So now I'll show you the horror show of what can go wrong with HDOs. It's actually always fun to talk about other people's complication. I do a lot of osteotomies. And it is a great, that's not me, it's a great operation. You just have to, like anything else we do, it's still not me. Do you have the last one? No? Is there anyone here? Is it me? There we go. Gomoly is the more frequent type. All right. So actually, for this, no disclosures, shockingly. So avoiding, recognizing, and treating complications in osteotomy. So first off, sound silly, but pick the right type of osteotomy. You've heard a lot about closing versus opening wedge. This is really just talking about the tibia for now. An opening wedge will be much easier, a medial opening wedge versus a lateral closing wedge. Medial opening wedge will be much easier to titrate. You stay away from the neurovascular bundle. So when we talk about HDOs, I would say 99% of them will be medial opening wedge osteotomies. I would encourage you to do that. Pick the right fixation system. So I think this day and age, there's really no reason slash justification to use non-locking screw systems. The image at the bottom left, that's an old, non-locking PUDU plate. I would not use that anymore. Use locking plate systems. They're much more stable. They're much more forgiving. If you have a hinge fracture, you can get away with that a little bit better if you have a locking system. And then the picture on the right, that's an all-inside transparent. What's nice about these, potentially, is that because they're in the bone, they're not on the bone, you reduce the hardware removal rate dramatically. Your MCL goes back where it came from. I still don't use it. I like metal. I like taking it out. I like the x-ray at some point looking like you've never been there, which obviously the one on the right does not. And talking to my arthroplasty colleagues, they don't necessarily feel very comfortable doing, for example, a uni on top of this. So that's why I personally don't use the system, but I don't have experience with it myself. Avoiding complications. So just in terms of the approach, how you handle the soft tissues, there are many different ways. I'll just show you my way, not saying that that's the right way. But what you're looking at, this is the PES. So this is essentially like a hamstring harvest. So I take the PES off, move that distal, then you look at your MCL, and then I make an incision. So that black from the bovie, that follows the posterior aspect of the MCL. And you just do, let's say, a centimeter or two of that. You do your knee and your figure four position, and you immediately see Pavlitea's muscle. And I just take that off the bone with the bovie, makes the muscle contract. So essentially, it does the dissection for you. And once you're in a couple centimeters, the rest you can do with your finger or really gently with a cob, just don't slip. You don't have to do crazy, deep dissection back there. It's a normal space that exists. And you can wiggle your finger all the way over to the fibula head. And I do this on a tourniquet nine times out of 10. When you do it that way, your finger comes out, and there's no blood on your finger, which I don't like seeing blood when I'm back around those vascular bundles. I don't put the sponge back there anymore, but I put a retractor. What you see on the bottom left is a malleable retractor I put in. And you make sure that that's over on your fibula head. And when you cut, you cut and you listen. And as long as you hear metal, your saw hitting the retractor, you know that you're OK. So you don't have to floor all the way. But take floor shots liberally just to make sure that you don't exceed the protection that your posterior retractor offers you. The X-ray on the left, that's what you don't do. You don't just cut. So as you can see on the right, there's a retractor protecting the saw. I say here saw for the anterior cortex and the body. I actually do use the saw for the posterior cortex with the retractor. That's safe. But I do finish my posterior cut with the osteotome. I put my finger on the edge of the osteotome and essentially guide it across. Two benefits. You know where the tip of your osteotome is. You don't go where you shouldn't go. And you don't have to floor all the time because as soon as the tip of your finger reaches the fibula head, you know you're done. Be mindful of vascular abnormalities. That image on the left, that's an abnormal or aberrant anterior tibial artery. It's really rare. It's 2% of patients have that. But just stay on the lookout. So the green arrow, that's the normal publiteus. The red, that's a high branching anterior tibial artery. And in this case, you see how the publiteus muscle is between the two rather than the vessels being posterior to that. So the yellow, that's the publiteus muscle. It's usually not something that leads to loss of a foot, but it's just more bleeding than you really want. The person on the right is a good example of why. So if you've done a lot, you can make that incision and be comfortable and be safe. But especially when you start, make it a little bit of a bigger incision so that you can see, you can expose, and you can protect. Ironically, this was a patient who had seen me. We talked about an osteotomy. And then he went more local to someone who just had bad luck, I guess. So the incision in the front looked good. The incision in the back of his knee didn't look so good. Neither did his toes. So bad stuff can happen. But as long as you know where you are and you put your protection in, it's fine. The risk of having neurovascular complications is really low. Speaking of neurovascular complications, so this is for TTOs. This is just someone I saw in the office who had a TTO somewhere else. And the red arrow, that's the direction of the TTO screws. The yellow, that's the publiteal artery in the back. It could not aim more perfectly. Now, nothing happened. The publitea is between where the screw tip is and the vessel. You just don't want to plunge when you have your screws aiming that direction. So always, always make sure that my screws aim a little medially, like that green arrow. That's sort of perpendicular to your line, to your osteotomy line anyway. So you want to angle them a little bit. And there's nothing medially that's even remotely interesting. So just aim medially. Make sure that you look at where your foot is rotated, because usually patients lie a little externally rotated. So you think you aim medially, but if the foot lies externally rotated, you're actually aiming straight back. Wedge open carefully. So what I show you on the left, I don't do anymore. Because if you look at the black lines that show you the wedge of the osteotomy, and you look at the wedge itself, it suggests that it spreads the opening forces a little evenly. But you see that there's really only point contact right at the cortex. So if you haven't done a good job completing your osteotomy over here, all those forces go straight up, and you get a fracture into the tibial plateau. The best thing, I think, is use stacked osteotomes. You put your first osteotome as far over as you can. The second osteotome goes distal to that, not proximal. Because if you do proximal, then you have the same situation. So use the first osteotome sort of as a rafting almost. And then you put your subsequent forces distal to that. And then you gently open it up. One good thing that I always do before I put anything in, I do my cut, and then just by hand, I move it a little bit. If you see the osteotomy moving, you know you're pretty good. If you don't see any movement, don't even bother trying to open it up. Revisit your osteotomy with the osteotome. Now what can go wrong? Well, patella baja is something that we talk about. So on the top right, you see an osteotomy that didn't only increase posterior slope, but also resulted in patella baja. That patient on the left, that's my patient who had a pretty big correction. And there's no more patella baja than it was pre-op. And why is that? Well, because she had a distal retrotubercular cut, not what we usually do, meaning this is an osteotomy that technically is behind the tibial tubercle. And then there's a biplanar cut that goes distal. By doing that, your tibial tubercle stays with the proximal fragment, and you don't change patella height at all with that. I don't routinely do that, but if you have, I think this was a 14 millimeter correction, if you have anything, if I have anything that's, let's say, larger than 10 or 12, I start thinking about this. And thinking means you look at the preoperative patella position. And if you have a patient who's already in a little bit of baja, then I would do a distal cut. It's pretty rare that you need that. Increased posterior slope, the picture bottom left is the same one I had just showed you. So that can definitely happen. If you look at this image here, so when you look at the final outcome, you want to make sure that the wedge that you see is larger posteriorly than anteriorly. That doesn't mean that you change position. That means that you preserve posterior slope. And why is that? Because the tibia is triangular. So just based on the somewhat screwed up anatomy, that posterior gap will always be larger than the gap that your eye sees, because that gap is closer to the tibial tubercle, so it's already farther along the triangle. So Frank Noyes did a nice study that the gap needs to be twice larger posteriorly than directly next to the tibial tubercle. And if you have that, then you preserve posterior slope. You don't improve posterior slope. Hinge instability, that can happen frequently. I see that more in DFOs than HTOs. The bottom left is an example where I used a staple. And for corrections as big as that, I put the staple in before I open them. So I put my pin in, I do my cut, and then leaving the pin in on the floor, I put a large Richard staple, just lateral to the tibial tubercle. That way, I have a hinge. I don't care about what happens with the bone, because if that breaks, it becomes surprisingly unstable. And then trying to put that back together is tough. So if you make either a large enough incision to just bring the flap over, or you make a small incision and put the staple in beforehand, no stress. On the DFO picture, you see that little crack in the cortex. This is someone who misstepped two weeks post-op. It might have been their introp. Oftentimes, you don't see them. They have more medial pain. They usually heal, especially if you have angled, stable implants. So that's why I always look to use locking plates. I don't use that plate anymore, because it's a little bit too much of an AP diameter. I use, sorry for mentioning that, but a Tomofix. Fractures into tibial plateau. This, luckily, is from fellowship. You had mentioned Bernie Bach before saying, love your complications. I think what he meant was, love the patients with complications, meaning they should have your cell phone, they should have your email. You should be all over them. Love them more than your standard patient, because that's what makes unhappy patients, if they feel that they're being sort of shut out. But in terms of loving complications, we opened it up, we heard a crack. There was a fracture. I said, that's great, because now I get to see how to fix that. The attending at the time was less amused, but we fixed that by essentially, you bring the osteotomy back down. That should reduce the fracture. You put a clamp on. You put some rafting screws across. You revisit your osteotomy site, and then you very gently, with stacking osteotome, bring it up. Nowadays, I would use a different plate, but that patient healed uneventfully. So having that fracture is not the end of the world. You just need to fix it. Non-union. This is an orthopedic surgeon from Brazil. That didn't go well. Why a, you know, I used that plate for years, but now I use a bigger plate, so that gives you a little bit more safety. And then if you look at where that osteotomy cut goes, it ends in the lateral tibial plateau, which is bad for two reasons. One, if you are lower, so always aim for the waist of the fibular head, even if you get a fracture, you have the tip-fib joint, the joint capsule to stabilize that a little bit. There, there's nothing there. It cracks and it slides. And then you have no proximal bone to do anything about that. So the whole staple that I showed you, I guess you can go just lateral to the tibial tubercle, but this is a very hard complication to come back from. And then you heard about this previously, this is old thing, oh, you shouldn't have an HTO because that screws up your following arthroplasty. That's not really true anymore. I think not with the opening wedge osteotomies, they don't distort anatomy as the lateral closing, which did, which ironically, this was a lateral closing wedge, but this is from Aaron Critch. They did a large study looking at the outcomes of total knee arthroplasty, bilateral total knee arthroplasty in patients who had a unilateral prior HTO and the outcomes were no different. So as Bill had said, a well-done HTO is not a contraindication or does not compromise subsequent arthroplasty. So we see a lot of, I see a lot of early OA in young patients. I can't tell you how many, hey, I had a discoid lateral meniscus resected when I was 14. I had my first ACL at 13 and now I had three other ones. I don't have a meniscus. You see these patients in their mid-20s, mid-30s and for them, arthroplasty is not a great option. Many of them are not candidates for joint restoration in terms of cartilage transplants because they're too far gone. And osteotomies really are great. And if you do the technique right, none of these things will happen. So they're all rare. As long as you're aware of them, you can deal with them. So it's a great, really great operation. I would encourage all of you to do that. Thanks very much. Thank you. I think we have probably time for a few questions. Does anyone have any general questions from the, go ahead. Yes, I would like your thoughts on graft preference. When you use it, do you use auto, allo, and when you use allo, what type do you use? For bone graft and PSG on the side? Yes. So, our colleagues from Europe would tell you that up to 10 millimeters, you don't have to bone graft at all. And it heals, I just hate looking at that gap. So I use something. I used to use a wedged spacer plate. Now I use, again, sorry for naming trade names, but now I use a Tomofix, which doesn't have that wedged spacer. And technically it makes it a little challenging because you wedge it open, and then you hold it with like laminar spreaders, and then you need to get your plate in, and there's too much stuff in your incision. So now what I do is based on how much I open it, I use an allograft cortical wedge that come in six, eight, 10, 12 millimeters. You open it up, you put that wedge in, then you take all your hardware out. I let the tourniquet down, you see everything, and then I put my plate on. So to answer your question, I use a structural graft, mainly because it makes it technically easier. And then I fill the rest of the osteotomy site with DBX. Probably don't need any of that. That's just what I do now. If I have like a 14 millimeter, like a really large correction, I would do a small, like a mini subvassus approach on the femur, take an oats harvester, take a few cores of autograft and stick that in, and never go to the iliac crest. But that's really for large corrections where I worry. That's exactly what I'll do for a DFO, a cortical piece, but for an H-chair, Yeah. I'll make a wedge out of femoral head allograft, which is a great, great wedge to put it. It takes a little time to make, but it fills it and supports it, so. Yeah. It's exactly what you chose. In your approach that you showed, how did you handle the MCL? Oh, sorry, I missed that. So I just cut it. So superficial MCL, I know, it's, I usually let the resident do that, because it's sort of this, you know, you bad thing. No, I put a pin in. So check my location, and then I just bovie through the MCL. And then I put the plate back on top of the MCL for two reasons. One is you sort of staple it back down. There are no instabilities, and there are a bunch of studies now showing that that's totally fine. And then also, rates of plate removal are pretty high. So I feel, as I said before, there are different ways to handle your soft tissue. So some just take the MCL off as a sleeve, put the plate on the bone, but then it's not as if the MCL kind of fits over these plates again, because they're too bulky, and it's too long. And if you take the plate out, then you have to mess with the MCL again. You have to brace them post-op. And if you do it this way, you just take the plate out. I don't brace them post-op. So it's easier, I think. I pulled a panel. I cut, too. And there is some biomechanical stuff saying that if you don't release the MCL, whether peel or cut, then you don't relieve the pressure in the joint. What does the rest of the panel do? The patient-specific, it's CT-based. So you have to be on the bone, and so I do an inverted L, take down the PEDs and the soft tissue sleeve. And fortunately, the plate I'm using actually goes a bit more interior. So I can repair the vast majority of that soft tissue sleeve. And it's relatively behind the plate. So I can disrupt it a bit less than classically, if and when I have to come back for harder treatment. I try to elevate it, peel it off, and I put it on the implant, as best I can. Sorry, the MCL over the bone. One question. I like to use the implant, because it's very flexible. Seth, one question for patient-specific. So if you have someone who has a little bit of joint space narrowing from a cartilage defect, so let's say they fall into their cartilage defect inflection, you see a little bit of joint space narrowing. Tell me, not just joint-specific, but do you do your OCA, for example, first, and then you do your correction, or not? Because that's a pointed question, because one of the issues is, if you have a little bit of joint space narrowing from a cartilage defect, you do your cartilage transplant. You correct them a little bit, a couple of millimeters, just by doing that. So my concern with patient-specific instrumentation has always been, you need to take that into account, or you overcorrect. Yeah, it's clearly a limitation, because it's not as modular in the operating room. You can get two different corrections and try to do that, but most of the time, you're getting one correction, you pre-ordain, and then you go with it. So clearly a limitation, and I probably don't think as carefully about that as I should. I guess that would be my short answer for you. Let's do maybe one more question, just in the interest of time, and then we'll wrap it up. That's a great point. You guys have much more experience, but Bob Burks at Utah I said you'll check it, but you don't alter your plan based on what you see with the bobycord So it should sort of be sort of what you plan, but I won't make big changes And then one thing to that point, too, is ligament instability. So really beware of someone who, let's say, is in so much varus that their lateral ligaments have stretched, because you can really overcorrect them a lot. Because as soon as you correct them to biomechanically being straight, then all of a sudden the lateral joint is in contact again. So you might overcorrect by four, five, six degrees. So for patients where they have a little varus thrust when they walk, really make sure that you do stress fuse, for example, where you do a forced valgus, just to make sure that the lateral joint space is closed. Then look at their alignment by doing that, because you need to subtract that from your correction. Otherwise, you can significantly overcorrect. Excellent. Well, thanks everybody for the panel. This was a great talk.

osteotomy complications

medial opening wedge osteotomy

locking plate systems

soft tissue handling

grafting techniques

potential complications