I haven't had enough patellofemoral. I'll show one patellofemoral case, then we'll go on to some of the tibiofemoral joint. Please do not judge me. Okay, Seth, is he here? Somebody can go grab Seth and tell him to come on in. Because I see, and is Volker here? So I'm taking it over because we're five minutes past. You want to place them in the corner. Well, no, I just see that they're here. So we'll just start. Okay, I'm gonna go. Oh, wait, shit, shit. Okay, we have to get them in because they had a little preamble here. Mm. Ha ha ha. Yeah, that's bad. All right. Last session of the day. We still have a full room. So Volker and I hate complications, but we like beer, and so I guess I like Truly, so you could judge me. But I'm trying to watch my figure, and there are no champions here. So let's see if we can get that video to play. This is the dreaded hinge fracture, and Volker, I'm joining you in the ACC now. So I'll have to come learn some tips and tricks from you after you air your dirty laundry over the next 15, 20 minutes. The all-coast conference now, not the Atlantic. Before we start, and we have a bunch of faculty who have graciously allowed us to kind of share some of their most challenging complications, this is what I learned in my fellowship from Bernie Bock, who's here in Chicago, recently retired. But he told us to like your patients and to love your complications. So interpret that whatever way that means for you, for me. That means any inclination to run away and hide, you throw out the window. You go straight to these patients. You communicate. You give them your number. They get access. You see them frequently. You take care of the problem. You be the doctor that you wanted to be and you trained to be. And I think, you know, if we don't learn much anything more from this session, one is that stuff happens, and two, it's how we deal with it that I think defines us as kind of doctors and surgeons. So hopefully with that mindset and with more of an M&M spirit, we start this session. One of our co-chairs, Liza, will be first up, and we'll go from there. I'll get to the point pretty quickly. But this was a 33-year-old female. She did have Crohn's disease. She had a history of a mesenteric blood clot. She was a smoker. She was on Humira, patellofemoral pain, patellofemoral instability. And so we did an appropriate workup, and this was August of 2016. Just trust me that I thought that what she needed was a tibial-tubal osteotomy, and what I was going to do is distalize and medialize her approximately 8 millimeters using a gracilis allograft graft for the MPFL reconstruction. However, in the medical optimization, it was important to try to reduce her BMI. She had to stop smoking. And then with Humira, I do talk to the rheumatologist, and we typically stop it for one month. But as you know, they need it for other factors. But we do tend to treat Humira very seriously. So again, I did a straight shingle, again, maybe a little too thin. All my screws are bicortical. I usually use two. And you can see at four months, and the reason I was saying it before when Maria Tuco was saying it, is that I very rarely have problems with posterior healing, and I do have lots of concern about this distal gap. Well, this is both. Okay, so at four months post-op, and I typically keep a partial weight bearing for six to eight weeks and wait for healing until I let them completely off crutches. So the next step. So what would you do here? Anybody? Because I think that this was my first error. Well, let's just ask for a show of hands. How many feel that maybe it's a fixation problem and would just go back and try to place a more sturdy compression screws? Anybody? More. More. More? More? Would anybody take down the osteotomy site and try to redo it? I think it's down already. The patella is up. No, I don't mean down. I mean, would you... Take it down. So take it down. Take it down versus just to refix it. So take it down. How many? Take it down. And how many refixit? Okay. Well, there were a couple hands in the back the first time around. So what I did is I did what I thought was the easy thing. It was not obviously mobile at the time of the second surgery. So I did a screw exchange. I used a washer because I thought the graft was getting to be a little thin, the tibial slab, and I used a bigger screw. Bigger is better, right? At what juncture do you ask the plastic surgeons to come in and take a look and help you? You know, we never had a problem with skin issues. And we were just talking up here. That is one of my most dreaded things. Luckily, I've had enough problems with no skin issues with healing. Bone issue healing, yes. Did you take samples at this time? Samples? No. Culture? Yeah. Yes. And so again, I'm just going to quickly remind myself. So this was November 16th, four months. And so this is four months later. Okay. So I thought it was pretty good. I could have maybe brought it down a little bit more, but now I'm just worried about healing. Screw the patella height, right? Okay. So here's March of 2017, April of 2017. You kind of see where we're going, right? So before my very eyes, the bone is just dissolving. And so, not to belabor the point, watch for waiting, revision. So what I did is I did a revision distillation, took down the tibial tubercle, went down to a bleeding surface. I revised it with swivel lock anchors and the transverse tubular plate. Here's my, at the time of surgery, you can see we don't have much bone left. And so I ended up using this cross-interoperative crossing with fiber wire. I used a tubular plate in a horizontal manner. I've done vertical as well. I chose horizontal. Maybe another mistake. She on medication. She, okay. Bisphosphonates. And so, we'll get to that. So bisphosphonates, what are you saying? Maybe look at bone health. So she's back on Humira. We try to get it on and off. Okay. So we're July 17th. And again, it's just like the whole thing is just like dissolving in front of me. So with the semi-tubular plate, and what I wanted to do was secure the graft, whoops, and go on either side. We just lost my video. So I tried to put the semi-tubular plate across, you know, two into the bone. Anyway, there's lots of things I could have done different, which I'll try to talk about at the end. And she went on, this is July 17th, so now we're a year and three months. And you can see that I fractured the bone. And so now she's having progressive ALTA. She's actually worse than when I started. And her CD, well, actually, it's about the way I started, CD of 1.5. So you can see that, so this is a progressive issue. So I think, yeah, it's a bad problem. And so during this time, not to belabor the point completely, she had multiple GI issues. She started off with a BMI of 36. She's now down to a BMI of 32 without trying to lose weight. She could still do a straight leg raise without a lag, believe it or not. She did not have instability, but she didn't trust her knee. And she chose to have no further surgery. Now, she was a graduate student at the time, she was trying to finish her PhD. She was really sort of overwhelmed with some of this GI issue that they really couldn't completely define. But what I thought was, and she chose not to have any further surgery. This is 2.5 years later, January of 2020. I actually recently called her in the beginning part of this year, and she still said the same thing. She never had further surgery. She doesn't trust her knee with steps and declines, but her life is complicated enough she doesn't want any more surgery. So what do I think that I could have, should have done? Many different things. I think that the first time that I went back to this area, and I chose the easy way, which I'm still kind of annoyed at myself with. I should have never just done a screw exchange. Or maybe I should have done a CT scan to assess for any kind of bony healing across what looks like it's a fibrous nonunion. But it was only four months, I thought, oh, well, let's just try it. Because it wasn't super mobile, anyway, I thought this was my first mistake. But then I probably should have used, whoops, sorry, I'm going backwards. I probably should have looked at bone health. I never checked for vitamin D, which again, as a surgeon, I'm mad at myself. As a female, I'm triply mad at myself. Because I should have known better to look at bone healing. And when this bone was just dissolving in front of me, I was thinking more of the fact that she had some kind of inflammatory thing. And so it is a biological issue. But what could we have done once I started down this track? I also could have considered bone grafting with iliac crest or some kind of bone demineralized matrix. Maybe when I did the revision osteotomy, I could have done some kind of V-shape so that I, well, initially, knowing that she was on Humira, and knowing that she was going to go back on Humira, I probably should have done a V-shaped osteotomy for sure, given us more cancellous surface. And then I think that I've sort of had it with, this is another nonunion, not mine, but this is one I'd fix, is that I believe that, especially when you have not too much bone left in your tibial tubercle slab, that you shouldn't be using a vertical plate. I'm sorry, a horizontal plate, that you should probably be doing some kind of vertical plate. So that's my complication. I learned a lot from it. And as you know, the first one I started in 2016, at that time, I was a surgeon for well over 20 years. So I wish I could say this was early in my career. Yes, Seth. I'm curious if, at any point, you consulted trauma colleagues to see how they might handle this with regard to both fixation and biologics, because I always wrestle with when to phone a friend, and I'm pretty quick to do that. I'm just curious. Well, I did talk to Mark Swientowski. As you know, he's our trauma guy and our former chair. And he is the one that has made some suggestions in general, but he's the one that actually suggested the semi-tubular plate, where I think that I like this construct better. But no, I mean, I do. This particular time, I'm not sure they could have helped me, but maybe. Anybody else? Yes, Ned. I've had a few of these as well. And you know, you wrote on the Hauser procedure. And that's what I do for these. The reason they fail is I make a hole in the bone, and I put that bone that's left over inside, like inside the bone, so that you can't go proximal. You know, that proximal part of the tubercle gets hooked on the cortex of the tibia, and it's in the bone. It's surrounded by healthy bone. And you can really control distally where the patella goes. Once it's in the bone, I put anchors, four anchors around it, and suture down all the soft tissue and tendon. And it actually works, and I think it heals well. Rather than trying to keep it superficial and putting fixation on it, it actually works very well. So there is a use for the Hauser procedure for complications of this type. So the Hauser procedure, only old folks like Ned and I know. But they used to make a square on the medial side of the tibial tubercle, and kind of take a bone block and kind of flip it in there. And some of the complications were anterior compartment syndrome, because it caused bleeding in the anterior compartment, and then relative shortening of the patella. But when your patella was as high as this one, I mean, that way you can afford to push it into bone. It's very, very clever. Yes. David. Yes, it's very sobering. It's very well described in the arthroplasty when you do a tubal osteotomy for exposure and you fix it back with circlized wires and that's a way and so that some of them can go through the fragments just around the fragments and that actually works pretty well so that's another just another option. It's a good option. Any other comments or questions? Yes? Just what kind of along that same line you know I wonder about you know like you say talking to the trauma colleagues is using some tape suture in like a detensioning fashion so just above the patella and coming through on the tibial cortex and just to help take the tension off. I don't know if anybody's tried that or if that's a good or bad idea but that just kind of. Well actually it's kind of what I did this these fiber wires that's what I did. I sutured the it's what am I looking for I anchored the fiber wire in good bone on the distal inferior medial and the distal lateral aspect of the bone block and then you can see that crisscross. So these are this is crisscrossing over I think this looks great didn't work but I felt pretty good leaving. Yeah I crisscrossed it so I got it in good bone with some suture anchor fixation and crossed it over like this. I did not bring it up over the patella. I could have done that yeah. Yes? Well in hello in the biologic problems I like PRP and shock wave therapy. I'm sorry what was the question? Oh well yeah maybe I don't know maybe I didn't think of PRP or shockwave I think those are all things that might add to the biology of it. So yes those those are thoughts good thoughts. Anything else? Yeah I have a quick question. Have you or would you operate or do this procedure on somebody on Humira who is a smoker again? Well Humira yes but not as well I mean we do in her I did check for her nicotine level before surgery. I don't do that for everybody but I mean I can't not operate on people with Humira. I don't think because there's a fair number of people that are but what I have I mean I think that there are things that I could have done better right from the start and probably number one I would have taken a bigger deeper osteotomy cut and maybe done a little bit more looking at bone health and maybe even nutritional optimization. I mean she was a little bit heavy when she started but I never really looked at her nutritional values and things like that. So yes. Right. That is something that, you know, Don Shelburne does it. That's something that David Parker said. So that's just using a small plate. That actually helps with the distal plate healing, or that dreaded black line, or the distal osteotomy healing. For her, I don't know. It was just a biology of healing. Yeah, that's a good thought. And there was one more question. That will be the last one. There was one behind. Wisconsin boy. I don't for everybody. For her, I actually did. Well, the nicotine level that we get takes about four days to get back from our lab. And it shows you the nicotine level over the last couple of weeks. I'm not sure exactly. I don't know it like an A1C. But it's not perfect, because it's not in the moment. But I do ask. I usually ask. It's like under 0.4, or something like that. But it's imperfect. So, okay. We're going to go on to Nan Patella. Thanks for sharing, Liza. Yes, Liza. Thanks. Thanks for sharing. What's all this? Wait, let me show one thing. I'll just show my soft underbelly real quick. This is mine in board collection. Similar type of distillation catastrophe. So I think this has happened to a lot of us. The points are well taken. And now we will turn it over to none other than Rachel Frank, who self-proclaimed that she has several fun complications to share. Thank you, Seth. I believe that I was invited to this meeting for this particular session. I do specialize in complications. Who in the room has never had a complication? Never? Never? Okay. So important, like Seth said, important to admit your complications and treat them well. One of my mentors, while the slides are pulling up, I'm going to try it on the other. Oh, there we go. Used to talk about the four stages of regret of being an orthopedic surgeon. So this is Aaron Rosenberg, for those who know him. He's a joint replacement surgeon. We just lost the slides again. There we go. So stage one regret, I regret doing this case, like we've all been in that stage. Stage two regret, I regret coming to work today, so that's when case after case after case having a problem. Stage three regret, I regret becoming an orthopedic surgeon. That's bad. When you get to stage three regret, you're having a bad week, month. And then stage four regret, I regret being born. You hope you never have a complication that gets you to stage four, but I think all of us in the room who do enough surgery have probably been through stage one, two and three. These cases are not that, but one's something that for surgeons of all levels and experience levels may experience, and it's one of those moments you would think in the OR, what should I do? So this is a 53-year-old male, varice malalignment, medial knee pain. Took him for a high tibial osteotomy using PSI, thinking everything's going well. And then I see this upon opening. So this is why I go a millimeter a minute from now on. So this is a Type 1 hinge fracture recognized intraoperatively. Now those who are super experienced in the room may say no big deal, this is a stable injury pattern. But if you haven't ever had one of these before, or you're not aware of what these mean, you might have a little freak out moment in the OR and think, what should I do? So is anyone doing anything different than putting on their locking plate? What are you doing? I think it's Type 2 because it's going a bit distal there? Okay, so Type 2s are bad, Type 3s are bad. So what—so first you have to recognize it. Type 2 goes down there. You think it goes down? All right, so what are you going to do? Add a hinge screw. Hinge screw? Or plate. Or plate? This one has worse. Anyone else doing anything different? Okay, so this is where for all of my osteotomies I have the kitchen sink on backup. I'm putting in a compression staple. And fortunately this patient ended up doing quite well. So this is an intraoperative complication. You have to have tools in your toolbox to manage it. If you don't bring things to these cases, whether it be backup plates, your trauma plates, staples, screws, whatever you think you might need to bail yourself out, you will get caught in a situation where you don't have anything and then you have a big problem. If you choose to not recognize the fracture or kind of ignore it and take a different fluoro shot and maybe not save the fracture shot, you'll be sorry when they come back to the clinic and they've either lost their correction or they're having a lot of difficulty. So fortunately this went well. Patient did quite well. Super happy. We don't change his recovery. I still don't change or limit their weight bearing any longer. You know, one of my happier patients, we did our interview in Spanish because he's a Spanish speaking patient and he's super grateful and happy. This is a simple fracture that can happen but can happen to any of us and you want to know how to manage it. Seth, you had a comment? Yeah. Just can you clarify your order of operations so you're there, you see the fracture, what's next? Are you stopping everything, fixing the hinge, then going on with your osteotomy? Take us through that. Yeah. I'd be curious as to what the panel or what the faculty think, but when I recognized this, I stopped. I actually did go ahead because I had a screw above and a screw below and I left everything. I went ahead and put on my staple at that point. I didn't want to risk anything. I think, quite frankly, I probably could have fixed the rest of the plate and then done the staple as long as I'm checking that nothing's moving. But I just wanted to make sure that as I'm torquing on those screws, getting final tightening, that I'm not going to make this worse because it's already a problem. I've recognized it. I'm going to fix it. Any of the other faculty or, you know, delegates here do anything different? Okay. So not the worst day in the OR, but not a fun experience and you've got to be ready for anything. This one's a little bit different. This will take just a little bit longer to get through, but not too much. So this is a 29-year-old male who presented to my office my first year in practice. And just for background, I didn't really learn osteotomies in residency or fellowship, but very interested in joint preservation and you have to have an osteotomy component to your practice to do that. So I was quickly becoming one of our osteotomy people at the U. And so this guy comes in with an abnormal gait and instability and his only relevant history, he's totally healthy, totally normal, athlete. He had an injury four months prior while playing soccer. So he had a soccer injury four months prior. He underwent a surgery. And I'm telling you this story as he told it to me. So you have all the information I have in real time. He states that he developed some sort of wound cellulitis after that surgery. He was treated by his surgeon with oral antibiotics. On exam BMI-22, he had an abnormal gait with valgus malalignment that you could see was asymmetric on the surgical knee. On that knee, he had a moderate effusion. He had this oblique incision over his proximal medial tibia and a longitudinal incision over the lateral knee. His range of motion was limited as you see here, guarded ligamentous examination, slightly loose ACL. And valgus, that was his baseline valgus, correctable to neutral, neurovascularly intact. This is his gait. So again, I'm a sports surgeon and this is this guy coming into my sports medicine clinic and probably could have come into like a limb deformity or a limb restoration clinic. And again, he was walking totally normal, playing soccer four months prior. So something's obviously wrong with this. He has Coban because I aspirated his knee to rule out infection. This is just his valgus examination here. And are you ready for his radiographs? I'll show you his kind of stability examination. Okay, here's his x-rays. So here I'm trying to figure out what happened with respect to the soccer injury because he's not sure what was done. He just knew that he had a surgery. And so it looks from here that he had a high tibial osteotomy, some sort of lateral sided ligament reconstruction, and then possibly an ACL just based on all of this. And one heck of a hinge hole, as you can see here. But not a hinge hole. That's actually from his posterolateral corner. And then these are his standing alignment films. You can see he's an asymmetric valgus. That is correctable when you push on the medial side of his knee, but certainly asymmetric. These are some radiographs. I took stress radiographs. We got an MRI that was kind of unhelpful just given all the metal in the knee. So what would you do at this point? And to get to the rest, to give the other speakers opportunity to talk, I aspirated the knee because he had this history of infection. He was swollen. He was not currently infected. And then I said, we got to get your old records because I don't know what's happened here. I have a thought in terms of what I need to do to fix it, but I need to see what happened. So we got a hold of his old records and his previous surgeon did a full workup. It was actually amazing in terms of the workup. So this is his baseline limb alignment at the time of the injury from the other surgeon. So you can see here, and I showed you the line on the other knee on the previous x-ray, but essentially symmetrics, you know, physiologic varus in both knees. The other surgeon also did stress x-rays on both knees. And as you can see here, they're the same. And then got in— Safety. Sorry? Radiation safety. Yeah. Oh, yeah. You can see a good hand x-ray sign there. And then we had an MRI that shows no pivot shift bone bruise, certainly a disruption to the lateral side of the knee, no appreciable ACL tear, although I will say it's always easy to play Monday morning quarterback and judge other surgeons' decisions. I wasn't there. I don't know what the patient presented like at the time, but it just seems like the x-rays and the story with surgery didn't match up. So what ended up being done that we got from the records was an arthroscopy, an ACL with hamstring, a post-lateral corner using Dr. LaPrade's technique with allograft, and then a valgus producing high tibial osteotomy with a 10-degree correction for this acute soccer injury. So now what would you do, because this is a complication, right, from this first surgery. It's a complication of indications and potentially execution just based on that kind of hole in the proximal superlateral tibia. What's everyone doing at this point before I get into what I did? I'm just curious. Volker, what do you think? No, I would like a little more data on exactly what the numbers are on your distal femur, your proximal tibia. The 10-degree correction is a bit crazy, and you may need to consider undoing the correction. I don't know if his lateral side is working. It's hard to tell. It's a little bit hard to tell, yeah. CT? I think you need a bit more data. Seth? I'll defer to the other experts on what to actually do, but I want to know if the patient asks you, Doc, what went wrong? How do you manage this as a person? Well he did ask that, Seth, so that's a great question. A lot of these patients ask that. That part, Seth, is easy. I wasn't there at the time. Let's just work with what we have. That's usually where I go with this. Yes. Yeah, so you could ask this. We're all second, third, fourth opinion surgeons, I think, in the room. If you're doing osteotomies, you're doing complex work. My go-to for this is lots of surgeons have different approaches to the same problem. We go to conferences, and we put up an x-ray, and there's five surgeons, and there's eight different answers because many of us have multiple opinions. Fortunately, in orthopedics, there's many right ways to do things. I wasn't there at the time of your surgery, so it's really difficult for me to comment on what was done and why, but let's focus on what we need to do now. Sometimes they push you. My approach is I don't give in because, quite frankly, I wasn't there, and I'm sure I have complications floating around that maybe some of you in the room have fixed, and I don't even know about them. I hope not, but I try not to play that game because I just don't know. Even if you see an egregious vertical tunnel, you weren't there. You don't know. You don't know what happened, so I just don't go down that road. Anyway, my plan for him, I agree, Volcker would be great to have some additional data which I didn't share with you, and a CT. I think we actually did end up getting a CT just because I wanted to check his old tunnels and check his alignment in a bit more detail. This was before I was familiar with PSI, not really thinking about that at this point. This is where I'm thinking, how do I fix this problem? Do I need to phone a friend? Is this in my toolbox? I actually did do this. Again, I was in my first year in practice, so I want to give credit where credit's due with my partner Armando Vidal at the time, and we tackled this together, and we planned for removal of hardware, closing wedge HTO to kind of bring him back to where we thought his baseline would be, and prepare for fracture because of that hole. So these are the intraoperative films, and you can see that hole that I think is for his tibial-based posteroidal corner reconstruction, at least that's my best guess as to why that hole is there. But you can imagine if you're going to take that plate out and try to close this down, you're probably going to fracture. So we planned for that, so we took the hardware out, and then we used a K-wire to osteoclase the lateral cortex through that hole, kind of minimize the stress that would be through that hole when we closed it down. And of course, we did have a controlled fracture in that setting. We brought him right to neutral. We did not touch his corner. We did not touch his ACL. And then we put on the biggest, fattest, most sturdiest plate I could find and locked him down, and fortunately, he did quite well. I think in hindsight, you know, knowing what I know now, we may have been able to play with his slope a little bit in this case, given his ACL, but we didn't even approach that in this case. This is him. That was him in recovery, walking more normally. I actually see him back yearly now because I want to make sure he's doing okay. He just came back for another knee problem in the opposite knee, but super grateful to have kind of a normal knee. So I bring this case up because a couple reasons. One, I think it's important to talk about when things come into your office, you've got to get a workup as best you can. You've got to figure out what was done the first time. You've got to be respectful of whoever was in the case the first time. You weren't there. Don't talk bad about them. But also have a game plan for how to fix this because it seems like the first surgeon was well intended. They did stress x-rays. They got the standing alignment. They had all the right thoughts, but didn't execute the right way for the right indication, and this is what happens. So we have to not just use the knowledge that we're learning in this course here, but apply it appropriately. So I have many more complications, but I want to let other people have the opportunity to present. But if you want to learn about complications, you go to the experts to learn about osteotomies. I'll tell you how to deal with the complications. Thank you. Thank you. Okay, that was a pretty crazy case. So this is a very fun 35-year-old gentleman who actually drove into clinic with his big pickup truck right in front of me, and the back window of the pickup truck had the American flag on and big MAGA letters and all this. It was just really a funny gentleman, but so he underwent this osteotomy about five months prior to appearing in my clinic, and years earlier had done the contralateral leg. So obviously when you see this broken screw, you know you're probably dealing with a non-union, and so what's, you know, and again the narrative is the same that Seth just brought up, you know, so I'm not sure exactly what the deformity was to begin with, although I kind of knew from my previous surgery, but what we're dealing with is that he's still in seven degrees of varus. We're dealing with an 18-degree slope, so that was increased by the plate being placed typically to anterior. And I want to highlight this case because I love playing around with these 3D printed, so I get CT scans and then 3D print from the CT scan the actual bone, and it gave me a much better understanding in this case what to do and where. But so on this very left image, the black part is all the non-union, and then you can see here that obviously he was trying to heal it here, except the plate was not only placed to anteriorly, but also it wasn't placed into the osteotomy gap that was made, but proximal to it. But then when you have this model in your hand, you kind of get an idea of where to go with your non-union repair. And in this case, I mean, there are different options what to do, and you can most likely do this in one stage, but I just didn't dare do that. So initially I removed the hardware, and then instead of repairing the whole non-union, we just went distal to it, went into the appropriate plane and corrected his varus. And then later, you know, he came back, and then we did, like Rob LaPrade showed earlier today, with the tubercle elevation, the slope correction, revision ACL reconstruction. So the point here is, you know, respect your posterior structures. Make appropriate MCL and posterior releases. Make sure you get the entire posterior cortex. And I think all the software that's been shown today is really the way to go, so you can appropriately plan what angles you need to go after. So any questions for this case? It's just a short little case. Anyone would have done anything different, maybe one stage or closing wedge? I think you're right. I mean, it's very hard to correct what was done with a single postural opening wedge, trying to return back to the good side without having bad issue with the nonunion and so on. So staged it is what was, I think, a good option, to be honest. Yeah. OK. Now, this is a classic case of bad indication. And I was the one that made the indication for this case. So this is a 45-year-old who originally had a multiligament knee injury, underwent an ACL reconstruction. They had failed this and had revision ACL, pain, stiffness, instability. Now, most importantly, he's diabetic, and he's a smoker, and he's not a very healthy person, but had a 9-degree varus and a 10-degree posterior slope. And so I was very clear what needs to be done. But these are the MRIs, not very interesting. And so the whole story, of course, is a long, nasty story that will happen to you, ending up on a nice gastrocnemius flap. But the problem, obviously, was first there were wound infections, massive swelling, lots of noncompliance, as you can imagine. Coming back to clinic with a leg twice the size of that of the other leg, gets admitted, and then discharged again, and then had multiple INDs, which eventually led to the place where the plate was exposed, and then had, eventually, the gastroc flap, and then hardware removal. So once all that was done, of course, it was left quite stiff, and it was very difficult. So the lesson on a case like this is, obviously, a patient selection, like Liza had mentioned earlier. So it's probably a good idea to follow the A1C and really optimize the patients and give them sort of this perioperative center or preoperative center where they can go on and do all the optimization, measure nicotine level, et cetera, and set realistic goals. Infections are not very common. Deep infections, 0.6%. So if you want to see them, come to me. I'll show you. Seth? I'll just comment that the eventuality of having a gastroc flap as a ramification of TTO or HTO surgery is real if you're high volume and for different etiologies. I had a string of a few DVT-PEs early in my osteotomy experience that led me to think that I could do Xarelto instead of aspirin. And that led to a subsequent string of wound issues and complications. And now I do aspirin only, 81, wondering what the group does. But just that's a really challenging thing to deal with for a doctor and a patient. It's a deformity in and of itself, but a superficial one. And this is the most challenging one where you've got to like your patients and love your complications. Yeah, and I think most importantly, you need to consent. The moment of consent is a very long moment, a very long pause, and with hopefully questions coming from the other side and also explanations. What all can happen? Really explaining what a non-union is and what it entails, hardware removal, these things, infection. I did not spell out gastroc flap for him. He has no hard feelings, by the way. But this is something you sit on this like Bernie Bach told you and Freddie told me, like every week, every week you see this patient and just be on top of it. But can I ask before, Anil, who in the room uses routinely Lovenox or low molecular heparin for this? So only about six people. And then who would go to something like Eloquiz routinely? Few. And then who does aspirin routinely? Wow. And who does no DVT prophylaxis routinely? So very interesting. I struggle with aspirin. Not sure in coming home from a congress like this or meeting, you always think, should I change something? And Werner Müller had a super quote. He's like, you know what the worst day is for your patient to come to your office? The day after you return from a conference. So be careful. Anil. Well, the non-union is a different issue. But the question is a drain. How many people do a drain with an opening wedge osteotomy, even though we've, one of my old philosophies why I use allograft to fill the bone, because I was always trained by the Swiss and the German not to fill the bone, because that was terrible, was because of cancellous bone, hematoma, bleeding. You have bad protoplasm. I like to fill the bone to control the bleeding. And I still always use a drain, especially on bad protoplasm. I'm curious what everyone thinks about using a drain. I've never resented using a drain. I've only resented not using a drain. Who uses a drain routinely? Who uses a drain sometimes and never a drain? Yeah, it's interesting. It's a great point. I certainly wish I had a drain here. I don't usually use it. I really have minimal blood loss. Yeah. And I'm not, I've left, I've never even. Yeah. So the question is tourniquet, and I mean, after your exposure is done, there really isn't all that much more bleeding. Now, once you open the bone, then there's blood. I like not using tourniquets, so I see what's happening. If I use a tourniquet, then I certainly let it down before I go home, but. Yeah, TXA, does everybody routinely use TXA? I think that's helpful, and it helps intra-op and also post-op. Please. Come on up. Yeah, so I, nothing is routine anymore in the United States, so because sometimes people just get shoo-shooed out of the hospital and then have hard feelings afterwards, I now tell them, I give you the option of staying overnight. If I have it my way, yes, they stay overnight. I would just prefer that, just so also I can see him the next morning. But so who does this as an outpatient? Clearly outpatient surgery. And femoral osteotomy, clearly outpatient surgery also. OK. Good. The real question is, does he get medical care in the hospital, or does he have a good family? Yeah, yeah, yeah. It's a good question. I agree. If you have a good family and a good social situation, I agree with you. But not all of my patients do. He did not. Yeah. Go ahead. Thank you. I feel better now. Thank you. Thank you. All right, Volker had his catharsis. We have 11 minutes, a hard stop at 830. We have Al, Ned, and maybe Matt. Let's go. All right, I got to get through this really quickly because it's too painful to even think about. It's quite a while ago. OK, so hang on. So go back. So 45-year-old male. He has this alignment. And this was actually, I think this was probably about seven or eight years ago. And I did a double level. I think this was possibly one of the first DLOs I did. Didn't quite get his correction, but not bad. I mean, he did very well. This was not a problem that was you could have. Maybe. Possibly. OK, Rob. All right, so it's OK. This guy was a little bit, he's a bit of a troubled guy. So I can't remember. I think it was maybe like maybe three months or so post-op. He went to, I think he was in Cuba over New Year. And he partied pretty hard. And he was dancing on a tile floor. And he fell. And oh, no, sorry, hang on. I actually did a double. I did the other side as well. Got the correction better that time. OK, well done, me. OK, but then, right? So the second time around, I think he was actually a little bit more confident in what was going on. So then he falls, and this happens. So he's now got his left side. He's fallen, and he's got this fracture, OK? Yeah. It's like, just purely from looking at that, because we all have those issues, it looks like you had probably too much of the biplane that was too thick, actually. So you almost had no support of the true osteotomy. And this is when all those spiral fractures occur. And you notice that. I can show you one of those now. I also only got three screws, approximately. I didn't put in that most proximal screw. We got away with it on the right-hand side. But on the left-hand side, it didn't work out so well. So anyway, this actually isn't the complication that I wanted to show you. It gets better, OK? So anyway, so obviously, you've got to sort that out. So I'm going to obviously replay it, OK? So operating in Canada sometimes can be a little bit difficult. So I managed to get this case at the same time I was doing another list. So I had a double list, OK? And so I think, in my wisdom, I put him in this emergency list. And I have my fellow at the time. He's going to take the plate out while I'm doing an HTO in the other room, OK? No problems, right? That should be easy. So I'm in the middle of doing my HTO. And one of the senior nurses runs into my room and said, you needed an OR7 stat, OK? So I pull off my gear. And off I go to OR7. And I walk in. And the fellow has got his hand in the wound. And he looks like this. I can't see his face, but his eyes are. I say, what's up? And he takes his hands off and poof. So not good. So obviously, it hit the superficial vermal vessel, OK? So what do you guys do? Rob, what do you do in that scenario? Let's take any vascular complication. What would you do? We don't have a vascular surgeon at our surgery center. So we put him in an ambulance and send him over. And you probably have to go in the ambulance with him to have pressure on it. OK, so David and I were at a meeting recently where it was actually one of our fellow's meeting. It was spectacular. And it was a video of damage to the aberrant vessel, the anterior tibial artery. And somehow, they actually managed to have the time to take a video of it. So it was watching. And this thing's just spurting out. You think, maybe you might want to put the tourniquet on, right? It was kind of interesting. But anyway, so with this one, we basically got the control of the bleeding, vascular clamps, clamped it off, called vascular. And then the vascular guys came in, did a vein patch, so repaired the artery. And then I fixed the distal femur with this locking plate. That being said, do you perform these procedures in ambulatory surgery centers or only in the hospital setting where the vascular surgeon is there? So this was done at the university hospital. But we didn't have a vascular surgeon on site yet to come from the different hospitals. So he came in. But you can put a tourniquet on. You can put vascular clamps on. You can isolate the vessel, control the bleeding, buy yourself some time while we were doing that. We could also then basically get on and fix it. And then he came in and did the surgery. And then we finished off the fixation. But what was very interesting for me, anyway, was that because I actually hadn't personally caused the vessel injury, it was much easier for me to deal with. I didn't have that sort of guilty feeling, sort of, oh my god, what did I do? What did I do? I can actually be a lot more level-headed about it. And I think if I had done it myself, it would have been absolute torture. But it was definitely a tough case to deal with. But the other point that I want to bring up with this is that this is ultimately my responsibility. At no point in time did I ever throw my fellow under the bus on this one. It was, you know, yes, we had this injury and we dealt with it. And thankfully, he did very well. And he's been on aspirin ever since. But the other fellow finished that one and then had to go back and sort that out. So anyway, so vascular injuries, unfortunately, do happen. And it was certainly, it was a learning opportunity for me. So did you feel like you needed to do much to help him? Yeah, so I mean, so you obviously with the medial side, and I showed in the demo today, that when you're cleaning off the muscle in a virgin knee, you basically can easily strip the muscle off the intermuscular septum. And you've got about 12 to 14 centimeters proximal to the femoral condyle. It's usually about 15 to 20 centimeters from the distal end. The plate is designed in such a manner that it should be within that safe window, right? So you're not close to the hunter's canal. He, unfortunately, because of a lot more scar tissue, was using cautery to, like a lot of time when we do hardware removal, and they've been taught, I don't like to use cautery. But cautery was being used to do the dissection. He just went a little bit too far, and boom. So he learned an awful lot from it. But you know, I learned a lot from it as well, in terms of actually recognizing the potential for that complication and making sure that people are adequately versed ahead of time. Seth. You and others do a lot of osteotomy. How do you, and when do you look for an aberrant artery? And maybe explain just the level set, like what that is and what the incisions are. So aberrant vessel basically comes off, normally that the anterior tibial artery comes off posterior to popliteus. What you can have is an aberrant branch, which comes anterior to popliteus muscle belly. And there has been some case reports shown that at the time of osteotomy, that can be damaged with, you know, either your osteotome, your saw. And some people would advocate doing an MRI scan to check for that on a routine basis. If it does happen, you can essentially, well, one is recognizing it's happening. So if you release the tourniquet, or as Matt said earlier on, you do the surgery without tourniquet control. So if you do get bleeding, you can deal with it. You can essentially open up your osteotomy even wider, and then you can clip the vessel, hopefully. Okay, and it's not a big issue if you do that. It's never happened to me. Question of what you, do I go looking for it? No, because for me, it doesn't change anything that I do. My surgery is the same. Even if I saw it with an MRI scan, I'm gonna do exactly the same approach. I use a window behind the superficial MCL in front of popliteus, rather than elevating everything. I think you guys have published on that before. And so we can show that in the lab tomorrow. It's a very, very safe approach. Across the back of the knee, you've got a blunt retractor, always at the back. And so for me, it does not change what I do, so I'm not gonna go looking for it. But interested to understand if anybody else does anything different. So it happened to me. And in fact, there is no way to avoid it. It's impossible, because even if you recognize that, you cannot put any retractor to protect it. So basically, you just, when it happened, it's bleeding like hell. So you already have the impression that you cut all the vessels behind. And in fact, it's a tiny branch. And when you do, you take your laminar spreader, you open more, you put some water inside, and you see where the vessel is, and you just use any kind of forceps, and you just coagulate it. And it's done, it's over in five minutes. So it's not something that you really need to be afraid, but you need to know that it's there. And the only way to do is to get through the osteotomy site. Don't try to get from behind, it's impossible. I got this vessel doing an eye balance, like the peak one, because I thought I had the perfect safety margin. I was plugged in, and my fellow was doing the case, I was hanging out. And then it started bleeding. And by the time, I call vascular, do the things that you normally do, coagulate, like Matt said, by the time vascular shows up, there's no bleeding, it was solved, and they looked at me like I'm an idiot, and then walked out of the room. So that was a great outcome for me and the patient. Sometimes it's just good to look like an idiot. Obviously, we're at the hour, so you make the call. So we have a hard stop at 8.30, because the staff here, they all need to go home, obviously. So a couple of housekeeping things for tomorrow. Registration, well, breakfast starts at 8 a.m. tomorrow. 9 a.m. is the start of the lab. At 8.30, we have a demo by Christian and Matt, who are going to demo the new CLIP instrumentations. That means that's going to facilitate your experience with the lab a little bit easier, so you get the maximal learning opportunities in the lab. So 8.30, it'll be a demo in here over breakfast. Enjoy the evening, and I look forward to seeing you all tomorrow. Thank you. Thank you, guys.

knee osteotomy complications

patellofemoral hinge fracture

healing issues

tibial tubercle nonunion

infection

wound cellulitis

double-level osteotomy

fractured tibia

complication management