Richmond. So I'd like to ask Chris Travers whether or not he allows his unis to run afterwards. I've traditionally done HTOs in those patients that want to go back to reffing soccer or basketball and unis for those people who aren't going to be running athletes post-surgery. Yeah, it's a good question. I think that I kind of hedge my answer a little bit when patients ask. I tell them that if they can avoid running on a hard surface or avoid high impact activity, I recommend that. But if they do want to run, I do allow them. I say that it may wear out the implant faster or may accelerate the disease, but I do allow them without a restriction. Dr. Shelborn, since extension is so critical, do you think it ever makes sense to do an extension osteotomy for these people that can't get their extension back? No, because you're artificially getting the extension back that way. What we're doing with getting the extension back with the native knee is stretching the posterior capsule and the capsule of the knee that's tight. I think just the fact that the knee extends and osteotomy is not going to correct the intra-articular problem in the joint. So I think it's more important to try to do it non-operatively. We don't, even our ACL patients, ever do a posterior capsule or release, because most of the problem with ACL patients is there's a mechanical block to extension from the intra-articular scar. Once you get that out, the posterior capsule can stretch. Once I realized how important it was to get the extension back in the ACL patients, I saw all the people with osteoarthritis that had flexion problems, and I saw our ACL patients that 10 and 20 years later, the worst patients were the ones that couldn't straighten their knee out. Their meniscus tears and chondral injuries magnified the pain by having a flexion contracture. So then can we take our patients now that have flexion contractures with osteoarthritis and make them better by reducing it? And I was shocked how well it works. Another question for Dr. Shelborn. Do you ever see a rule for removing posterior osteophytes that you think are limiting extension or posterior capsulotomies or capsulectomies? I've had very few patients, but I've had some patients that have a big tibial osteophyte that are about 50 years old. Their x-rays aren't that bad. And I can't get their extension back because of the mechanical block inside the knee joint. And so rather than do a total knee, I've had about five people over the years that I've gone in and taken out the mechanical block to extension, like we do our ACL patients, get the bony osteophyte out, get their extension back. And that buys them a lot of time. Arthroscopically? Arthroscopically. Because most of these are in the tibia. It's the tibial osteophyte blocking an extension in the intercondylar notch. I want to follow up on what Don has been saying. Because for me, and I think probably for a lot of us, when a patient comes in with arthritis, the treatment algorithm was steroid injection, VSCO, or something more invasive from the standpoint of a surgical intervention. But oftentimes for me, the VSCO and the steroid was not accompanied by a physical therapy. Because it was my impression that once you're arthritic and worn out, you're kind of past where therapy can be of much value. And that thinking is actually wrong. I would agree with Don. I've had a lot of people who either because of a hands-on with a therapist or probably more particularly, as Don talked about, the restoration of extension, they actually feel quite a bit better. So I think PT should be part of your treatment algorithm for arthritis, along with steroids and along with VSCO and the other things that we typically do. I agree. One of the problems I have is that people have been told by other doctors that they have end stage osteoarthritis, which I hate. They have bone on bone, which I hate. How can I get better non-operatively when I have end stage osteoarthritis? If people come in with an arthritic knee with a flexion contracture, my therapists are excited because we have a way to make them better. And so everybody that has an arthritic knee has to fail therapy first. And 2 3rds of them get better to the point they don't want a total knee. And they're happy patients. The ones that get their extension back and still have pain, we know that their pain is from their osteoarthritis. Failed total knees are frequently because of failure to find out if their flexion contracture was the cause of their symptoms instead of their osteoarthritis prior to surgery. I think we have time for one more question. My question to Dr. Robert Hunter about osteotomy, two things. First, is there an upper limit that we can do in the opening wedge osteotomy without injuring the lateral cortex? How many millimeters can I open safely without injuring the lateral cortex? This is first. Second, what do you think about the biplanar osteotomy in order not to affect the length of the patellar tendon? Do you find it better? Let me answer them backward. I don't have experience with the biplanar osteotomy. There's good evidence in the literature that if you change the resting length of the patella and the patellar tendon a little bit, that it doesn't really impact clinical outcomes too much. From the standpoint of how much to open, I think 15 degrees to me is the upper level of what I will do with an opening wedge osteotomy. I think if you're truly dealing with a varus knee that's just on the medial side, just varus, I haven't seen a situation in years where it needed more than 15 degrees to create the appropriate alignment. Typically, it's more like 10 to 12 degrees. I'd like to thank the panelists. And we'll get on to the next session.

knee osteoarthritis

surgery

non-operative methods

physical therapy

osteotomies