Thank you, Andreas, great talk. And now from Luxembourg, Romain Zael, ACL reconstruction with osteotomists. Thank you. Everything is getting lost and we have to work on the bones. Thank you for inviting me. It's a pleasure to be here. My disclosure is nothing relevant to this talk. So actually I have a practice where we see between 250 and 300 ACLs per year. And this is basically the distribution of associated procedures we do. Meniscus repair in roughly three patients out of four. And LAT in roughly 25% of the cases. You see the collaterals. Cartilage procedures and osteotomies which are rarely done actually in primary ACL reconstruction setting. Often if we look at our primary ACL reconstructions, time from injury to surgery, those patients where we did knee osteotomies, they are really in the range where the time from injury to surgery is really high. So two years or more. That's in the primary setting. In the revision setting it's probably even more. Osteotomy is a very, very powerful tool to protect the soft tissue procedure or to prevent soft tissue injuries, both in the coronal and in the sagittal plane, as you know. Now which are the indications we could consider? If we have an osteotomy and an instability, it's usually in physically active and biologically young and active patients with a symptomatic unicompartmental overload and instability and very often malalignment. So either in the coronal or in the sagittal plane or in worst case in the two of them. Here are the three major indications. So we can have cartilage meniscus status influencing the indication, the ligament status, or the bone morphology. And then we have roughly three clinical situations. The first being a chronic ACL insufficiency and unicompartmental overload. And that's what we will have a look at now. You know about the natural history of ACL insufficiency with anterior tubal translation and the post-remedial cupula as an end-stage result, so to speak. And these are patients who come with instability, pain, swelling, and abdominal gait, as the guy you see here on his right leg. This is a case of a 40-year-old patient who had a chronic ACL injury 20 years before. He came with instability and pain, had a 7-degree sparse knee, grade 2 medial osteoarthritis, free range of motion, and positive Lachmann and a grade 1 pivot shift. So in this case, we decided to do in the primary ACL reconstruction with hamstring graft, medial open wedge proximal tibial osteotomy. We corrected him by 7 degrees and had to do, unfortunately, a partial medial meniscectomy. You see his pre- and post-operative values of the medial proximal tibial angle and lateral distal femoral angle. That's where we did the correction. And we came up with a correct joint line inclination. And this patient did fine. What is a surgical sequence if we do that? We do it usually in a single-stage procedure. We start with graft harvesting, then doing the femoral tunnel, then a proximal tibial osteotomy, finally the tibial tunnel, and then we place the graft and fix it. Would there be alternative scenarios to such a single-stage procedure as well? Yes, probably there are, but we don't do them. So you could do an isolated osteotomy in the past. Slope changes were discussed in these patients, which we don't favor anymore. Or you could do a two-stage osteotomy and then an ACL reconstruction eventually. One thing is sure, if there is instability but no decompensation of the knee and no pain, we go for an isolated ACL reconstruction. We don't consider proximal tibial osteotomy if there is no pain. So no prophylactic osteotomies, that's basically the message, even if you have a metaphyseal virus. Now, if we have instability, decompensation, and pain, then we consider these options, combining ACL and valgus osteotomy. And if there is an excessive tibial slope of more than 12 degrees, we consider decreasing the slope in order to achieve an ACL protection. Now, in some cases, we also have to go to the distal femur. This was the case of a 40-year-old male who had a failure of an ACL repair and the total lateral meniscectomy 20 years before. He came with lateral knee pain. He had a valgus knee, as you see on his right side, free range of motion, grade II pivot, and negative Lachman edge. In this case, we did an ACL reconstruction with an autologous quad tendon graft and an medial closing matched distal B-planar distal femoral osteotomy. That's him at day one post-op, and I saw him recently. He's at two years now, and he's doing fine. Ligament status, second indication, so chronic ACL insufficiency and post-olateral coronary instability, something we see also sometimes. Here, the case of a 20-year-old, 9-year-old male. He had five years before an ACL, partial PCL, post-olateral coronary peroneal nerve palsy, and he came with this triple varus deformity, which was really a static deformity. He had no varus thrust, and he had a free range of motion. He felt unstable somehow, so that's why we did this ACL reconstruction with a BTB graft, medial open wedge proximal tibial osteotomy, and a partial, again, a partial median meniscectomy. We didn't touch the ligaments on the lateral side. That's him 10 years post-op. He's doing pretty fine, and so also this is some rare indications. Now, what about bone morphology? That's the third, I would say, influencing factor pushing us into these indications. Chronic ACL insufficiency and excessive posterior tibial slope being the most frequent one. Actually, there are, again, three situations. Those patients who come for a second revision ACL reconstruction, that's where we consider it, I would say, systematically. The first revision ACL reconstruction in some cases if they have meniscus deficiency or grade 3 pivot shift. What about the primary ACLs with a high slope and a high risk of re-tear? These are the ones we don't consider yet for doing these osteotomies. We know that slope is an important risk factor for primary ACL injuries and ACL graft failure. You see here on the left, this patient who had a high slope and a chronic anterior tibial translation. Something we do on a systematic basis, these monopodal weight-bearing images. Very, very helpful. We know that from the biomechanical work coming from the Imhof family from Germany that the decrease of the tibial slope decreases anterior tibial translation and decreases the ACL graft forces. That's what we try to achieve in this case with a 16 degree slope, which we decrease to 7 degrees. You see how nicely you can correct the anterior tibial translation. These are rare indications. It's not so easy surgery. Patient selection needs to be really clean and the expectations in these third revision patients, they are pretty limited. Again, which options, which surgical options can we take in these cases? We need to evaluate the supratuberosity space and ACL tunnel positioning. Then you decide to where you go. Either supratuberosity at the height of the tibial tubercle, then you need to lift up the tuberosity or you can do it in infratuberosity or osteotomy. You need to anticipate the altered postoperative anatomy, which is that you increase the rate of atom by the degrees of correction you make basically. Here is a short video showing how we do that. That's a supratuberosity osteotomy. You see here you place the K wires and then you need to consider actually the joint line inclination when you do that. It's rarely remarked or reported, but it's clinically important. You stay above. You take down this bone wedge. Then you mobilize a little bit the posterior cortex until you're able to mobilize it. Then we bring the knee into extension. This was obviously a cadaver knee. As you see, look now, boom, it goes pretty easily. Then fix it anteriorly with the staples. Look at the patella tendon, which is really sloppy here. That's basically what you achieve. Now, the big question we have now is, especially for the primaries, should we consider that in primary cases sometimes or should we do lateral LETs? What is more powerful? We still don't know. That's really something we need to discover in the next years. Now, what if you have this big deformities both in the sagittal and in the coronal plane? That's where PSI is really something very valuable, where you need an individualized solution based on complex planning, CT planning, and then you can do basically miracles if you correct these patients in these two planes. This is pretty powerful and very helpful in these patients. In summary, these are relatively rare indications. Surgery is challenging. It's nothing for beginners. Chronic instabilities of degenerative natures or ligamentous origins are the main causes where we do that. Alignment correction only, again, if these knees are symptomatic in my hands. The results are encouraging. There's a few outcome studies in the literature. Then slope correcting osteotomies to prevent the ACL reconstruction failure. That has a big potential so far in my hands, not in primaries. We definitely need more science in these cases. Thank you for your attention. Thank you, Romain.

ACL reconstruction

osteotomies

meniscus repairs

bone alignment

surgical sequences

meniscus repair

instability

surgical planning