he's going to be talking about slope-increasing PTO, and then we'll go back to Volker in the lab. The video is seven minutes, Volker, be ready. So, yeah, just a relive surgery to get in between so Volker can set up, and I will try to join him to help then. So, I'm sorry. So, yeah, I'm going to show you, if you can switch to my screen, please. Come on. This is me, obviously. Do you have my screen? No? No? That's okay. So, I will comment it. So, it's nearly the same patient, but not with kites of injury again, because, once again, it's the favorite sport of my town. So, you see, it was a very – not so bad. So, the surgeon thinks that you can fix it like that without being in trouble. So, he just fixed the slope with a reverse aspect. This guy got not a major, but let's say plus 10-degree slope now. So, we return back to the previous incision. He had a recurvatum, and he felt anterior knee pain. Most of the time, they have anterior knee pain because the patella is not positioned well, and the quadriceps is not functioning well because of the recurvatum. So, he has only two years after the initial trauma. So, I will show you how I played with the tubular tuberosity. The reason of this video is just for you. Stop looking at the computer. I'm kidding. So, this is what – so, we assess the tubular tuberosity. So, the approach was pretty tricky because it was a very lateral plate. Usually, I'm getting very central to get this slope change osteotomy done. And, specifically, this day, I had a very known visitor. His name is Walter Lowe. He's working in Texas. And he asked me, how do you manage the patella barra? And I was like, oh wow, I didn't realize that. So we need to do something interop. So I think, okay, Walter, we'll show you how it works. So you assess the tibialis anterioris fascia, you open it, I mean, it's not a very big deal, it's just like any plating on lateral side. I'm never using any tourniquet for my osteotomy, so this way it's bleeding, because if I cut something bad, I want to know it immediately. This is one good point, I think. So even if I do ACL or thing like that at the same time with a tourniquet, I deflate the tourniquet before closing. So wire position, you don't need to have four wires, two is enough, but you see my protective key wire getting high up in the sky, so it will stop my saw blade before getting into the popliteus artery. And so then I'm cutting below my key wire, because if something happens, I want my saw to get distal onto the diaphysis, not inside of the joint, of course, and I want to be trapped by my key wire from the beginning to the end, major lateral, and then you see I'm doing classic tibial tuberosity osteotomy, but I leave it attached to the proximal fragment. So this is what we call a descending biplanar cut, so the patella will be kept with the proximal fragment of my osteotomy. So it's exactly the same, so I'm not detaching it, I'm just keeping it attached to a proximal aspect, so exactly the same that Rob showed you, but I leave it attached to the proximal fragment, so the patella will stay at the exact same position, because it's still attached to the proximal tibia. Then I'm just removing it, and when it's done, I can do my opening wedge osteotomy, just below my key wire, so you see the cut is done. I can remove my key wire if I want, and then if you want to do a symmetric opening, you of course do the same opening at both sides. If you want to do a symmetric, you can use two different shaped triangle to open differently on the major and lateral side. But it's more tricky to do if you keep the tuberosity attached to the proximal tibia. So my proximal tibia is there, this is my GERDI tubercle, and you see my descending cut need to be long, because you need to put screw on it, and then I'm just opening like always with my triangular shaped wedges, major side, lateral side, until I reach the ideal position. It was a 10 degree correction that was planned, so I put two 10 degree or 10 millimeter, you can argue, methanic wedge, and you see my tibial tuberosity is getting slightly higher. I will fix it with a screw at the end. It's mandatory to use an additional fixation, because the quadriceps itself can breaks everything up after the surgery at the first contraction. So two allograft wedge that I put inside of my osteotomy gap, they have two millimeter wedge. They are very, very strong. It's dried allograft, but I really liked it, so it's stronger than the real femoral head we have usually. So I just put it inside, 10 millimeter opening both side, and then when this is done, I will stabilize it, I will stabilize my tibial tuberosity and fix it back to have some compression. You know, it's always easier to get it to the second aspect than the first one, because it maintained the opening of the tibia. So once you're happy and you have your measure done, you can fix it with a plate. So I use the plate here to stabilize my osteotomy. You can do staples that we discuss. It's not a big deal, but first, I want to compress back my tibial tuberosity position, so I would put two compressive screws anterior to posterior. So this is why I need a very long, six, seven centimeter osteotomy, tibial tuberosity osteotomy, to be able to fix it back. Patient often bother with the screws, so prepare it well. Do some, spend some time preparing the screw position, then fix it, and then you can fix your osteotomy, because it's still stable because of the bone blocks, actually. So you can wait for some times like this, and once again, if you really want to do sheep, do two staples, it's enough, and once you see my QI are still positioned, I'm putting my plate inside, and not a very big deal. We're going to move forward a little bit. You put some screws, blah, blah, blah, blah, You see the Walter Lowe is very happy. Oh, super. And then you fix it, of course, under fluoroscopic control, and when everything is done, you can just finalize your compression of the tibia tuberosity, and you don't have to bother too much about patella height, because everything was kept with the proximal aspect of your tibia. I think there is no more, no much to say on that. And this is your final aspect with two screws, and the thing is done with the plate. And at this specific time, and it's something you need to know, you see my, I have the, this is a good thing, I guess. You see my plate is exactly ending at the exact same position on my distal cut of my tibial tuberosity. This was a big mistake, because if you leave it like that, you can have a big fracture just below the plate at one month. First time they got work on it, stress propagation. So if this happen, you need to protect the zone from fracture. So I had a little tiny four-hole plate at the end to protect, just to gap, you know, to have something around this fracture zone, potential fracture zone. And so you have this tiny plate at the end to protect this zone from fracture at the end. And this is it, I think we can switch to Volker. Volker, are you ready? When do you use a biplaner, when you don't? Did the patient have Baha Prayag? So once again, I have this American in my room saying, what do you do with the Pate a la Baha? And I was like, oh gosh, I didn't realize that. And it was my bad. So I say, okay, I will show you. And I will say that I think nearly the same as opening or closing wedge, the Pate a la is not moving much. To be honest, it's very, it's not so much, maybe two, three millimeter. I do think that we have exactly the same outcomes in terms of Pate a la height than the closing wedge of ACL surgery. So I would say never, except when somebody is saying that. It's just like, you know, it's just like a bad luck thing. Somebody saying, did you look at the Pate a la Baha? You're like, oh shit. Of course, there would be a problem because of that. You know what I mean? Don't play the seven with everything on the seven. Don't think too much about it. Thank you. Another complex operation in seven minutes. Yeah, of course. That should be your new Instagram account. Volker, are you there? Yes, can you hear me? Yes. Perfect. I can hear you very well too, but I can get right back into it. So I think Mathieu does not like to talk about the Pate a la. So just check, note it. I don't usually sit during surgery, but it's late in the day, so it feels much better. I have Arianna a lot with me. She's my fellow right now. She's helping me and actually Mathieu already did all the steps for this procedure so that I can look like it's easy. But so yeah, you can see the field. So maybe let's put a retractor in here. So four windows, okay? Most importantly, you know, figure out your patella tendon and protect it, right? So you got to make an incision, lateral parapatella, make an incision, medial parapatella. And I don't know if you can see this here very well. I basically recessed the patella tendon since I'm going to go supra-tubical. I don't see it well on this screen. I don't know how well you see it. Can you see me well there, Anil? Yeah, we can see it very well. Okay, good, good. So I recessed the patella tendon just a little bit to get a bit more space. And then very much on the lateral side here, I make an incision in my anterior compartment fascia, and then I continue it up to the girdus tubercle and make a release. And then, come on the other side. On the medial side, same idea. So I have the patella tendon a little bit recessed. Can you see this right here, nicely? And then the MCL is subperioste elevated. These are my pest tendons. So now I have a big field. I like using a spinal needle or something, and I put it in the joint space. So now I know, you know, what little real estate I have. I usually have about two to maybe two and a half centimeters to put a ruler from the proximal part down to the tubercle. And so, can I get a saw, please? I start with a biplanar cut that, right. Any, the saw we had before is fine. Or this one. I start with a biplanar cut just to give me just a tiny little bit more real estate. And I think the technique that Rob just showed is what I, so far, mostly have used because it is actually much easier. So I'm going to have a Army Navy come into the patella tendon here, over that. That's perfect. Actually, if you lift this, I can see better. And so then I'm going to just start with my biplanar cut right here. Something like this will be enough. Okay, let me come from the other side. Let me see if I can complete this. I think this is pretty good. Okay, go ahead and give me a little osteotome. So then, or the really big osteotome right here. That's nice, too. So Volker, how distal did you go? About a centimeter and a half, maybe, at most. Yeah, something smaller. And have you always done this, or have you just taken a ranger in the past and just taken something? Exactly. I only recently started doing this. And just after coming home from a course like this. There you go. And we're coming through, almost. And I think it helps a little bit, because in the end, what my goal is going to be is, and I'll show you in a second, using a plate rather than a staple, because I don't like the staple so much, me being German and all this. I feel I like a lot more staple fixation. Okay, so then I take a K-wire, please. Yeah, so let me come back in here. So the position that I like is something like this. Yeah, that's a better view. Okay, hold on. I'm going to go a little bit more anterior. Okay, so here's my tibia. You can see it? Yep. You can see that gap nicely. Ready to go? Let's go. Let me see, x-ray right here. So I aim to the, basically the proximal edge right here of the tibia, the PCL insertion, if you will. And that's a nice stable area. And like Rob said, if the hinge breaks, I don't really care very much about it. Okay. No. Yes. Right at the cortex here. Maybe I need to drop my hand just a little bit more. Something like this. Okay. Third pin. So four guide pins basically does the trick. So now, not to introduce any varus or valgus, I try to go on the exact same plane that I did on the medial side. So do you think with your tubercle cut, you can get a little bit more distal and get a little bit more real estate? Yes. And your angle of your osteotomy is a little bit more acute? Yes, you can. Absolutely. Volker, have you ever done this for a primary ACL yet? You want to start that conversation again? Well, I just, I got to be, I'm really getting bobbed right now. He's like, you asked me four times. I know, everybody wants to talk about this. And the answer is no. Would I consider it in the case that Ned Amendola just mentioned? Absolutely. And what's the lowest number I would consider it? I'm not going to give that to you because I don't know. But, you know, I have a patient who comes in with a huge slope, with a bilateral ACL, with two failed on one side, one failed on the other side. And mom tells me that her surgery has always failed and she learned to live with it. And I asked her, do you want me to take an X-ray of you? Sure. So she had a 17 degree slope. Her daughter had a 17 degree slope. And then she asked me, is my son doomed? He's the only one in the family that doesn't have an ACL. So I told her, I don't know, but if you want me to bring him in, and I X-ray him too. So there are probably cases that you can consider this. There are some published series of, you know, very strong family histories of multiple ACLs. They just never took lateral X-rays on them. Okay, go ahead. It'd be very fascinating to go back to those classic JBJS papers. The big one. Yeah. So, you know, so far I haven't done a primary, but I'm sure Walt Lowe is going to start publishing his series pretty soon. And then there's data all of a sudden. It seems like your pins are much more shallower than Matthew's pins. Is that purposeful? I want this, I want this, not this. Yeah, there you go. Perfect. There you go. Say again what you said. Your pins are much more shallow. Matthew's pins were much more, you know, posterior. Yes. Because he wants to protect his saw blade. Yep. It seems like he's worried about the saw, you're worried about your pins. Yes. He's right. You tell me. I don't know. I never liked sawing posteriorly anyway. So I guess the rest of the demo is a little bit difficult to talk, unfortunately with the saw, but I think you make both of your cuts first. Something Matthew just taught me a few days ago on Pittsburgh, then you know you won't introduce any more veils of valgus. And then I go along the pin all the way to the back. Christian, you've been very quiet. What's, what is your take on supra versus intertypical PTO here? I'm actually busy with the later talk, but anyway, I get it. So the take is that most of my slope changing osteotomies technically are supra because I do them in a biplanar way and I leave the tubercle on. So, which makes it effectively a supra osteotomy. Which makes it effectively a supra osteotomy. Although I would say I aim towards the insertion directly. But technically speaking, it's supra tubercular osteotomy. And I'm with Matt. I don't think that there is a huge effect on the height of the propeller. And what's your fixation usually? The fixation? Well, if I close it, it interferes staples and if I open it, I have four cases where I just put, as I said, we don't have access to I have a series of cases where I took tricortical iliac crest, put three iliac crest pieces inside, wedges inside and left it without any fixation. Nothing. So even that, even that works. But although it's not considered to be a standard of care and my general recommendation, it really depends on the case. But even there you could, if it's not very high open, then you could go for staples or you just use a plate. Volker, you made a comment saying that you change your saw cutting order. Can you make that comment again? I don't think that was. Yes. Now that I don't have a saw in my hand, I can tell you again. So I make both of my saws. Right now I'm on the medial side. So I make my distal and my proximal cuts first just to score the cortex. Then I see and make sure I have a box, not a triangle that I take out. And then I finish, then I finish the cuts. That make sense? Right, so you're scoring a parallel line on both sides and then finishing. What were you doing before? I was just doing one cut completely to the posterior cortex and then I would stop in my second cut and do that completely. So you did your virtual Volker Muschel PSI guide from. Yes. Yeah, the German PSI hand guide. Yeah, and I think just trying to evolve over time, right? And keep learning, I think is the way to go. And I mean, I've done this procedure a few times too, but certainly not like you guys doing like 70 or a hundred of them, but maybe a few dozen. And probably with time, the indications will get more generous, you know. The one thing that I've done, I've used a PSI instrument and where you do a cutting jig from medial to lateral. That's very reproducible and you have a hinge pin and it's the same medial approach that Rachel showed. It's a big medial and you have a protected hinge pin and you're sawing in a direction that you like to saw. And to me, it's a great way to start your closing wedge career. Cause you know, you're seeing two experts. Let me see that saw again, if it's intact again. I still have a little bit to do here on the medial side. It may get a little bit boring to watch just to do this particular part. No, it's the important point to make that this is a difficult procedure, right? You actually got to do a little bit of work and you've got to take your time and you can't rush things. It's a tough thing to do. And Ali, when you're doing this, you're doing this all in 90 degrees of flexion? Yes, all at 90, single foot roll. Yeah. Well, I mean, the advantage of 90, I think, is because you've got your x-ray right there and you're constantly taking x-ray and there are vessels in the back. The advantage of extension is that, you know, you could say some people are more comfortable just operating front to back. Yeah. I've always done these in 90 just because I'm thinking my vessels are giving me a little more love and my x-ray is right there. A lot of ways to skin a cat. Okay, so now we have basically a nice wedge here. You guys can see that. And we extend the knee, probably break a little bit the hinge here to get this closed down. Would you ever take a saw and feather the back? Ooh, nice question. Can I get the saw back? Yes. I asked that same question earlier today. Did Al whisper that to you? No, but we call it a German tickle now. That's nice. How about just a K-wire? The K-wire, I probably wouldn't like so much because I don't want to go beyond that cortex as much, but I would have no problem feathering a little bit or just put the osteotome back in again and just kind of give a little extra. I think on the lateral side, the proximal hip joint can be quite tight and close you down a little bit. Okay. Okay, Volker, you got two more minutes to finish this complicated osteotomy. Good. So now, we're basically closed. So this is a nice little plate that was recently developed. And so I think this is nice because I don't like the staples as much. So with this plate, you have the opportunity to give a little bit compression. There you go. So do you feel like you're getting a little bit more So do you fix proximally first? Yes, fix proximally first. And then you have a nicer compression hole if you see that there. Yeah. So that's nice. And then you can give it a little extra compression. Now you need to have about, you know, what do you need? About 15 to 20 millimeters of proximal bone, which I think we have. I still have that K-wire or I say spinal needle in the joint so I know I'm not too proximal. Would you normally take an x-ray before you put your screws in? Yes, yes, yes. Come on in with the x-ray. Yes, Dr. Barnabas, we can do that. No, I'm not saying because you have six seconds. But I would just, I would think before, you know, whenever I put screws, when I do a closing wedge, because I'm always worried about, you know, if I'm, my resonance off plane and, you know, the plate could be fine, but your orientation could be off. Yes, exactly. Well, Volker, that was an excellent job. That's amazing. Thank you so much. And I think we'll go to Algen. Thanks, Volker. Okay, so I think everyone's earned themselves a well-deserved break. We are gonna change the timing a little bit. So we're gonna push the break to finish at 10 past five. So that's basically giving everybody a good 25 minutes. So, you know, have a refreshment, restroom, but also please do visit the exhibitors. You know, we've gone through the whole day and you've seen progressively, we've gone from more, maybe more straightforward cases, coming right to the very end with some.

tibial slope deformity

kite surfing accident

total knee arthroplasty

asymmetric opening wedge osteotomy

posterior tibial slope

lateral side

tubercle osteotomy

patella position

plates

Taylor spatial frame

customizing treatment plan

techniques

cuts

extensor mechanism

fixation methods