I was privileged to be joined by three colleagues this month while doing a new minimally invasive HTO procedure with bone wedge, as well as two ACL revision/ALL reconstruction with the doubled gracilis technique.
Mohi El-Shazly is obviously an extremely experienced limb deformity guy - an expert in limb deformity actually - and I think he was really interested to see the minimally invasive high tibial osteotomy procedure that I’ve been developing because previously high tibial osteotomy has been quite an invasive operation involving a lot of soft tissue stripping so that you can see what you’re doing to make the saw cuts, long incisions, perhaps as much as 15 centimetres.
Mohi very much believes in not disturbing the soft tissues when allowing the bone to heal, because you keep a good bloody supply by not disturbing the surrounding soft tissue envelope. His experience has mainly been in the use of external fixators - but what I showed him was the minimally invasive approach. This involves a 3½ to 4 centimetre incision, a very careful dissection (minimal dissection actually), and then the saw cuts are made with this precision saw blade. I think he was really very surprised at how small the incision was and how we had developed the operation.
I also explained the advantages of the bone wedge - the fact that you get immediate stability and it’s like a cork in a bottle, with patients actually feeling a lot better because they get, not only a strong plate put in, but they also have the bone acting as a 'cork' stopping blood from coming out from the osteotomy and causing swelling. I’ve seen a remarkable reduction in post-operative pain and much more rapid discharge and rapid rehabilitation with the patients that I’ve used that on. We’ve now got nearly two years’ experience - with up to a hundred cases - and it’s just revolutionised the practice for me.
Andrew Morris is a final year trainee, on fellowship in Southampton. He wants to have a practice, when he gets back home to Adelaide, focused on the adolescent and paediatric knee, so he came to learn about ACL repair and the anterolateral ligament (ALL). He is actually joining me for a few weeks and scrubbed for all the cases that day. I think he found it very interesting, because he had never been exposed to the concept of 'all-inside' ACL surgery, the anterolateral ligament or ACL 'repair', all of which he was truly fascinated by. He also noted that the high tibial osteotomy was a procedure that he had never seen done in that fashion.
The final member of the trio that joined me was Takeshi Kamitani from Japan, who actually I just heard was an Olympic Gold Medallist in Judo as well as a soft tissue knee surgeon. He was very interested to gain more insight about the anterolateral ligament, because it hasn’t really taken off in Japan yet. So he was fascinated by that. Also he had not seen a high tibial osteotomy done through such a small incision.
So, lots of great discussion, experienced guys, and a great case mix. We had a small boy with a very large osteochondral defect to start the list, and we managed to key it in really nicely and actually save it. Then followed with two revision ACLs with anterolateral ligaments done with allograft - which went extremely well.I was concerned that one was going to be a two-stage but we were able to do the whole thing in one stage, which was brilliant, and the minimally invasive HTO. So that was the case mix. Fantastic day and fabulous visitors.
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Author: Adrian Wilson
From left to right - Mohi El-Shazly (orthopaedic surgeon from Droitwich/Bromsgrove), Adrian Wilson (me), Andrew Morris (orthopaedic surgeon from Melbourne), Takeshi Kamitani (orthopaedic surgeon from Tokyo).