Left leg, who checked? So maybe we can have an aspect of the table that we laid out. Can you first, can you first shoot the table, there, Nokia Plus, last one, just here, here, this one, sorry, the instruments, yeah, that's it, maybe, and a slightly larger view, maybe? Not a big deal, not a big deal, do we have a feedback, guys, do we have feedback here, can anybody hear me? We don't have anything, okay, so then, I guess then we just start, so this is the live demo for actually a double level osteotomy and Matt and I were doing this, well, we decided it's probably the best idea to run you through these procedures and show you, well, all the stuff that you're not told in textbooks, so how to get things sorted, how to easily do these procedures and, well, then we can all benefit from that, I guess. So, first at hand, this is the layout, so these are the instruments that we need for double level osteotomy. Actually, as you see, it's just a couple of tools, you don't need a fancy toolkit for that, you just reduce yourself to what is really essential and Matt is pointing that out already, this is what we found on the tray, I think this is the most essential tool on the kit, so you should have that, otherwise it doesn't work, okay? So, now let's get back to the overview and this is obviously the anatomy, I like to draw that out so that I have some certain idea of what I'm doing here. My personal approach to, we are starting here with the lateral closing wedge and then Matt will go to a medial open for like a massive varus correction. So, my personal approach is I mark out my phalanx, my thumb, my interdigital joint and put it onto the epicondyle, then I roll up the thumb, grab over with my index finger and in between, that would be roughly my approach, okay? So, that's my approach for distal femoral osteotomy and for you, we go at either side one centimeter longer so that you can see more. So, the next thing is we just incise that here and what we'd be needing is just the level where we gain access to the IT band, that's where we are right now. So, this is blunt dissection, you free all the adhesions here and then we have this nice little army-navy retractor to see where we are and what you then need to find is the upper border of the IT band. Well, let's pretend that's somewhere here. So, I just incise that and then in a blunt way, I strip it all the way proximally and then we go to the distal side and then I take my bovine, so let's pretend that's my bovine, okay? And we make a curved incision downwards here. Okay, so we're all the way down here and as we've achieved that, obviously there are some bleeders coming up. Fortunately, in this situation, that doesn't happen, so we can just go straight on and it's a bit like on the medial side where you just take your muscle and push it out of its bed so that you go a bit forwards, northwards and then you just clear these little adhesions to the intermuscular septum so that you gain access to here. So, the next most important thing is, I hope you can see that, next most important thing, let's make it a bit wider, this approach, for you to see more, is that you get access to the Kaplan fibers and these are these reverted fibers coming from the IT band going all the way up here to the femur. So, if you detect those fibers here in the back, then you know actually where you have to detach them from the posterior edge of the femur to actually incise this intermuscular septum, lift up the vastus a bit more, and once you've come to that point, you can then, like on the medial side, safely go all the way to the contralateral condyle. So, in this scenario, just like I was showing you yesterday, you take a periosteal elevator or a cop and go all the way through to the contralateral side and you can really palpate the notch from the back and the contralateral condyle. So, once you have done that, you lift up the muscle, obviously the job in the back is done, everything is free so far, and now in the front here, you just need to make sure that at this particular level, this will probably be the height of osteotomy, you just need to find access to up here for your biplanar. So, just mark that out and that's the first step. So, now we can just release the tangent and take a first K-wire, and as a rough assumption, I just go like one and a half centimeters anterior to the posterior cortex, just go over to the contralateral side and shoot my first K-wire. And this K-wire, obviously, as you can see, is a bit high in the aiming area, so the hinge is not directly on top of the contralateral condyle, but we try to place it there, and now we're there. So, now you can see that actually here, we have a situation where when you take the tangent on the starting cortex, if you look to the X-ray, take a tangent on the starting cortex and the K-wire, then obviously you can see that this angle indicated here is under 90 degrees and this one here is over 90 degrees. So, that's why this has to be the upper wire, because this probably is the center of the osteotomy and that is then the inferior part of the osteotomy. Okay, so this is why we shoot now the next K-wire inferior to that, and let's say we do roughly any correction. We don't measure here, because obviously you know how to measure. You can, for example, measure this and say, well, that's, I don't know, 12 mils, hold it in between, and then you know about it, or you do it like Al has shown you yesterday with a ruler that you just shorten. All these things are possible. Matt, you need to remove your head a bit for me to see it. Let's sneak to that one. Okay, so now you might be thinking, well, hold on, here's a problem, because these wires, they converge and they intersect. And as a matter of fact, you're right, and it would actually bring my hinge closer to my starting cortex, but I'll show you a trick how to actually deal with this. So, the next thing I'm doing is I perform the first saw cut, and I do this under fluoroscopic control. So, I actually force my saw blade towards the K wire and the starting cortex, and I look at it and see under fluoroscopic control where it's at its thinnest. So, the only thing I do there is I incise the cortex, move directly to the opposing cortex of the wedge, and incise that one as well. Okay, so now I have two starting cortices, and one K wire to me is absolutely enough and sufficient, because if you look at what I'm doing here, I cannot rotate the saw blade anymore as the slot is given by the cortex. So, the guide is actually given by the cortex. So, now you see I have nothing in the back to protect me. So, there is now multiple ways. Either you take this very fancy and sophisticated tool that you see here. And we've designed that to actually be fixed to the bone. We will probably show you in the tibia. You can fix it to the bone with some K wires, and it actually provides you with a trough that holds or in-houses the saw blade so that it accommodates for the throw of the saw blade. And you can cut the posterior cortex without hitting to the retractor directly. So, my technique is actually this technique. So, I have the finger retractor, and I take my finger, put it here so that I know what I'm doing, take the saw, and advance the saw along with my finger. All the way through, till I probably, in this case, get somewhat captured by the cage that I created myself. So, now the wires are coming out as it's rattling a bit. So, what I now see is that obviously the saw blade's stuck. And the only way to actually help me out is to open this cage. And do we have a needle holder? Perfect. Perfect. And we open this cage by just retracting this K wire a bit, or removing it maybe even. And sneaking along this other K wire, which is already in place there. So, and that is all done under fluorocontrol, so that we make sure that we don't cut the hinge. If they approach and converge that far, meaning the saw blade and the K wire, that you don't know where your saw blade is, retract the K wire a bit. And for the last centimeter or millimeters, you can actually go yourself under control, under fluoroscopic control. So, when we have performed these cuts, then we just need to make sure that we have extended far enough anteriorly. And in this case, we are short by maybe two millimeters. So, we perform this cut now. Now, with the BOVI, I'd be clearing up the anterior edges, just to see where I am. In this case, I can just scratch it. But in fact, in real life, I want to keep my periosteum. And you see that this is already becoming mobile. So, what I would now in this part of the surgery, just take that and try to remove it. And so, you have a beautiful wedge coming out here. Okay. So, the next thing, it would be the ascending cut. When you now perform an ascending cut, you have trouble, because then it all becomes shaky. This way around, it's completely fixed. So, what I'm doing next is, in between the epicondyle on the contralateral side and the distal border of the femur, I will just take a K-wire, poke through the skin, see where I am. Can you fix the… Perfect. So, I will just poke through the skin, enter the bone, and then align my K-wire proximally. And I just tip it in and try to sneak along the cortex. Starting point is a bit low here. It could be better if we'd be going the other way around. But let's say that's okay. So now, for clearing up this gap that I've created and the wedge that I've taken out, this gives me a natural stop to the medial side here, to the contralateral side. And I could do this tickle thing, this maneuver where I repetitively go in and weaken that cortex with the saw without protruding through to the other side. So, the next thing is I rotate the saw and perform this ascending cut. And you need to make sure to exit the femur up here. So, once you have this drive through phenomenon, you just go to the other side. Then, on another x-ray, you confirm that the cut is complete and that you actually are in line with your inferior osteotomy cut. And as that's the case, it should start to move already. And that's what it's doing. Okay? But we're not quite there. And the reason is because there is plenty of remnants inside that we need to clear. And now your finger goes once again to the back, protecting every structure which is there. And then you gradually go in. And from the hinge on, you can see that here on the x-ray, from the hinge on, you start to clear everything. And gradually retract your saw blade whilst doing that. And that all is done under constant axial compression. So, you ask your assistant actually to gradually close that. And then, sooner or later, mostly it's the posterior parts that are not directly the tough, but the part which sits on the condyle, which is not really removed properly. But if you have then achieved that, and your assistant compresses the osteotomy, you cannot retract your saw blade anymore. The blade is captured. We call this blade capture. Nice name for that. And then you can close the osteotomy like this. And once you have it closed like this, and you know that you have a blade capture, you don't have to go further, because then you know that just the width of the saw blade, the one millimeter, is persisting. And one millimeter is what the plate allows you to compress. So, the next thing is, under constant valgus alignment here, we just take our plate. And this is a nuclear plate, and it's anatomically preformed, actually fitting nicely. And we fix it temporarily with one K-wire. So, we need a K-wire again. Right here. And I always make sure that I actually place this K-wire first, because that is the screw that approximates to Blumensatz line closest. And I don't want to have the plate in a position, I want to have it posterior, but not that posterior, that I actually have notch issues. So, this is why this is my first screw. And I just put it in. Try to temporarily secure everything. And then I take the next drill tower and go to the shaft part. I don't see anything. Can we have the Army-Navy? Yes, of course. Perfect. So, here you have the hole, actually. And once you have inserted that one, you fix it there as well. And to fix it there, you need to find the center of the shaft, obviously. And to do that is, you can toggle around this digital fixation to change the proximal height. And once you're in the middle of your long bone, you just close it and make sure that the osteotomy got closed prior to that. This is here not the case, because there was no valgus applied. So, we take it out again and just put it in again. And let's check if we have closed it in a better way. Not good enough. Let's do it again. Proper valgus. Okay. So, that looks better. And I guess I'm okay with that for the demo here. It should be really under compression. So, what we do next is... But we will see whether we get some compression. So, what we do next is, we perform a lateral X-ray. And that's what we do here. Just to make sure that the plate aligns nicely. And that is actually the case. And you see that this crucial screw in the back is actually anterior and proximal to Blum's line. So, we can just proceed and go ahead and put those long drill towers in. And they have to be the long ones now. Because actually here we see that the short one with the K-wire would be an interference for our drilling process. What I want to have is actually a completely undisturbed drilling process. So, I take the long towers and the long drill. And then just go inside. And you can have two 50s. And drill two times. One and two. What's going on here? Nice. Still deeply frozen. And then you can measure off with this long drill from the calibration on the drill actually the length of the screw. So, let's have two 50s here. And that is number one. And another one. Perfect. So, and for the sake of speed, I actually allow me not to do these other ones. Otherwise, I would now just remove this one. Wait, there is one trick that I want to show you because we told you that we go through the stuff that is never told you. So, I only have a long drill for these DFOs. Because what I do here now is, in this multi-angle hole, I just drill this one. And I drill the other one. So, let's do that. Let's have the long drill. Just to show them. Because I'm lazy. And I don't want to change this short locking sleeve here. Can we do something to that? Anyhow, I don't want to change that. So, I actually drill it till I tap on the cortex, on the contralateral cortex. And I read it off from this long tower. So, never change that one. You just need to refer to this depth here. Okay? So, let's say we drilled those, put in the screws, that's it. So, that's a trick actually to facilitate and take care of some speed. The next thing we do is, we actually compress the osteotomy. And then almost everything is done. And then I can give over to Matt. So, compressing the osteotomy is easy with this oblong hole here. So, there is equally an oblong hole and this little tool that allows you to de-center your screw insertion for the compression screw. So, that brings now the hole to the contralateral side. And you can measure the length of this screw off from this device. So, it's a 55. The contralateral cortex was indicated as 50 mils plus 5 millimeters for the cortex is 55. So, you don't take a depth gauge to measure it. You just take a 55 and put it in. So, now as we compress it, just fiddly with the attachment here. So, now we just insert the screw. You approximate it to here. And that's where you stop now. Because now if you'd be compressing, you'd be compressing against the K-wire that you placed. So, you give yourself 1 millimeter without causing too much hassle in terms of stability. So, I just leave the K-wire in and the surrounding, this little sleeve limiter is actually now just removed, allowing me this extra millimeter to compress the osteotomy. And now we take the X-ray again and you see it's compressed on the medial side. So, the rest is just throwing screws inside. Obviously, you remove this one. Then you just take the long sleeves, put them in here. And I don't take actually a long sleeve for the very proximal screw here, but just this one because my proximal screws are anyhow monocortical. So, I don't need these sleeves to be the long ones to measure off my drill tower. Okay. Yeah, that was it. Rest is routine closure, suture of the IT band and then subcutaneous and cutaneous level at whatever your preferred choice is. So, that was step one. And now we go to step two. Let's go. So, I have five minutes. It's enough. No, you have seven. Seven is enough. Go for it. So, let's go for the tibia then. So, we're going to do an opening wedge of the tibia. So, I'm not as good as Christian to draw, as you can see, it's only basic things. But the one thing you need to know is here we will have to play with the major collateral ligament and everything is there. So as a Christian... Hey Matt, you've got lots of time, don't worry. So take your time and you know, it's a great demo. So how was the party last night, guys? Everything OK? Fantastic, fantastic. So this is my drawing line. This is the only thing you really need to know. You can use a spinal needle or something like that or a key wire to be sure that your level of the drawing line is somewhere there. So I'm inside of the drawing line, of the drawing now. You don't need much to do that. To be honest, the only thing you need to know is you need to make an incision. So the classic incision would be very anterior. I was trained to make anterior incision and to dissect everything, which changed a little bit that because of Christian's double window technique that I love. And there's something that changed my life and I'm going to show you how. So usually we do one centimeter below the drawing line and four centimeter incision. The idea is it's pretty tough to have less than this size because this will be the plate that we'll put inside. It's a pretty tiny one. There is a type one and type two. I'm going to the bigger one after eight millimeter opening. But here, for the sake of the demo, it's easier because there is only six holes to be fixed. So we incise the skin. No big deal. Pretty posterior. So once again, this is my tibial tuberosity. This is the posterior aspect of our tibia. Pretty posterior, we incise the skin and we're going to do slightly higher for the sake of the, so you can watch what I'm doing. But usually I will stop my incision here. So then just as Christian does, you dissect the subcutaneous fascia. No big deal here. And you need to go posterior and specifically anterior because we're going to do a biplanar cut on our tibial tuberosity. So the first thing I do is finding the position of my patellar tendon, which is actually here. So this is my patellar tendon. So this will be my biplanar cut there. Okay. I don't know if you see it well, maybe slightly here. Yeah, great. So this is, this is my patellar tendon. So my scissor is below it. So you can see, I will have to cut this zone at the end of my osteotome. Then we go to the sartorius fascia, which is everything. So we take this forceps. And like I do when I do ACL surgery, I'm trying, I would try to remove the hamstrings from the MCL deeper. So I'm putting, I'm holding my hamstring here, opening my fascia with my scissor, pretty tough, very big. And at the end, you see Christian automatically, because he's trained, help me to retract the hamstring. So sometimes you need to release them. You can do that inflection or extension if you want. And then you see here, I, my hamstring are below this retractor. And I just incise everything until I see my MCL. So I don't know if we see it well. Yeah. So I remove some of the tissue behind that. And you see here, I only have my MCL. So this is my MCL, my hamstring out there. And the question is now how to handle that, how to protect it, how to not to cutting. So I was trained at the early phase of my career to cut here and peel everything off. We stopped doing that because this MCL is key. I mean, we don't want to have instability and we don't want to resect too much periosteum. And the MCL and the periosteum is the only, it's a single fascia there. So what we're going to do is a double window. So we start with my anterior window. You see here, I'm cutting in a vertical fashion, the MCL. So they will be my anterior MCL, my posterior MCL. You can imagine that this is the POL if you want. For me, specifically in cadavers, it's only fascia. And then you take any kind of cub elevator. We have a cub elevator here and we peel the MCL from the back of the tibia just like this. So this is my MCL. And I need to have, I will protect it at the end during my sewing process. So I need to remove this thing from my tibia up and down. And this is it. My second window need to be behind. So I'm usually doing that with a bowie, same thing. And you see here, I will incise just behind of my MCL onto the bone. So the idea is to dissect the gastrocnemius muscle to the somnambulomus muscle to the popliteus muscle. And then with the same cub elevator, I'm getting behind. And the idea is I need to scratch. So I don't know if you hear that, but we really need to listen to the scratching. I don't know if you hear it in the room. So when you hear that, you know that you're in between the popliteus muscle and the tibia. And same as before, we use this funny retractor to put it just behind of the tibia. And you will reach, you can use your finger at the beginning and you can feel that you're going to the popliteus, to the fibula head, just behind there. And you use this fancy tool that Chris had created to get there, to get to the, here I feel, and we can shot an x-ray maybe, I'm sorry. So not really here, yeah, we can shoot an x-ray here. So here I'm touching behind my fibula head and this is, I'm just on the fibula head there. And this also gives you the ideal cutting plane. We didn't discuss that too much, but you need to know that there is an ideal position of the, you want to fix it? Yeah, do it. Why not? You take this one. So you can, I usually not fixing it to the bone, but you can fix it to the bone with this key wire. That's okay. One is enough. And you see here, so it will not move. So you don't have the lazy resident that will stop holding it at the end. And when you cut, it's somewhere behind in between the muscles and the nerve and you completely cut everything because you feel confident because of that, but it's not at the good position. Here, it's over. It will not move. The leg is moving without, with it. So globally, the idea is now we need to position key wires and there is, there is an ideal position of the cutting plane. Nobody would tell you that, but ideally this is the, this will be the cutting plane. So I need to know, or should I go in this horizontal, is this vertical? And the idea is you need to make 110 degree. Why 110? I will tell you why. Here. So compared to the, to the, to the, compared to the, to the lateral cortex of the tibia, this key wire need to make an 110 degree. Why? Because it's the ideal angle to have enough space above to put three screws at the end here and also it's high enough to have a metaphysical cut and enhancing the rate of healing and the healing rate of your osteotomy site. So when this is done, the only thing you need to know is to shoot a key wire to make your cutting plane better. Yeah, of course. So we, do we have the, we don't have a foot, it's more urban retractor now. It's okay. Don't take the big one. We don't have a foot. So what we do is protecting the MCL from behind and we remove it from our cutting plane. Then I would just position a key wire here, now remove it and we'll finish this later. I would just put one key wire here to be pretty proximal and try to have this 110 degree compared to the fibula head. One thing that nobody will teach you also is that this key wire should be above the fibula head. So here it's very too much, it's slightly too much vertical. It needs to be above the tip fib. Start a bit lower, start where the retractor is. So it needs to be above the tibial fibula joint. Why? Because the tip fib is your worst enemy. If you really want to do a posture, a real good opening without changing the slope, one of the things you need to do is being able to cut completely above the tip fib. Otherwise, this posterior attachment will avoid the posterior opening to occur and what we create is an increased slope. So you need to cut above the tip fib here and my saw will be cutting below this key wire at the end. But the thing is you need to cut pretty high. Second key wire then, and this is one thing also that now you need to check. So I'm looking at my x-ray, give me a second Chris, and the question is, it can be like that or it can be like that. You see what changed? The only thing I changed is the aspect of my tibial slope. This is a pretty neutral tibial slope here. I mean my x-ray are getting into the slope and here I'm completely, I see a round shaped slope on my medial compartment. I need to, and if I want to be parallel to the slope and realize that I'm not changing the slope unintentionally, I need to have a cutting plane which is exactly parallel to the slope. And to do that, I'm using two key wires that I shoot in a parallel fashion. Once I see only, you see here, when I see only the position of my, when I see my slope as a thin line. Here I only see one key wire I can shoot and go completely parallel from the beginning to the end, sorry, and this is it. So you see, I see only one key wire and I see my medial compartment here as a thin line. It's a thin line. So if I see it like this, of course the two key wires are not parallel anymore, but the x-ray is not parallel to the slope. So you need to create a control way where you see the slope as a thin line and two parallel key wires from the beginning to the end. So now it's the cutting process. But what we need to do first is, of course, it's not like Christian showed you, we need to protect the hinge now. We need to put a stopping point to my sewing plane now. So what I'm going to do is, as Haniel showed yesterday, we need to have a hinge which is pretty anterior to avoid an intentional slope changing. So Christian will put the key wire, usually my resident or my fellow is doing that. He's putting the key wire here and once you're happy, just with a hammer, you smash it through your sewing plane. Look at this. I will hire you as a fellow. You're very good, Christian. Thank you. Thank you. So now everything is ready for the cut. I have my protecting key wire here. I have two parallel wires that are parallel to the tubular slope. I can cut. The only thing you need to remember is to protect the MCL now because nothing's protected. So if I do that now, I will probably cut everything without noticing it. Now I don't really need to see the key wire anymore on the X-ray. Do you want to change the saw blade? Yeah, maybe give me a bigger one, please. So the only thing I need is protecting, verifying maybe that this one is still attached, which is okay, protecting the MCL here, having two parallel wires parallel to the slope that drive the saw blade from the beginning to end. Give me the big one, please. And then I can cut. This is the worst part of the surgery. Of course, because everybody's afraid of that. But to be honest here, I have low risk to make a big problem. Everything is protected there. So I can go very, very posterior. And in fact, you need to, because if you don't do that... Make an X-ray. Make an X-ray and show them. Make an X-ray and show them. What you hear now is... I'm stopped by my key wire, I can't go further. I cannot go further than that because this key wire stopped me. So I cannot go anterior to that, so my hinge is protected anteriorly. And what I need to do is, of course, cutting the posture aspect of my tibia completely. So I'm ready to go behind, and you see, I'm protected by my retractor anyway, but I can go and cut completely the posture aspect of the tibia and go really to the end. So now what we're going to do is, of course, doing the bi-planar cut. So I use a Hohmann retractor, for example, to allow me to see. So yeah, what Christian is saying that you can check that your posture aspect with this thin ruler, we can remove this one, with a thin ruler, we can check that we cut completely the posture aspect of the tibia. So here I'm behind, everything is completely cut behind. And the only thing that is not cut is there. So my hinge is protected completely. Everything is done. So now what we're going to do is doing the bi-planar cut. So we use the saw blade, you can switch to a smaller one. I just finish anteriorly my cut to be completely close to my tibial tuberosity. And then same as Christian has done, you do a cut which is behind the tibial tuberosity there. And usually you hit your key wire at the same spot there, because of course this one is also protecting you from creating a too big cut. So here, anteriorly, I hit my key wire. So I cannot go further, but it's okay. And now the opening process can start. So you see my osteolomy is already moving. So don't break it, don't break it, Chris. So you can use this kind of instrument just to test the elasticity of your opening, you see? Everything is very stable. And now how to open. And this is something that Christian told me, and I will show you. So you need to dissect slightly the posterior aspect of your MCL to be able to open from behind. So you need to have an instrument to do that, and you need to have an opening to do that. So what I usually do, I'm stabilizing the opening with this, for example, this small six millimeter wedge anteriorly, or any kind of implant can do that. And as Christian told me, I'm doing my opening with this. So what I'm doing is I'm looking at the, if I want to do an eight millimeter opening, for example, I'm taking my ruler and I'm going, what is my eight millimeter opening onto that? And for example, here, let's say it's somewhere there. So I asked Christian to mark where is the eight millimeter opening, so we don't see that much. It's in between second and third. So in between the second and the third mark. And then I take this and I go into my osteotomy site from behind, and I will use a hammer. And I use this to go, and you just smash it inside. This thing became loose, of course, and from behind, I put that in, and you can see that my opening is occurring in a very posterior fashion. So if you look anteriorly, almost nothing happened. The good thing is if you want to compress anteriorly, you can always rotate because there is nothing anteriorly. And you can, you see, rotate, rotate slightly your opener to correct the slope or increase the slope. So this one is not very convenient, it's small, but you see, I can rotate that a little bit to compress my osteotomy site anteriorly. And now the best thing of that, of course, you can speak to your medial collateral ligament. Christian, you do the collateral ligament? Yeah. How do you feel, my dear, today? Ow! I'm tight! You're very tight. Give me... Oh, I will help you. Give me a small blade, please. I will help you because I feel you're very tight in the back. So let me help you. Let's do that. Are you here? Here? I hear you're very tight. Yeah, that bike resting feels better now. Nice to meet you. Yeah, that's good. Yeah. Thank you. This is it. And now, how do you feel, my dear MCL? You feel better, huh? So you can even push a little bit more of that and your osteotomy site is open. Let's remove the Q wires. Then the only thing is just like Christian showed you, basic tricks to put a plate on a stable fracture. Nothing will move. I mean, this thing is holding still. You see, the construct is complete. My hinge is stable. Opening is done in the back. I have very, so I have a, let's say, eight millimeter opening in the back. Only have two, three millimeter anteriorly. Everything is perfect. So then plate. So I use the tower and the plate like Christian showed you. The first good question is, where should I put the plate compared to my hamstring? Should I put it below the hamstring or above the hamstring? And at the beginning of my experience, I will put anything below here saying, oh, this is very good. It's protecting my plate. I have tons of tenosynovitis. So now I stopped and I just put it above the hamstring. So then I need a Q wire, just like Christian showed you. We put this reducer and I shoot one Q wire here. I try to find the optimal position of my plate firmly. Let's see. It's a very small one. And I look at the position of my Q wire and it's an anatomical plate, so you can rotate a little bit. But it's made to sit in a good position. One millimeter? Yes. I think slightly more. Yeah. Yeah. Great. But the wire is very small. Anyway, it's OK. So now, X-ray. We see that that's good. The position is nice. So what are we going to do? We can fix it distally at the same time. And then, just like Christian showed you, we do very easy fixate position. Another Q wire. Another Q wire. Thanks. So this is a very fast, flash-forward fixation. So Christian creates a system that gives you the... Hold the screws at the same time with the plastic aimer, but we don't have it here. And what we're going to do is just shooting some drills and do some pins. So usually, I'm always having almost the same size. I'm doing 55, 60, 45. The reason is this one, 55, 60, 45. The reason for that is this one is sometimes getting very anterior-posterior. So I love to have a small one. So you will not have any issue with the posterior tissues. So then, this one, we're going to measure it for you guys. So this is my 55, OK? You can go to 60 if you want, but 55 is OK. And this one will be my 45, you see why. So this is my limit. How much do you see, Christian, on the ruler? 40, 40. So even not 45 because it's a small caliber, I would say. So put a small one. So let's start with a 40, please, because it's still uphill. You see, this is very convenient. And I know if... Christian showed me that. I didn't know for years. You can put your tower with the screwdriver. It's very easy to do. Far easier than sometimes with fat people, it's very hard to dig into it. It's very easy to have it like that. So I put the 40 here, right? Let's do a 55. And we stop there. Then I will remove the entire part. And then, so we don't have to put any compressor there. So we can remove this. Of course, the plate will stay still. We can remove this one. We take this tower to get distal. And we just put one here. So usually this size will be 50, 45 and 40 for the last one. And this is, I mean, we can, I think we can stop here. We'll just remove this to show you how it works at the end. So now you have room. You have to put one screw inside when you want to remove the... The idea is you have room to put an allograft if you want, because you see, there is nothing holding me for putting an allograft inside because the opener is behind. I don't have this problem. So yeah, perfect. Don't worry. So give me a 50 please again. Yeah. We'll see. But 45, 45. Be careful, yeah. Tough bone, huh? Yeah, it's frozen. But he loves it. 50. Workout. Morning workout, Christian, huh? So let's just do a 50 here and we are done. We'll just stabilize, remove that and show you how the constructs is working on x-ray because actually you don't see much because the, the, the, this, this, this grasper is inside. Perfect. Yeah, this is it. Okay. Yeah. No, it's okay. And this is it. I mean, Christian, my, my fellow is, is talking the screw at the end, of course, because I don't have much energy left and you see how the, the, the, the perfection of the, of the astronomy gap, the hinges table, no big deal. Everything is very, uh, uh, is, is straightforward and we can graft because we have room, uh, to put another graph here. And I think the job is done. Perfect. Thanks very much guys. Big round of applause. That was excellent. Two demos. We have, um, any questions from the audience for Christian and Matt Jordan first deal. What are you doing? What are you doing for the MCL now? Is there going to be any sort of MCL repair or just leave it, just leave it distally guys? I think there is enough MCL inserted. I think there is enough MCL inserted above, uh, to have this, the, to not having any issue of instability. As, as you see my POL and my postural ligament is completely intact till now. I mean, I didn't, I didn't touch it. Huh? You see my MCL is still completely intact here. So the POL is intact, let's say, or the postural MCL if you want, and the anterior part is still attached above. So I don't have any laxity in my osteotomy. It's very rare. The only one that I get laxity is because I do... Perfect. What I suggest you do is, uh, there's a lab time now, so everyone can go get changed, get into the lab. We should be starting around about 9.30 by the time everyone's changed and we'll just make some housekeeping announcements once we're in there. Once you do get, get changed and get through to the, the sort of anterior room, you'll see, uh, some posters up in terms of the stations that you're meant to go to.

double-level osteotomy

femur

IT band

saw cuts

plate fixation

closure process

opening wedge osteotomy

tibia