Now, the reason we're all here is to see our worst complications. So I'm going to start with one that I'm going through right now. So it's very fortunate that this gentleman has been injured by me, so now I can talk about it here at this conference. So this is a 55-year-old gentleman who's had three years of medial-sided knee pain. He status posts a bunch of different kinds of treatment, physical therapy, bracing, cortisone, physical supplementation, NSAIDs, and he's got symptoms that are corresponding with medially-based arthritis. And here's your pre-op imaging to, again, support it. He's got medial DJD on his left knee, patella femoral compartment, lateral compartment relatively well spared. Preoperative MRI shows pretty significant cartilage loss and bone marrow edema, some meniscus deficiency in the medial compartment. Lateral compartment looks pretty clean, and here's his alignment view showing slight varus alignment. You know, with this, you've got a gentleman who's failed non-operative management. Just a quick poll from the panelists, what would you do for this patient if you opted to go for surgery? So I guess, Darren, what do you think? 55 years, skinny, non-smoker, very active. Yeah, so my joint colleagues might want to put a uni in him as opposed to an osteotomy, but a lot of it depends on his, not his chronological age, what is his physiologic age, and what does he like to do? So his activity. So it's either probably uni versus an osteotomy. Jason? Yeah, I mean, I think, you know, if he's a guy who's, like, out hiking and doing a lot of very physically active stuff, you know, he looks thin, and, you know, some of these patients do really well with a high tibial osteotomy. If he's sedentary, you're wondering, like, is it going to be crappy bone, then probably a uni by one of your partners, or if you do them, it would be probably a good idea. I agree. Yeah. So this is a skinny gentleman, very active, likes to run, play tennis, play golf. We went over the options again, uni versus HTO, and we elected— Mike, Mike, can I say something? Of course, Chris, what's up? Let me go back. What's his alignment? Maybe I missed it. How many degrees of varus is he? He's in about five or six degrees of varus. So if the correction's less than a sinometer, I'm doing a closing wedge osteotomy. If it's bigger, I do an opening wedge. He seems active. I think an osteotomy's indicated. Yeah. So we did an osteotomy for him. So first we scoped him just to make sure that the disease was isolated to the medial compartment, which it was. His lateral compartment was pristine. The telephemeral compartment was pristine. It was all medial, grade four significant loss on the femur and the tibia, and we did an opening wedge high tibial osteotomy using an inset plate, and everything went well. We didn't see any complications based on this initial image, so everybody was happy. Two weeks post-operatively, he was doing great. He pretty much had full range of motion. He was eager to start with physical therapy. Everything was going nice and smooth. Six weeks post-operatively, he comes back. He's in pretty much no pain. He's eager to start weight-bearing. Again, the x-rays look pretty good. I mean, Lathe, you've seen me do worse than this. So I'm pretty happy with what we've got so far. Then he comes back three months out from his surgery, and he goes, Doc, I'm having some lateral pain now. It's like, I don't know why I'm having so much pain on the other side of my knee. So we go in, he walks into my office, and you can see that his leg is in about 10 degrees of varus now. So he went from totally neutral, or excuse me, a little bit over-corrected, to now in a pretty significant amount of varus, more varus than what he had pre-operatively. And you can see a laterally-based fracture. I guess this is a type two fracture, if you want to use the classification system, and that fracture's coming out, aiming towards the fibular head. He's lost all of his correction, and now is more varus than what he started with. So you see these X-rays. What are your options? What do you guys want to do? We'll start on the other side. Yeah, I think you would want to rule out infection, make sure there's no infection, because I've seen some of these get infected, and then it's a disaster. They go down the tubes pretty fast, so rule out infection. The other thing you'd want to do is maybe get a CT scan to assess further what exactly is going on. I think you're going to end up revising this with probably a locking plate and some autographed bone. Rob? Yeah, this is one of the cases that is similar to what we were talking about in my presentation, but he's got at least two problems. I don't know if his alignment's changed. You say he's in more varus? Yes, you did. I think in this case, you've got three issues to deal with. He's lost his alignment. His fixation, therefore, is not adequate, and he's got a crack laterally that seems to be open. So I would put a small plate laterally. I'd restore his alignment. I'd clean that very aggressively. I'd graft with autographed, and I'd apply a strong medial plate, assuming he's not infected. J.R., anything different? No, I would do exactly that. Definitely plate him on both sides. I'd use a big tomofix-type plate on the medial side to make sure you had enough fixation, and again, I'd use autographed and take it from the iliac crest just because you've got a big defect there. I look at that picture, and I'm really worried about infection. He looks like he's infected. So we got infection labs. Everything thankfully was normal, so we planned to do pretty much what everybody said here was revise the osteotomy, put a locking plate on it, clean out the nonunion site, and put a big plate on it. Some might say you have to put a plate on a lateral. Some people might say you don't have to as long as the fixation is good. You can get the correction back to where you want to be because there will be some compression along the lateral side simply by doing that, but I guess it's pretty much dealer's choice. So we went in, we revised him, we changed the osteotomy, crest bone graft, put in this large plate, and we were pretty happy with our outcome. This is post-op follow-up x-rays. This is two weeks. He's doing pretty good. X-rays look good. It looks like the initial varus that we had after the initial injury, the initial insults has now been remedied. So everybody's high-fiving, everybody's happy. We think we got a good outcome, and then I get this message two days later from the lovely Epic MyChart. It says, it appears as though my wound is draining. My wife says that it smells funny. It's continuously dripping down my leg. So now we have the problem of the revision osteotomy. You've already gone in twice, and now he's infected. So CRP is 80, ESR is 55. Now what are our thoughts? Yeah, you're going to have to obviously go in, do an IND, drain it out, thorough irrigation, and then probably put an X-Fix on until you get control of the infection, then go back and do a second stage later. I know, actually, one of a very well-known orthopedic surgeon, this very thing happened. Yeah, I don't disagree, although I'd tell his wife to mind her own business. I agree in that. I'd really worry that if you tried to leave the plate and you sort of look at, can I save the plating and just clean it up? With polymicrobial stuff like that, and staph epidermis being so hard to treat, I would take the plate out, X-Fix it, clear it up, and then put it back. I think one of the problems is that we don't know what the bug is as we're going in. We're just going in and cleaning it out. And then when you get this polymicrobial back, even if you wash it out once, then you're sitting there, you're scratching your head, you're a little bit upset. So we washed him out, everything was looking good, and then obviously nine days later, he started straining again. So now you have a failed IND. You're now gone through the same tibial incision three times. So we're worried about the skin, we're worried about his bone, we're worried about pretty much everything. So now our options are really limited. We know that everything's got to come out, the plate has to come out, all that bone grafting that you did has got to come out. And we had this initial implant design that forces you to core out large pieces of bone. So we're going to be left with a pretty large bony defect here. So this is pretty much the perfect storm after a high tibial osteotomy. And then you have to worry about the fact of whether or not this patient is going to need some sort of soft tissue coverage, medial gastroc flap, et cetera. So now what? So there's something that's going on in the trauma world. I don't know how many people are familiar with Mescalet procedures. You can raise your hands if you have. All right, good. So we got some familiarity with it. So I consulted with my trauma partners for this kind of case. And the Mescalet procedure, you take all the hardware out, take the plate out, and then what you do is you basically fill the void with antibiotic-coated cement. You leave it in there until the infection clears. So you continue them on antibiotics. And then about six to eight weeks later after the infection is healed, you basically go in. You make a small incision in this pseudomembrane that forms around that cement base. And you can actually take the cement out and put in bone graft again. So at this point, the plan for this gentleman, it was either X fix versus do this procedure. There was an extensive discussion about the risks and benefits of both. And we thought, given his bone loss on this one, that the Mescalet would probably provide a little bit of a more reliable outcome. So we are now currently middle of this. This is literally happening to us as we speak. But our plan is to fill this with bone graft from his other side, to put on a new plate once the infection heals, and most likely a gastroc flap at the same time. So I guess the lessons of this story is that even if you do a pretty decent surgery and you think it's well-indicated, what we do is not entirely benign. So always think about the worst thing that can happen, because if you do enough of them, it probably will. Mike, just a quick question. When you initially did him, was he full weight-bearing as tolerated? No, six weeks non-weight-bearing. Was he compliant? Absolutely. Because it looks to me like that could have been the cause of this. I wish it was. This is like the most compliant, nice guy in the world, and I wish I could blame anybody but myself for this one. How did you, what stage is the cement put in? It's kind of formable, or you pack it in? Because you don't want it interdigitating with the Kentzel's bone. Yeah, it's sort of like you're doing a cement bead. You know, let's say for trauma, high-velocity trauma, the open fracture, you're putting in cement beads. You have to form it first and then put it in. Is it stable, the construct afterwards, or is it kind of wobbly? It's a little bit wobbly. It's more stable than you think. I mean, this is the first time I ever have to do this kind of procedure, so it's more stable than you think. As long as the patient's non-weight-bearing and braced, they should be okay. You'll be very gun-shy the next patient you see that's exactly like him, because you'll be in the back of your head going, wait a minute now, I just saw this, and I, you know, He's a nice guy, young, perfect candidate for osteotomy.

knee pain

medial arthritis

high tibial osteotomy

complications

infection