Nice to share a podium with Brother Don. I have severe knee arthritis. I have full extension. I still play golf and I still carry my own bag from the cart to the bag drop. That's really great information. My task is to talk a little bit about high proximal tibial osteotomy. The question is, is it still relevant? I think it is still relevant because the title has changed from management of the varus painful knee to the management of chondral and meniscal defects as well as arthritis. I think because of that, it's not only relevant but critically important to us as we begin to do more complicated surgery that are chondral or meniscal sparing. These are my conflicts that are also at the website. So classically, the ideal patient was this. As you can see, this was for proximal tibial osteotomies. In my practice, I always had a high volume of people who were antericruciate deficient who had had meniscectomy and now are arthritic on the medial side. And I never thought there was a difference. And when Kim published their data last year, they confirmed that observation of mine. They saw no difference with ACL insufficiency or with an intact ACL. I learned this test from Jack Burt. I think it's very important. He uses it for unis. I use it for osteotomies. It's a one-finger test. If you ask your patient, where does your knee hurt, and they can take one finger and point to the joint line, and that's where the arthritis is, that's a knee that can lend itself to proximal tibial osteotomy. If they have this knee grab sign where you ask them where they hurt, and they have this global pain, no matter what the x-ray looks like, that knee is probably not a good candidate for either a uni or a proximal tibial osteotomy. So newer indications, instability, and complementary for chondral sparing issues. So we have three indications, don't we, pain, instability, and protection. If you look at the literature and look at the systematic review, looking at factors affecting limitation, progression, treatment of focal chondral defects from a couple of years ago, the literature would show that correcting patellofemoral and ortibiofemoral alignment improved clinical outcomes when done concurrently. And I think that's the take-home message from this discussion. So if you have this varus knee, no matter what you're doing to correct the chondral surface, you need to think about doing something to correct alignment or you will overload your chondral or meniscal work. What's correct? I use for my correction for pain this 6% line as suggested years ago by Dugdale and Frank Noyes. This is a patient of mine who did this at age 62, and his goal was to climb every 14,000 foot peak in Colorado, and here he is at the top of the highest. But you notice he's got a valgus alignment to his knee, and you have to end up with that if you're over-correcting. This is his knee now. This is 20 years later, though. And so he got a good 20 years, and now he's got his total knee, and he's happy once again. For instability, I think correcting it to normal anatomy is about right. And for chondral sparing, my target is just at the bottom of the slope on the lateral side of the knee. So it's about three degrees of correction, not more. My rule is if the mechanical axis passes through the affected compartment, I'll do an osteotomy in order to move the axis out of that compartment. And there's data to support that. This is a study looking at 43 patients with very small osteotomies following chondral resurfacing, and the osteotomies were less than or equal to five degrees. But if you look at the survivorship with ACI alone, 58% versus 90% if you added the osteotomy. So there's clear evidence that even a small osteotomy can be helpful. Opening wedge is what I do preferentially. This is an example of an osteotomy, and you can see by five weeks, it's beginning to heal pretty well. How do they do? The survivorship depends on your population, but you can see that in this isolated PTO survivorship of 92% at five years, 72% at 20 years, so not too bad. If you add osteotomy to that and articular cartilage, it's still about a 97% survival rate at five years. So you can anticipate that these patients can do well. I just want to show you a couple of important points. When you're planning this, I start at the tubercle and I move lateral and proximal exiting about a centimeter to a centimeter and a half below the joint. I cut beneath those two pins that I've placed that are tangential to the plateau, and I use a spring test. Once I've made my cut, if I can flex the proximal tibia and I can see it move a little bit, then I know I've done enough release with my oscillating saw and osteotomes that I can wedge it open without creating a pathologic fracture. So use the spring test, and I think you'll be happy. When you place your plate, the important thing to note is that the plate has to be posterior. If your plate is anterior along the anterior cortex of the tibia, you will increase dramatically your posterior tibial slope, and the goal is to maintain the slope, if not improve it a little bit, and to do that, your plate must be posterior. So there's our opening. There's our plate. The plate has to be in the posterior half of the tibia in order to be done correctly. There's fixation. There's two knees that never touched until he had his osteotomy done. He had bilateral varus knees, and he's doing well. There's some evidence that grafting helps, and I do graft. I use bioactive allograft now with croutons, and that seems to work very well for me. I do not use autogenous bone. There seems to be no advantage to adding HA to this. So the question that we're trying to answer is, is this relevant at this point? And I would argue to you, based on the fact that we're doing so much sophisticated chondral sparing or repairing or meniscal replacing surgery, that DAMWELL is still relevant. I think it has to be part of your armamentarian. Thank you.

high proximal tibial osteotomy

chondral and meniscal defects

arthritis

knee pain

alignment correction