Liza, thanks, Al, thanks for the opportunity to speak today. Thank you for you guys for giving me this topic that doesn't have an answer, so I appreciate that. I don't have any financial disclosures, I do serve on some committees. Okay, so here's our case as it was set up in the program, 32-year-old male, lateral sided knee pain, greater than five years duration, otherwise healthy, no comorbidities, no prior trauma, surgeries, or injuries. Exam shows pain in the outside, good ligaments, no ligament injuries, range of motion is preserved. And we have these x-rays here that I think that, you know, if you really query them closely and look at them closely, you can see changes in the lateral compartment already, and at least a suggestion of valgus. The MRI certainly confirms an at-risk lateral compartment with articular cartilage change and subchondral edema and probably even some cystic formation. So I think that this is certainly one that you do need to recognize that that lateral compartment is at risk, and when we obtain the standing alignment films, we can sure see, which I've blown up here because with our computer software, I couldn't make that line darker, but that's representing their weight-bearing access, and you can see on that symptomatic left side, it certainly falls pretty far through that lateral compartment, and certainly that area is being overloaded, and I think that's why we see those articular cartilage changes. Interestingly enough, you know, this patient doesn't have that on the contralateral side. You know, I measured that at maybe 8.5, 9 degrees, and so this patient here is kind of a summary, so 32-year-old male, valgus alignment, maybe 9-ish degrees, symptomatic lateral compartment. We know that's an at-risk lateral compartment, and so where do we correct on the femur or the tibia? So what are our options? So we could certainly do it through the distal femur with either lateral opening or medial closing wedge osteotomies, as we saw some images of before, or even we can talk about the proximal tibia, and I think that's going to be an important point to at least reference here and something that we should be aware of. So let's go through these. I think distal femoral osteotomies, you know, I do think they probably provide more of an opportunity, especially for these larger corrections. I think on the tibial side, we're going to see we're going to have to keep them for smaller corrections. Those corrections get really big, certainly up above 10, 12 degrees, I think you need to go on the femur. And at least in my hands, when I do a surgery in the context of a meniscus transplant, not in this index case, but I do, I correct in the femoral side as well. Medial closing wedge osteotomies have, well described, they're certainly a very stable construct. It allows early union, early weight bearing. You can argue whether or not you need to use a brace or not, and even allow immediate or very soon weight bearing following a medial closing wedge osteotomy. So there's lots of pros from that in this example here, courtesy of Dr. Critch from the Mayo Clinic. You can see excellent opposition and a very stable construct. Lateral opening wedge osteotomies similarly have a familiar approach, and you can really dial in that correction where you can, after you make your cut, you can continue to open it, maybe even assess intraoperatively to know exactly how much you're opening. You do have to maybe bone graft those, especially for these bigger corrections, as we've heard. And there is a risk for delayed union, and it is somewhat inherently a less stable construct. You know, I think really an outstanding reference, if you're going to get into the game of distal femoral osteotomies, I think an excellent review that really pulls a lot of different things together comes from Dr. Sherman's article here in the Yellow Journal from just two or three years ago. And I didn't want to go through a litany of all these papers. I think you can look at that if you want yourself. But overall, distal femoral osteotomies were associated with really very good 10-year survival, 60% to 80% in the articles that they reviewed, with really good outcomes and significant improvement in patient scores. However, the rates of re-operation were high. These were very complex patients, and so the rates of re-operation could be upwards of 20%, 30%, 40%. They also highlighted a significant rates of complications. And with longer follow-up in these patients, we did see progressive disease. So it's something that you need to prepare your patients for from the beginning. Proximal tibial osteotomies are also done. I think they're usually done for smaller corrections. We might be able to talk on the panel here to argue what your limit would be, but I think 8, 10, 12 degrees, somewhere in that range or less is needed on the tibial side. A real benefit of tibial-sided osteotomies is you get better unloading throughout an entire arc of motion, whereas just on the femoral side, you really just unload an extension. Tibial-sided osteotomies unload both in extension and flexion through that entire arc, which can provide real benefit to your patients. And I do think another indication for a tibial-sided osteotomy would be if there is a post-traumatic deformity isolating to the tibia. An example of that would be like a split-depression tibial plateau fracture treated with open reduction internal fixation if it goes on and has residual valgus. Probably correcting it at the site of the deformity is the right answer. The medial closing wedge osteotomies have been discussed, it's been around for a very long time. Smaller corrections, stable construct, tibial-sided deformities are the time when you'd use it, though that cut has to be very precise, and we do want to try to limit any residual joint line obliquity. And that's why I would only reserve this for very small corrections. And specific attention should be paid to the medial collateral ligament, because since you're taking out this block of bone on the medial side, you do risk residual valgus instability. And so potentially assessing that intraoperatively and then correcting it or reefing it, I think is an important thing to consider. You know, recently in KSTTA they looked at a very large number of patients, 113 patients, 80 plus percent five-year survival from their medial closing wedge osteotomy, and 80 percent of patients were ultimately satisfied with their treatment. But that 25, 27 percent rate of residual MCN instability is a lot, and something that you need to certainly be aware of. I think another option, and one that's probably becoming a little bit more popular for tibial-sided corrections, would be a lateral opening wedge osteotomy. Again, reserving that for smaller corrections, less than that 8 to 10 degrees or 10 to 12 degree mark. The benefit being it unloading in both extension and flexion, as I described. It's an approach that we're familiar with for like lateral tibial plateau fractures. And you know, the instrumentation, there are multiple plates available for that now. Again, it'd be a good opportunity where you would do this in the context of a tibial-sided malunion, maybe from an old tibial plateau fracture. So here's a study recently, maybe not that recently anymore, by Dr. Getgood here, who provided their experience with this. And they saw overall excellent ability to obtain a correction, and no need for fibular osteotomies, which I think is important, because I think that scared some people away. They also saw improved adductor moments, so there may be a dynamic improvement of this as well, too. This is going back now, back to 2008. And I included this just pretty much for effect, but this is a devastating tibial plateau fracture, that went on to a nonunion. And they had the courage and the intestinal fortitude to proceed with an osteotomy for this patient, and reported overall 20 to 23 good to excellent results, which was about the only outcome score that they used. But it is an option for tibial-sided post-traumatic lesions, and it's in JBGS, so. All right, so I wanted to include this slide while we're trying to come to our decision here. I think it nicely encapsulates the available literature to us for comparing these different techniques. Any questions about that? So in summary, I would suggest that, as we all know, alignment is really of utmost importance in joint preservation and ligament reconstructive surgery. You really have to have this available to you when you see patients with coronal malalignment about the knee. Multiple options are available, and I think probably having multiple tools in the toolbox are useful to you as you go to treat your patients, because what might be right for one person might be different for a different one. So for DFOs, consider for larger corrections, and in my hands, I would do it with a meniscus transplant, as I think it's a little bit too much surgery on the tibial side. Also if patients have specific deformity to the lateral side, like a hypoplasia lateral femoral condyle, I'd probably correct it on the femur. On the tibial side, smaller corrections and loading both flexion and extension, and then just be aware of that joint line obliquity. So here's our index case again. So this is what I did. Again, a nine and a half correction. I ultimately chose to treat this patient with a lateral opening wedge osteotomy. She went on to union, and down the road at six months out, her pain had improved, her osteotomy healed, and her alignment was neutral. Thanks for your attention.

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