Thanks very much, Jorge. And it's my great pleasure to introduce Dr. Volker Mussel from the University of Pittsburgh, who is going to be demonstrating an anterior deflection osteotomy. So Volker, can you hear us? Yes, very well. How about you? Can you hear me? Yep, perfect. Great. Well, good morning, Nashville. On a Saturday morning, I expect there are about 10 of you in the audience right now. So in my dark voice, I always sound like this. So we're showing you today an anterior deflection osteotomy. It's a very interesting case. I have just a few slides I want to show you real quick. So I have absolutely no disclosures other than some educational and federal grants that have nothing to do with this procedure. Your general options are closing wedge, opening wedge, and then on the right side there, there's deflection osteotomy. And here's when we think about doing this type of procedure. In revision settings, second revision with a high slope greater than 12 degrees. That's currently the indications. We keep them really narrow for good reasons. Now, do not have a hyperextensive knee. That's probably a contraindication. What I'll be showing is this procedure through the tubercle. It gives you a nice real estate to work with. I'm going to show you this here in a second. Here are your instruments, the usual osteotomes. You need Hohmann retractors, ideally radiolucent. Radiolucent power tools. You can use any kind of plate system. This is a low-profile plate system. And the screws can be placed in different angles. So without further ado, I'm going to start the procedure here. I have with me here Tom, who is going to be my surgical tech from NuClip. I have Ryan and Chris also here. And then I have Jonathan Hughes with me. He's my partner in Pittsburgh. Brian Gottschall and Gian-Andrea Lucidia are my fellows. And then there's a big team here from OLC and camera and audio-visual. So this is basically a midline incision. Volker, are you doing this often as a staged procedure with a revision ACL, for example, or are you doing it all in the same setting? I usually do it in the same setting. How about you? Yeah, it depends. It depends really on the tunnels that you're obviously dealing with. There are multiple things you've got to really factor in. But it's certainly safe. And if you haven't done it before, maybe it's a good idea to do it as a staged procedure. And just a reminder to the audience, please use the app. If you have questions, come forward. Or use the mics and come up and ask Volker any questions that you may have. Let me see a curved males. So in this first step here of the procedure, you're just going to have to see the patella tendon. I hope you can see this really well here. Then we're going to take an Army Navy retractor. You can place that in here. So that's number one. I take the knife back, please. There are three steps for exposure. And I know the older people in the room, they have seen all this. But I've decided to show all this so that the younger people just see the exposure. So step one was the patella tendon. Step two is getting the MCL here. So you make a sharp incision around the MCL. You stop before the PES unless you want to take the hamstring tendons. I take a Cobb retractor next. You want to elevate the MCL off. And then you can place your Hohmann retractor. We're not going to do this right now. Just hang on for one second. Just like that. OK. Then I take the knife back. So that's a very important step so that you really have good exposure of that posterior medial cortex. Otherwise, sometimes it can be difficult to close the wedge, right? Can I take the Cobb back? So here's an incision in the anterior compartment. Protect the peroneal nerve, obviously. OK. I'm going to take my Hohmann retractor like this. Can this be held from up top? There you go. Can I get a marking pen? So now you have the tibial tubicle here. If you want to go through the tubicle. OK. Let me see the saw, please. Then you have a little bit of an easier field. If you go above the tubicle, it is getting a little bit more tricky. Because above the tubicle, you have not as much real estate. So we usually go and go through the tubicle. So I'm just going to do the osteotomy here real quick. So if you just think that's kind of really great. Sorry for that noise, huh? I guess the benefits of going with a tibial tubercle is you're going to get better exposure, better visualization of that proximal tibia, it's just a little bit easier to do this type of surgery. It's a complex osteotomy, so making that exposure a little bit easier, particularly in your first time around. Yeah, exactly. It's helpful. I mean, doing this, now you have a nice, clean field right here. Let me get this back down one more time. So I marked the two positions of my future screws. In this particular case, you know, I'm going to do about a 10 millimeter closing wedge. So I mark in between those two screws because then I can use them later for compression. Next step would be to cut my 10 millimeters off here so that I don't change the patella height. I'm going to skip that step right now. Next, I'm going to take a K-wire, please. So I'm going to freehand the first K-wire where I think it should go, and then I show you on the C-arm. Now, I placed two K-wires. So my first one, I just go a little bit medial. I try to aim for the posterior corner of the tibia here. Okay, so let's take a look, guys. Come on out. So I'm going to show you a C-arm shot. Okay, so here, give me a second pin. Here I'm way too low, and that's fine. I'm going to leave this pin and orient myself along that pin. I'm going to take the same starting point, except I'm going to aim quite a bit higher. Go ahead and give me a shot. So you're aiming for really just the sort of the most distal aspect of the PCL fossa. Yeah. So that's sort of champagne glass drop-off. Perfect. Shot. Shot. And the benefit of doing that, I would suggest, is because you're in metaphyseal bone, the more distal you go, you're in cortical bone, you've got a greater chance of fracturing the posterior hinge. Exactly. So now I have two pins where I want to go. Another shot. Okay, perfect. Now, give me a third pin. Perfect. So now that I have my, nope, just my free hand. Free hand with a hemostat and a ruler. This is the same length pin. So I have my two pins and I can do my cuts along exactly there. Now, I measure with the third pin exactly how long the distance is, which in this case is six centimeters. Then I take the saw back, and can you give me this piece of tape you gave me yesterday? If not, that's fine too. So I now know it's six centimeters. I want to leave about a one centimeter posterior hinge, right? It's really important that I don't hinge fracture in the back. Now this is a cadaver. No, that's fine. I have actually markings on here. So I'm going to stay short of five centimeters. It depends a little bit how sturdy the bone is that you're working on. This here is a soft bone, so I'm going to leave a bit more of a hinge. So sorry for the noise again, but I'm going to just show you these next steps. Can you give me these Hohmann retractors back? Don't want to quite do it fully freehand. So very important that you have protection. One, next one. There you go. So now I have a nice clean field. I go right along. Now I don't want to introduce varus or valgus. So I'm going to go nice and straight. So now I'm at about 35, no, that's 50 right here. It's good to let the saw run nice and soft. You don't have to push very hard, so you can feel the cortex while you're going. Is that the normal size of saw that you would use, or are you using something smaller? No, this is a big saw, like the one you would use for your total knee replacements. Okay, all right, let's take a little look here and see where we are. Can I get a second saw blade that is just empty? Okay, perfect. Okay, I'll put the saw blade in here. Give me a pin driver, please. How are we doing on time? We have about five minutes left. Yeah, we got about six minutes to go, so you're doing great. All right, very good. I'm going to pull my pins out, one, two, okay. Now you can put another set of pins so you get your angle better, but in this case I'm going to freehand this. So about 10 millimeters, you make your measurements again, you try to go parallel. I think an important tip for the audience here is you've got to know the thickness of your saw blade because that will play a role in the amount of wedge that you take out, so if you don't factor that in, you may make a 10 millimeter cut but end up with about a 14 millimeter gap, so just bear that in mind. You can see he's got his retractors in there, so he's got good soft tissue protection, and then just feeling his way to the back, so it's really well controlled, lots of exposure without TTO, which makes life a lot much easier. All right, so just nice and slow. Okay, let me see some osteotomes and a mallet. So if you're doing this well, you're getting one little wedge out, otherwise you have to do a little bit of extra work here. The idea obviously is that you have these two saw cuts meet about a centimeter from the posterior cortex. So I think that'll do in this particular case. So now take a look here, you want to know how the reduction goes, of course, so let me just go ahead and do this. So if the camera can go out a little bit more, please. So now I have about a 10 millimeter opening, yeah, so if I'm, for example, at a 15 slope, and we know that 7 degree slope is normal, then my goal usually is to just overshoot a little bit and overcorrect this, so I usually go to about, say, a 5, yes? And I slowly hyperextend the knee, if you can see that, and then once I have it reduced, then you can go ahead and place two screws across, so let's see if we have a C-arm shot right here. So you'll occasionally hear a little click, a little crack doing that, so it's nothing to worry about. Right, so here this is now basically reduced, and now the next step is putting plate on. Just go ahead and give me this plate real quick. I want to show you real quick, instead of doing all the screw fixation, unless you want me to show this to you, Al, which I doubt, I'd rather show you another osteotomy on the other leg that I prepared yesterday. Yeah, I'd prefer you show that. Right, so you put the plate on, you can see this probably pretty well here, and then of course you hold the reduction again by putting either a fellow here or a bump. You have hyperextension, you can place one pin in there, and then you have this reduced really well. Volker, do you ever drill the posterior cortex, just perforate that posterior cortex to help you close? Can you ask me this again, sorry? Sorry, do you ever drill, use a drill just to perforate the posterior cortex just to provide a control? Yeah, absolutely. In a big, sturdy patient, 100% that sometimes needs to be done, yes. So let me show you real quick. So this is the first technique I would recommend. It's a bit easier to do, and you've seen this, this is quite straightforward. Just respect all your orthopedic principles. Now the second technique, I need some home in place, we prepared yesterday a little bit just to show you. Now this one here is the way David Dujour described it, going over, going proximal to the tubercle. So let me just show you this real quick, hold on. Here we are. And then a Army-Navy retractor, please. And I'll take some forceps, please, it's their third hand somewhere. So you can see this here. So let me show you, here's the tibial tubercle, right? Here's my patellar tendon. Can you see that? Yeah, you can see it. Yeah, we got it. Go ahead and give me a K-wire. How much time do we have? We've got two minutes left. Oh yeah, it's perfect. Doing great. All right, so I'm going to place my K-wire right here. So just to orientate everyone, it's a super-tubercle closing wedge osteotomy, so you're going proximal to the tubercle. Exactly. Go ahead and give me an osteotome. It means you just leave the extensor mechanism intact and maybe can be a little bit more aggressive with a rehabilitation. Okay, give me the K-wire driver, just the driver. So this technique really utilizes all the same principles that Volcker's already demonstrated in the previous osteotomy. Give me a smaller osteotome. But just the exposure's a little bit more challenging. So the tricky part on this side is as following, right? So as Al just said, so I have the patella tendon I need to respect for the entirety of the procedure. So I go on the medial side, sorry, on the lateral side, I retract the patella medially. And give me another osteotome. There you go. Then I go on the opposite side and I retract the patella in the opposite direction. I can take my wedge out that I prepared yesterday. There you go. Volcker, we've got one question from the audience as to how often you remove the hardware after this type of procedure. Say 20 to 30 percent. My colleagues in Europe do it in 100 percent, just as a matter of fact. I would say not too many times. But knowing that I might need to remove the hardware, I still like to use a pretty heavy plate because I rather have a good fixation and no non-union. So you're taking two smaller pieces out instead of one bigger piece. Now the patella tendon is still protected. You do your reduction. Come on out, guys, for a second. Take this away. I'm going to show a little x-ray here real quick. And so now you have very little real estate and you do two staples for your fixation in this particular case, which is probably fine. I prefer plates, but this is a nice technique. You have a closing wedge. So if the camera wants to go back in and we can answer some questions, that's it. So we're pretty much coming up to the end. So if any questions from the audience, if not, we'll probably just move on. Volker, that was an outstanding demonstration. Those are two challenging osteotomies, and thank you very much for giving a very clear demonstration. Thank you. Perfect. Thank you very much.

osteotomies

knee surgery

closing wedge

opening wedge

deflection osteotomy