Happy to take any opportunity to talk about osteotomy, even bright and early in the morning. So my task is to talk about offloading for arthritis, specifically. My disclosures are online. These are some friends, including Eric, and mentors who've kind of helped me, and Andreas, actually, who've helped me kind of shape my thoughts for this talk. You know, osteotomy's often been thought of as a international solution. And I think it's our goal and task to bring this more to the forefront as also an American solution. As you'll see, it can solve a lot of our problems. We often go to these, you know, kind of three stools and want to maintain joint homeostasis. And I think, you know, we'll talk a lot about ligamentous stability, cartilage, meniscus, but behind it all, and really the foundation, is alignment and correcting malalignment. And frankly, if we look specific for this talk towards arthritis and medial arthritis here, you can see that we have the opportunity to get good or excellent outcomes for our patients. These are numbers that I think we would put up and quote for any of the joint preservation strategies, those combined procedures. And so even in a challenging military population, we can get success with isolated osteotomy alone. There are a couple of papers, one that we helped to write, looking specifically at lateral arthritis and correction with distal femoral osteotomy. Again, these are great numbers. These are not procedures typically that last forever. These are all bridging procedures. We need to counsel our patients effectively, but for a decade or more, especially when they're young and quite active, this can really be a life changer and a game changer. Here we can see specifically answering the questions our patients want to know. Can they return to work? Can they return to sport? And the answers are yes in the vast majority of patients. This gets to that question that Bill was talking about, the learning curve. And I think, you know, I didn't start practice for the young guys, you know, doing osteotomies right off the bat. I got comfortable doing bread and butter cases. And then you see that you get a little bit overzealous and probably do too many. And then, you know, if I look at my next five years, which I can add over time, you know, I'll probably get to that right number. And Andreas often talks to me about orthopedic math. And so I think if you think how many you actually do a month, you know, one a week or, you know, so that's four months. So that's, you know, basically, you know, 40, 50 a year. I mean, that's big numbers. For me, HTOs, it's basically 15 a year, you know, plus or minus. DFOs, maybe the same or less. TTOs, I do about 30 a year. And so for me, it's 50 or 60 osteotomies, you know, over time. And so just think about your own numbers and your own learning curve. This group, we're basically talking about symptomatic arthritis. And my thresholds are gonna be in and around that five degree correction, which is a little different than cartilage restoration, where I might correct malalignment, particularly asymmetric, when it's lower in that three degree zone. I love this because it gives you the ability to think and we'll parlay into Bill's talk. You know, who do you do HTO versus uni? I think it's instructive to have both in your toolbox so you can really treat the patient and individualize it. But in general, if patients are younger, I might go the HTO route. If they have lower grades of KL, I might go the HTO route versus uni. If they have larger deformities, that would push me towards HTO. If they have higher activity demands, again, pushing towards HTO. And for those patients who are willing to tolerate a little bit of pain, but they really wanna climb and be active and run and jump and cut and pivot, they may not be our best patients for arthroplasty. There's a huge group of them that fall right in the middle, which is why we have kind of dueling talks about this. These are the classic kind of contraindications. If we're talking about single plane corrections, you know, I think there are extremes and limits. Basically, Al Getgood's taught me and others, if the weight bearing line is going medial or lateral to the actual knee, you probably should measure precisely and consider double levels. And that gets a bit more involved. But in general, most of our alignment and mechanical axis are through the joint. And then obviously in patel femoral instability or other complex pathology, we can think about rotational and multi-plane deformities a little outside the scope of this particular talk. Smoking, I don't do. BMI is a relative contraindication for me. And these patients need to be compliant with rehab and we need appropriate goals and expectations. This again, just hits home on the bell curve of normal. For me, I'm always measuring and I'm more apt to do an osteotomy with asymmetry of varus or valgus. And I think it's important. You can now use proprietary softwares to really not just measure the overall limb, but know where the deformities lie. Know if it's in the femur, know if it's in the tibia, look at your joint line convergence angles. You can really be thoughtful about where the pathology is. And then you might go to that site of pathology for your corrections. And this is from Aaron Critch. It's just interesting to beware of how ligamentous instabilities might affect your long limb alignment. Here, you see this is a posterolateral corner. This is gapping open. If you do the measurements of the bone, it's pretty normal. And so, you know, I think it's just challenging. You just want to understand that in those patients before you correct or overcorrect. And so, Andrea showed us that more is not always better. Basically, these are the target zones. This is where we'd go for cartilage. This is where I might consider going for osteoarthritis. Typically, I'm going just to the slope of the lateral spine, not all the way over to 62% anymore. You could do an entire talk on presurgical planning. I think the key point is to have a consistent and reproducible system and do the same thing every time. With regard to exposures, you know, I think we should get comfortable with distal femoral and proximal tibial exposures, both on the medial and lateral sides. This is ripe for getting in the laboratory and really taking your time, getting with friends, colleagues, and experts, and, you know, trying to get over that learning curve. We always are using a fluoroscopy. I typically set my room up the same way every time, as you see here, with a lateral post and then a foot rest. Of course, protect yourself wearing lead. When you're starting out for the young guys, you know, be honest about your surgical times. Use a Foley, make sure everything's well padded. I don't use tourniquets for osteotomy. I do use TXA. Not sure if there's great evidence, but I haven't had issues with that. I know where my blood bank is, my vascular teams. I do use a drain. I keep them 23 hours, and I'll do femoral or adductor blocks, or sometimes no block, but most of my patients are getting a block and even a catheter. So if we're looking at options for varus, you can do lateral tibia closing wedges, you can weight-bear on, they have good healing, and so those are principles that we can take forward for the femur or the tibia, but it comes at a cost here. There's extensive dissection. You have to think about the nerve. You have to think about the tib-fib joint. You can shorten the leg, and so there might be very select times you do that, but in general, I think most of us are doing medial opening wedges in the vast majority of cases. There's less surgical dissection. We don't have to worry about the tib-fib joint. We titrate that correction after the osteotomy, but it is a prominent spot, and hardware removal is a real thought and concern. We do have to bone graft larger defects, and there is that risk of fracture and nonunion, as I'm sure we'll see in the complications talk. This is just two papers that are interesting, showing hardware removal rates with a peak implant versus metal, and you can see that those removal rates are quite lower. I've used this, and I think others have experience with it. I think for a select group, it's interesting, but I'm not using it for all comers, and so maybe we'll talk about when and why. Here's my take on this, is talking about avoiding complications, not managing them, and so the biggest complication, or one that we worry about, is fracturing that hinge, and I think most of the companies now, when you go out into the exhibit hall, do a good job of trying to protect that hinge, and so there's different ways that you can either have a hinge protection screw, or a K-wire, but whatever it is, I think you want to be mindful, and protect that hinge, and evaluate it intraoperatively. Of course, we're all worried about neurovascular. This is rare, but it's catastrophic. You can see the incidents here, and also, our instrument companies are getting more savvy about helping us to protect the nerves and vessels, but if you're doing medial HTOs, I think one thing we teach our residents and fellows is, you know, if you can't feel all the way across the back, and shuck the fibular head, you're not ready to do your osteotomy, so just get comfortable getting that exposure, getting your retractor, most are all the way over, and then I think you'll keep yourself safe. There's an aberrant anterior tibial artery. It has seen you, have you seen it? Well, you won't see it if you don't look for it, so make it part of your presurgical plan, and just look for it on all the axial imaging. Don't change the slope. There's a two-to-one back-to-front slope in these, unless you want to, and so if you want to increase the slope, then you make it more rectangular, as you see here, and so I think that's one thing. Patellofemoral complications, you know, I think the things that we need to be aware of, we can create patella baja. It's more of a concern with medial opening and larger corrections. You can do more heroic things in cases of baja, like work on the tibial tubercle as well. That gets a bit more involved, but just be aware about it. I'd say most of the time, we might create a little baja, and it's typically not a problem. Conversion to totals. I'd love to hear Bill's perspective on this, but, you know, totals are technically demanding after this. Hardware, scar, the outcomes are controversial, but in general, I think the same survival rates and radiographic results, but longer cases, higher infection risks, some stiffness, so I think outcomes can be good, but I'm sure that they would rather do a primary than revise an HTO. On the lateral side, same exact principles. Most are doing the lateral opening. It's an easy approach. It's one cut. We can titrate that correction. We have stable locking implants. It can be prominent under the IT band, so that can be a problem, and, you know, sometimes you do have to remove that plate. I'm getting better at medial closing wedges. Obviously, you can wafer on them, and the soft tissue coverage is better, but any closing wedge is a bit harder to really get your correction initially, and so I think, as I'll allude to, at the end here, patient-specific instrumentation has helped me to become a better closing wedge surgeon, and it might help you as well. Here's kind of just the pros and cons, and I think I hit on most of them. Some, if they're taking a turn on smokers, even, or larger BMI, actually would prefer a closing wedge, but I don't do smokers, and I'm wondering if the others do. This is something I have incorporated, so this is a biplane cut for stability. It's not a two-plane correction, but it's a fairly easy thing to add to your DFO, and I think the biomechanical information is supportive of adding that additional cut for stability, and it decreases your time to union and can decrease your relative risk of rotational malalignment. DFOs don't unload inflection, and so for the younger patients, athletes who perform inflection who have posterior cartilage defects, meniscus deficiencies through the joint, so those will be smaller corrections. You might think about lateral opening HTOs, and you can see that there is techniques out there and small case series to guide you for those patients. I've been more apt in select cases to go to medial closing wedges. You can't do big corrections. You do have to worry about joint obliquity, but there are reasonable series with supportive evidence, and then lastly, the patient-specific osteotomies. You know, I think this has been a game-changer for my thought process and evolution. One concept is that you can make a single cut, and depending on where your hinge point is, lateral, anterior, posterior, you can actually change in two planes, so one cut, two-plane correction, so you can dial in slope. You can dial in your coronal correction. I think that's really powerful, obviously. You can plan out avoiding your ligament tunnels, and there's a learning curve for sure, but you can reduce fluoro, reduce overtime, and increase your accuracy, so here's a patient who failed a revision ACL and meniscus transplant. You can see they have asymmetric malalignment. Their slope is normal. Here, we can see the varus. You can see briefly on the MRI that they have no meniscus and chondrosis with osteophytes, so this is arthritis on the medial side, and so for this, I'll plan a one-plane correction alongside my revision ACL, and I'll know before I go, and I think that I might have staged this in the past, and now with these tools, I've moved towards doing these together. I think we can get accurate and reproducible images, and we can help the patient and avoid two surgeries. Here, we definitely did not want to increase the slope in an ACL patient, but we didn't have to decrease it, so alignment is a critical part of our algorithm for joint preservation and for young, active arthritics, and our techniques will vary based on many factors. Hopefully, I showed you most of them today. We strive to avoid complications with thoughtful pre-surgical planning and meticulous technique. This is a great one that Bernie Bach taught those of us who trained under him to like your patients but love your complications. These are patients you, I don't convince anyone to do an osteotomy. I give them the information. I send them out of my office. They go to my website. They ask me questions on the eHealth. I do a telehealth visit. I bring them back in. They tell me they need it, and I'm like, I knew that from the start, but I think if you plan to do it that way, then you won't get burned, and then keep a pulse on the new instrumentation. I think there are benefits over traditional, but obviously, we need multicenter studies and longer-term follow-up to prove that, so that's what I have, and if there are any pressing questions, we'll take them now. Yeah, Will. So as you mentioned, you don't unload inflection on the distal. When does that come into play? Is it 30 degrees, 60 degrees inflection? Are these people unhappy like going up and down stairs? Yeah, I think I'm just more hyper-aware that a distal femoral osteo, I mean, it's the same thoughts and principles if you're doing joint replacement, right? If you're doing something on the tibia, it affects change in extension and inflection. If you're doing something on different parts of the femur, you're just affecting a portion of that range of motion arc, and so I think most likely, for the majority of our patients in the cartilage restoration algorithm, the ones who have asymmetry of valgus and cartilage problem, those are, a lot of them, we get away with DFOs, and it's still my workhorse, but I think it's just for those younger arthritics who are quite active with smaller corrections. I've been starting to think about the tibia. Any thoughts from you guys about that? Yeah, I mean, medial tibial closing, which, for example, helps you correct small valgus and its effective inflection as well. You just can't do much more than, let's say, five to six millimeters because you really end up with joint laminoplicuity, and look at your pre-op x-rays. Some people have various poor valgus and proximal tibium, and ideally, if you have someone who has valgus and proximal tibium, that medial closing, which is great if you can make them normal. Someone who already has varus and proximal tibium, doing a closing bridge on top of that really makes a very weird-looking joint. Yes, I agree with that. If the tibia alignment, when you measure it, is a bit off, if the issues are through the joint line, if your problem is on the PA flexion view, if the corrections are pretty small numbers, those are times that draw me towards the tibia, also that posterior wear pattern or diffuse wear pattern. I think doing the math and spending time with the x-ray matters because you gotta know the anatomy, and if you don't have access to a long alignment film, don't do an osteotomy until you see that because you'll see interesting deformities. The Europeans have this all down, but most valgus knees are distal femoral valgus, and you correct that with the opening wedge and closing wedge, but sometimes that's not where the deformity is, and there's a whole lot to think about, so thinking a lot before you do this is important. Eric? So we're kind of focused on this young patient, you do your osteotomy, what are you letting them back to, are there any restrictions post-op? They came to you because they want to get back to an active lifestyle, are you breaking bad news to them, or are you letting them do whatever they want? Yeah, for me, I am much more keen to let these patients go back to higher level activities than the ones where I'm putting in cadaver meniscus tissue and or growing cartilage or transplanting it. If I have a patient that's in isolated osteotomy for arthritis, obviously they need to heal the bone, but then the plate and screws are rendered doing nothing, they're along for the ride. It's a big surgery, it's a soft tissue dissection, we keep them slow initially, and so it goes for minimum time, which is for bone healing and safety, and then to functional progression, but that functional progression for me can scale all the way to running, jumping, cutting, pivoting. Of course, I'm counseling the vast majority of these patients right off the bat that our first goals and priorities are for quality of life, daily life, return to your job, things about basically pain-free, low-impact recreational, but if you achieve all those goals within that first timeframe, that year, and everything's checking out on imaging, you have a dry knee, so you're in balance, then I scale, and I think the vast majority of these can get back to higher level. Any thoughts from you guys? I guess you'll talk about it in arthroplasty, and I think I would put arbitrary limits on them if we're doing metal and plastic, more so than the HTO or DFO. Other people do what they want, they figure it out. To have a big operation and be told you can't doesn't sit well with them. There's a really good paper in CORE about six months ago, patients will accept further surgery if they're allowed to go back to their highest level of function. They wouldn't really allow, ruin their knee, and then thinking they're gonna get more surgery if you let them, and that's okay with them. They actually accept that as an outcome, that yeah, I can be active, but I'll probably need earlier surgery than I would have if I did nothing. It's a real interesting. What do you think? I let them go, that's like the whole purpose of this. And I guess, I don't know about you guys, this is like my happiest patient population, is the HTO needle compartment OA, that you give them their active life back for a period of time. Yeah, I mean, these are former athletes, and these are former military or aging military, and people fit that bill. These are laborers. These are people who are extraordinarily active, high demand, and if they have asymmetry of varus or valgus, and bipolar disease, and you can't do the joint preservation strategies, I think it's an outstanding option. There's a couple of metrics that I have gotten interested in. Resiliency, it's a metric. There's five questions you ask people to determine how resilient they are. And osteopathy patients wanna make sure they're very resilient. And regret, people have regret for the choices they make, so I measure that in all my patients. It's really interesting to see the results and does that correlate with outcome. So. Thank you.

osteotomy

offloading

arthritis

alignment

success rates

bridging procedure