Thanks, this is a little change of gears here, my disclosures. So in dealing with an unstable osteotomy, I think you ask yourself three questions. Number one, is it really unstable? Number two, have I lost fixation and or correction? And number three, is there chronic lateral hinge fracture that we have to deal with? Talking about a medial opening wedge with a lateral fracture. Is it really unstable? This is the first question I think is kind of important. Takeuchi in 12 reviewed his experience with proximal tibial osteotomies and found that he had lateral hinge fractures in about a quarter of those. And if he followed them, he proposed a classification system. But when he followed them, there were no non-unions and only two delayed unions. If you look at the literature pretty carefully, this is consistent. This is also from last year, 20% incidence of lateral hinge fractures, all healed within three months and there was no difference in outcomes between those with fractures and those without. So, message number one, for lateral hinge fractures that you see acutely at the time of your osteotomy, don't panic. Delay weight-burning about two to four weeks to allow for some healing and follow until x-rays show good healing. Almost all of these will heal, some will not, as I'll show you. The other two questions, have I lost fixation and or correction and is there a chronic lateral hinge fracture? This was looked at very carefully and I think very well by Rosteos last year. And their conclusions are consistent with my thinking up to that time and I think they've given us a good algorithm to work with. And the algorithm is this, ask the two questions, is there a loss of correction and or fixation and is there a lateral hinge fracture? If the answer is yes to both, revise with a medial plate, add a lateral plate to stabilize your lateral fracture, do aggressive local debridement and use AutoGraft for your grafting material. If there's loss of correction and there is no lateral hinge fracture, you can just revise your medial plate, reestablish your correction, debride, always debride, always, always debride the nonunion and AutoGraft. If there is no loss of correction but there is a lateral hinge fracture, then adding a lateral plate and doing grafting is adequate once you've cleaned things up. And if there's no loss of fixation and correction and no hinge fracture, all you do is go back, debride, regraft and you're in good shape. And if you follow those guidelines, the outcomes are quite good. This is a case where you can see there's a nonunion but the plate, the fixation is good the correction is still good. So adding a lateral plate, doing an aggressive debridement and bone graft with autogenous tissue yields a good outcome in this case at six months. So the bottom line is expect to see lateral hinge fractures, don't worry about them, they're there in about 20 to 25% of cases. Slow weight bearing and watch. If there's loss of alignment and or fixation, this requires revision. Clean and graft every single case and the literature would suggest AutoGraft although I think you can make a pretty good argument if you wanted to discuss Allograft or bioactive materials. Thanks very much.

unstable osteotomy

fixation loss

correction loss

chronic lateral hinge fracture

proximal tibial osteotomy