Principles of Coronal plane deformity correction

right thank you hit ish so this is basically a small like for the next 25

30 minutes we'll be talking about coronal plane deformities of the lower length that is the principles involved in deformity analysis as well as

correction of the deformities so the next 2025 minutes we'll be talking on this particular topic the objective of this this we've been out of this lecture is to give you an

idea about how to analyze the coronal plane deformities of the lower limb and our specific focus would be on tibial deformities because it's it's a simplest

of the lot and once you are into that particular workflow it's going to be the same whether you are dealing with femur or whether you are dealing with an upper limb bow so we will start off with

tibial deformities and this particular lecture will be focusing on tibial deformities we will be touching around with the femur also but mostly on tibial deformities so once you are done with

this you will get an idea about how to plan a correction in case of a tibial deformity and once this is done the same principle applies to the sagittal as well as oblique plane deformities

oblique plane deformities are a little bit complicated you need an idea put the sagittal plane correction and then you need to assess both together that is the coronal as well as the sagittal plane

together and then you make a protocol for the oblique plane deformities so why do we choose coronal plane deformity analysis to start with the reason is the

coronal plane deformities are comparatively very less forgiving compared to a little plane deformities because if there is a coronal plane

deformity of the lower leg like if you have a virus in the femur or tibia the entire assault is going to be happening at your knee joint the knee already has

a tendency to degenerate and when there is an exaggeration of the like everybody has a little bit of virus a couple of degrees of virus so if there is an exaggeration of the virus or if there is

a reversal of the curve like if there was August deformity the chances of your knee getting degenerated is much higher that is why coronal plane deformity analysis and correction is given much

more importance compared to other deformities so these are the two common deformities that you see when you are dealing with currently that is a virus and the valgus deformity

so we'll be focusing on varus and valgus deformity of the lower so in that image you can see three different pictures externally if you see

everything is looking almost the same but when you look inside there are bones and as well as the joints this is just a

simulation of that the first image shows different alignment the second is again different the third is also different but externally once the muscle cover is

there everything appears to be similar the first one has a joint obliquity the middle one is almost the normal alignment that you see you see a

straight joint line and the third is a deformed more under deform joint so if you have a large magnitude of deformity

that can be externally made up but if there are only minimal deformities like especially when you are dealing with these extra articular deformities and all the external deformity might appear

to be much lesser but when you take an x-ray and analyze the deformity it's going to be much more so that is the importance of of deformity planning and

this is this if you are planning to do deformities on a regular basis and even if you are right from a surgeon this is one book that you should definitely read that is wrote Valley's principles of

deformity correction it has everything about deformities now just a little bit of mathematics before we go into the real deformity correction

part if you want to draw a line you have to either have two points that is connect two points or the second option is you have a line you have an already existing line you have a point on that

line and unhandled so you can draw a second line at a fixed angle to the first slide so now we come to the deformity proper there are access lines so a deformity

correction is basically a little bit of geometry so you have two axis when you are speaking about limp that is one is the mechanical axis which is actually the line of repairing it connects the

from the center to the center of the adjacent jars and if you want to take the whole limb it connects the proximal for most point of the the center of the proximal most joint and the center of

the distal most joint of that particularly and an article axis is the simplest thing that is the meter is a line of the particular book it's only regarding a particular book you cannot

draw an anatomical axis of the entire length it's only for a particular book so let's come to the two terminologies

one has like alignment and the second is actually what you call the orientation now these are two different terminologies will be which we would be

using regularly once we start discussing about deformities the alignment is actually the relationship between the hip knee and ankle to each other like they walk they follow a particular

relationship between each other in a normal limb orientation is something different which is the relationship of the axis lines of individual bones to

their adjacent terms like if you have a femur if you have a mechanical axis of female that has got a particular relationship with the hip joint as well

as the knee joint similarly if you are talking in terms of tibia tibia axis has gotten relationship with the knee joint as well as with the ankle joint so these

two terms are important and even ultimate aim of any deformity correction surgery is to restore the alignment and orientation of the limb to normal so

what is normal alignment of the limb in the coronal plane the normal alignment of the limb means the collinearity of the hip the knee and the anchor so if if

you are drawing a line from the center of the head of femur to centre of the anchor center of the head to centre of the anchor ankle join the your knee

joint should lie in that particular line so cool linearity of the hip knee and ankle that is what you call a normal alignment of the lower leg in the coronal plane so that's a clinical

example you have a pretty straight lower leg the line drawn from the center of the head to the center of the center of femur head of femur to centre of the ankle is passing through the centre of the knee joint

Turkey talking in terms of the John to orientation lands you have three John's like him John knee and the ankle so joint orientation like the the basic principle is that when a patient is

weight-bearing your limb goes into a little bit of adduction when you are walking and when you are abducting that all the three joints that is the hip the knee and the ankle joint orientation

line should come parallel to the ground it's only when it comes parallel to the ground you say that the orientation is normal so you have a hip joint orientation line which is from the

center of the head to the tip of the trochanter at the knee you have in fact to joint orientation lines one a set of the distal femur we are which is a line

connecting the two most prominent points of the femoral condyles then you have a third line which is the upper tibial joint length which connects the upper

surface of the tibia and until you have the joint line which is running parallel to the joint and connects the medial most point of the the latter the lateral

most point of the medial malleolus and the lateral end of the tibial platform so all these lines when you weighed bear has to be parallel to the ground so

these are the hip joint orientation lines the knee joint orientation lines and the ankle joint orientation laps now you need to have an understanding about

the mechanical axis of the limb as well as a mechanical axis of a particular bone when you are when you are planning a deformity so each bones of the lower limb that is the femur and the tibia they have got a

mechanical axis and they have got anatomical axis now what is anatomical axis it's just the mid diaphyseal and in this lecture we will be dealing mainly about the mechanical axis because

compared to anatomical axis mechanical axis is much more important because ultimately your aim of any deformity correction surgery is to correct the

mechanical axis to nominal so if you take the femur it is the center of the head to the center of the Condors that is the mechanical axis line of the femur

if you take the tibia it is the mechanical axis goes from the center of the tibial that is the midpoint of the tibial spine to the center of the platform now you have an anatomical axis

also in the tibia which is parallel to the to the mechanical axis so if when you're taking tibia then a technical as well as the mechanical axis are almost the same whereas in femur you are not a vehicle

axis is different from mechanical axis because all of you know that it is there is a seven degrees of mechanical and anatomical axis deviation when you think

in terms of femur so that is the mechanical axis of tibia and femur and when do lines meet you get an angle and by convention you prefer to name the

acute angle so it is the acute angle that is always taken into consideration and the bisector means and when we when we proceed with this lecture we'll be using this term bisector and when we

tell bisector it means a line which is bisecting the obtuse angle so two terms one is the acute angle which is usually used for Norman closure and the second is the bisector line which bisects the

obtuse angle the joint orientation lines of femur that's the proximal and the distal joint orientation lines and you can see that there is a relationship between the mechanical axis and the

joint orientation lines so you have four handles when you are talking about the lower limb alignment there are four handles one does the proximal femoral angle then you have the distal femur handle proximal tibial angel' and the

distal tubulin so in fact there are four atoms proximal femur distal femur and proximal tibia and the distal tibia and all these handles are more or less equal

to ninety degrees that is one thing that you can remember it's very easy to remember there are slight variations but it is almost equal to ninety degrees so if it's if you are talking about the proximal femoral and the lateral

proximal femoral angle is ninety degrees it can be there can be a variation of four degrees plus or minus then you have the digital femoral angle again it is a lateral distal femoral angle because it

is a acute angle it's 88 degrees you have the proximal tibial angle but here instead of lateral you are taking the medial proximal tibial handle why because the medial proximal tibial angle

is acute so medial proximal tubular angle it's again 87 degrees plus or minus four degrees then you have the lateral digital tibial angle which is 90 plus or minus four degree so all these

angles are more or less close to 90 degrees so your ultimate aim is to restore the sample and to get a kalinin hip knee and address so once you understand these lines and the jovian

joint orientation handles then rest of the things in deformity correction is much more easy join blank room that is another thing that you should be looked like in in

majority of cases of osteoarthritis you see the cartilage loss and when the patient walks with a virus usually the tibial and femoral and in sir usually normal but what you see is

opening up of the joint or converging joint joint line so if it's three degree medial convergence it's normal zero to three degrees if it's less than three degrees it's fine but if it goes more than three degrees

that means you have a lacks joint so where it lies the significance of these lines and angles is this only for a deformity correction surgery now the

answer is is a big no why because whenever you are reconstructing trauma the ultimate aim of reconstructing any fracture is to

restore these lands I don't know how frequently we check this when we do a DHS or say we do when we do a femoral nailing on a plate we hardly ever think about this but when it comes to

arthroplasty all the people are very much worried about restoring the handles restoring the banks and all but this is equally important even if you are a trauma reconstruction surgeon because

even in my case only some thirty to forty percent is the deformity the corrections are the request is again the trauma surgeries so in terrassa you become a better trauma surgeon once you are well versed with these handles and

lights so what happens when there is a malalignment so the man there was a malalignment ultimate result is a degenerated mean so correction of

alignment and correction of these orientation lands the primary aim is to restore the alignment and to prevent the degeneration of the knee and its

associated problems like ligamentous laxity instability etc the consequences of malalignment the knee is the most vulnerable joint in the lower limb

because the articular cartilage has got only a very low healing potential normally if you take or normally a line lower leg 70% of the weight passes through the medial compartment and 30%

through the lateral compartment any change in these values like there is an accelerated degeneration like if a patient or a person has three or four degrees of errors what happens is ninety

percent of the load passes through the medial joint line and it leads to a meal of our twenty generation the reason for osteoarthritis is purely mechanical so and there is there is a resultant effect

on the ligaments also welcome to malalignment and maillot orientation now when there is a malalignment or when there is a Mallory intention of the JAMA clans we get a

deformity there is loss of collinearity and abnormal orientation Android's so now we are coming to the deformity correction proper

now first thing that you want to find out this whether there is a deformity or not and the second thing is if there is a deformity the next thing you want to find out this where actually is a

deformity then only you can plan correction like initial days we used to say that virus is usually corrected in the tibia and Vargas and the female that

that particular thing is gonna you have to assess properly you have to find out which bonus deformed and next is you go for correcting that particular deformity so it can be an intraosseous deformity

or it can be an extra option to family like ligaments joints and muscles in this particular session we'll be focusing mainly on the interosseous deformities the different types of

deformity what you see in the coronal plane can be an angulation it can be a translation deformity rotation deformity or shortening but most commonly what you get is a combination of these

deformities uninsulated uni planar deformities are comparatively rare except where you see what you see in the usual osteoarthritis is a scenario where you get only the wackest but there are

if the most of the cases like congenital deformities and all are usually a combination of these four things so it can be a pure angulation that can be a translation to vomiting it can be a

rotational deformity or it can be a shortening or absence of a segment of a little like in a proximal femoral deficiency you can have varying degrees of femoral deficiencies

I would be focusing mainly on the radiological analysis part because clinical examination is important but the most important aspect that you have to cover is the radiological analysis of

a deformity that helps in interoperating checking and also postoperatively whether you are correction is perfect or not you can be clear with your

radiographs so this is the gold standard for deformity analysis a full-length radiograph right from the hip to a single exposure it should be a single

exposure the patient has to be positioned at a distance of 10 feet from the x-ray machine the exposure factors should be set up for the hip joint

and the beam should be centered at the knee the pelvis should be squared so these are the basic things that you have to take care of when you are taking a full length radiograph and the most

important thing is the patellar should be facing tipped forward so a squared pelvis but am I at the center the distance between the x-ray tube and the

subject should be 10 feet and the beam should be centered at the knee joint now what does this full-length x-rays help us to do they've helped us in finding out the location of the deformity helps

you to plot the mechanical axis find out the magnitude of the deformity and also once you are done with the correction you can check whether your final alignment is perfect or not and you can

note that there is a white ball at the somewhere near the knee joint that is the magnification marker that we use it's a 30 mm steel ball that we use

which which helps us to calibrate the x-ray when we are when we input these x-rays into the software nowadays we use our software's for analysis earlier we used to draw these lines on the x-rays

using pin sets so mechanical axis deviation that is the first step in deformity correction selectivity the mechanical axis deviation so what is mechanical axis

deviation you find out how much the axis is deviated from the center of the knee joint you connect the center of the head of femur to center of the handle and measure the distance between the center

of the knee joint and the actual access line proper normal is 8 to 15 mm deviation is considered to be normal anything more than that is something

which we term as we give the terminology as mechanical axis deviation so if it's a medial deviation you coordinate a medial mechanical axis deviation the first images of RS of the knee whereas

of the knee generosity be aware the axis is deviated me-tv and the second one is Vargas femur where the mechanical axis deviation is towards the lateral side so

mechanical axis where the rails if it's passing through the center it is considered to be normal any amount of deviation to medial or lateral helps to define the deformity whether it's a

virus or a progress deformity so mechanical axis deviation is where is specific to define a deformity now once you define the mechanical axis find out

the mechanical axis deviation the next step in deformity correction surgery is to find out which bone is deformed like if you want to find out whether the

femur is the problematic bone or the tibia is crossing the issue so for that what you do is you draw the mechanical axis of individual bones you draw the

mechanical axis of femur the distal joint orientation line and the lateral distal femoral angry which is 88 degrees

it's close to 90 so it's normal you draw the tibial mechanical axis the proximal tibial joint orientation line and look at the medial proximal tubule amulet 64

degrees so it's well away from the normal 90 degrees so there is around 16 26 degrees of deformity in the tibia so the the conclusion is that the patient

is having a tibial deformity so this is how you go in a step-by-step manner first of all you draw the mechanical axis find out whether there is a mechanic deviation or not axis deviation or not

then you go to the axis of femur find out the LD FA that is a lateral lateral distal femoral angle this is normal in this case you go to the tibia find out

the proximal tibial angle and this is of normal so it is a TBL deformity similarly a wireless femur you draw the axis lines you found that the mechanical

axis is deviated towards the lateral side ephemeral mechanical axis femoral joint orientation line at 75 degrees so again it is a sub normal I will go to the TV

and find out whether there is a t-bill deformity or not so that's the mechanical axis of tibia joint orientation line of the tibia and it's

91 degrees more or less normal it can be 87 plus or minus 4 so this is an example of a femoral worldís see when a single bone is deformed it's fine but sometimes

what you get is a little bit of I will be coming to that later you will get some deformity in the tibia either there will be another deformity in the tibia which will be either compensating

further or it might be a deformity in the opposite direction joint line congruence it's fine here the joint line is fine it's less than three degrees

convergence now once you are done with finding out the source of the deformity whether the degree or female is deformed you come to the next important aspects

that is affects of the deformity where exactly is the deformity located which part of the bone is deformed and the second is hinge that is angle that is the axis around which you do the

correction so the FX is otherwise fault pora when you discuss about deformities it's the hora means center of rotation of ambulation and hinges otherwise fault akka ACA that is the angulation

correction axis so the coral is along the transverse bisector line of the meeting point of the proximal and distal axis we'll discuss that in detail the first

image is a normal bone you are drawing the axis that this is the tibia here your mechanical and anatomical axes have seen jaunt orientation angles that's fine now

you have a second image where the deformity is actually in the middle of the devices so that is the axis of the proximal

fragment so how exactly do you find out the location of the deformity so if a bone is deformed you draw the axis of the proximal fragment and you draw the axis of the distal fragment the meeting

point of these two axis lines is going to be your effects of the deformity so that is the axis of your proximal fragment you go forward draw the axis of

the distal fragment and you have a meeting point which is actually called the quorum the water one of the

fragments is very small like if you have a very proximal tibial deformity how can you you will not be able to draw an axis like this when the deformity is very close to the joint so what does the

other way of drawing the proximal axis and when we discussed about lines we told them the second method of drawing a line is to have one line a point on that

line and then specified angle and you know that these angles are close to 90 degrees so you draw a line at 90 degrees to the joint orientation and so you that

is your proximal mechanical axis the second line is your modify cl9 that is the digital axis so the point where

these two meet is called the korra or actually the effects of the deformity now we discussed about bisectors earlier now what is the significance of bisector

this is the obtuse angle that you see here and you get a line which path which bisects or which divides up to handle into two so that is called the

transverse bisector line and your Cora can be anywhere along this transverse bisector of line you can correct the deformity by placing your inch anywhere

along this line it need not be exactly in the center you can place your inch here you can place your inch here you can place at the convex and you can place at the concave end the resultant deformity correction will be a little

bit different but your axis lines will be aligned so what is the ultimate aim of any deformity correction surgery like if you are going to correct this particular deformity you

ultimate aim is to align the green line to this purple line that is the ultimate aim of any deformity correction surgery so you can correct that by placing your

hinge anywhere along this transverse bisector line so where do you place your hitch it's ideally placed in the level of the Quora that is somewhere along

this transverse bisector line if you have a hinge at the convex border what you get is an opening which correction if it's at the concave border it's going

to be a close which correction and if it is at the center it's going to be a neutral edge we'll come to that in the next slide now what does an osteotomy now co2 means basically you are dividing

the bone and the aim of this osteotomy is to correct the deformity and it's the your ultimate aim would be aligning these two axis that is the green line to

the purple line so the different types of osteotomy is our opening which crossing wedge osteotomy neutral which and then angulation translation osteotomy and though most Europeans do

miss a little bit of technically demanding so we won't be discussing Domo straight to me right now so what is opening which that's the two axis lines

you have a green line and a purple line violet line actually you are keeping the transverse bisector line is there you are keeping your hinge on the convex

border of the boom and you correct it now you can see that these two lines are aligned and you have an opening wedge here so that is the opening which osteotomy the next one is the closing

wedge osteotomy where you keep your hinge at the concave border and you do a closing Madras here to me there so that is the amount of bone that you

have to remove the virtue of the bone that you are going to remove when you are doing and closing which osteotomy the third is a neutral Ridge where you remove a wedge of bone from here and

place that wedge outside neutral wedge is very very rarely done usually what you do is either an operating wedge or a closing with just yet you

there are certain rules that has to be followed when you are doing an osteotomy rule one is you have a transverse bisector line here a kora is there at

the transverse bisector of line you place your hitch at the level of the kora you correct it what you're getting yourself your angular correction and the

axis is well aligned so osteotomy rule one says you need a kora you place the hinge at the kora and do a closing winter opening which whatever you want and the axis is aligned it's a pure

angular correction that's like example it's a velocity beta you have the proximal axis and the distal axis there is a transverse

bisector line that's a hinge that I've placed at the convex border and that's an opening wedge osteotomy there is a rule one closing with the osteotomy

where you have the proximal axis and a distal axis it says a small child so I prefer to do a closing which osteotomy here kept the hinge and the concave border removed a wedge of bone and

corrected it and fixed width wise it's a small child and that's the x-ray and the clinical picture after correction it's an epiphyseal dysplasia so look at the left side it's it's this is this is how

you plan for your procedure you have a wedge remote and this wedge is actually kept as a reference while you are doing the osteotomy on tables also to be route

to his hinge again it's kept at the Quora but you are doing an osteotomy somewhere away from the actual level of deformity so what whatever what is the situation

in which you do this like in a case of proximal tibial deformity suppose the effects of the deformity is proximal to the tibial tuberosity you will not be able to do the correction at that particular level your osteotomy has to

be a little bit away from the effects of the deformity so in that case if you place the hinge at the level of the pora but you do an osteotomy the still to that or our same proximal to that level of deformity this is this is one

situation which formally arises when you are dealing with Mal unions Man United fractures many times we'll have sclerosis at the apex of the deformity so it won't be a good idea

do an osteotomy it is loading area so what you do is you do an osteotomy little bit proximal or a little bit distal to that Epic's of the deformity so you keep a hinge at the level of the kora but you

do an osteotomy distill to that and rotate here along with angular correction what you get is a little bit of translation also but you can see that the axis is perfectly aligned if you

keep a hinge here and try to rotate it you will get this sort of perfect Corrections and this bump in due course of time we'll get remodeled alright so that is osteotomy rule number two you

haven't Quorra the hinges at the core apart osteotomy is at a different level axis lines are around so that's a VAR s tibia the

deformity is very proximal so the core is somewhere very close to the joint just below the tibial spines so we did an osteotomy distal to the tuberosity

and using a dexter particular range here is actually we use the sixaxis correction system correcting the deformity so that is that is the most important I mean application of osteotomy rule

number two this is the most commonly used osteotomy rule now third is osteotomy rule three where you have a kora but you keep a hinge away from the

core and do an osteotomy away from the kora here what you get is you get an angular correction but what happens this the axis is translated axis is not aligned so instead of a Rule three is

something which you will not use one and two are most commonly used and the three rule number three is just for your knowledge you should not do an austere to me I mean you should not do a correction like this the hinge has to be

kept at the level of the decoder but your osteotomy can be proximal or distal to the effects of the default will go to a clinic this will give you a better idea of how

to go up this is this is just to show the workflow of how to assess a deformity so 13 year old girl with the progressive virus of the left knee started at the

age of 17 11 she's a high jumper so she had difficulty in walking and mild pain that is a clinical picture and and and the x-ray and you can see that there is

an obvious to build virus here I will go to the deformity proper I am just showing a small video today nowadays we do this with software's after a lot of

software is available I personally work with bone ninja that is your magnifying the x-ray there and this is the calibration tool you can bring the

superimpose this tool on to your magnification marker and enter the value in the in the window provided so once that is done your calibration is proper

you will get a perfect measurement when you are doing the analysis the next step is to draw the mechanical axis of the limb and you can see that there is a

medial mechanical axis deviation the axis is passing outside the boom so there is a medial mechanical axis deviation at a virus deformity of the

limb now the next thing is you have to find out which bone is actually default so that is the mechanical axis of femur you can play around with these lines

so it's from the center of head of FEMA to the center of the to the epics of the novel launch that's the mechanical axis of of the tibia that we are drawing mechanical and

an article axis is same in case of tibia and you see that there is about 14 degrees 13 14 degrees of virus in the limb

all right so now there is a varus deformity and you have thirteen degrees of virus the next thing that you do is you find

out which bone is deformed so I'll go to the tibia first so you draw the proximal tibial joint orientation line it's a just article of deformity so I can't

rely on the axis here I have to draw the joint orientation line and the proximal axis at a specified angle that is 87 degrees medial side MPT a of 87 degrees

this way I can go along with the beta if I see a line and now here I see that there is around 23 degrees of deformity

or net deformity was 13 degrees but here I am getting 23 degrees of the virus of the tibia so what what is the issue here the issue here is there is a deformity

in the distal femur also which is for this deformed so I am having 23 degrees of a present that proximal tibia and 10 degrees of well Gazeta they still Freeman so the net deformity is only 13

degrees so that is the importance of of deformity analysis this is something which you are likely to miss when you are dealing with sport films if you have only an x-ray of the knee joint there is

all the possibility that you are going to miss the distal femoral deformity so that is the important of importance of full-length x-rays and proper deformity analysis next thing we do is

we pluck on the osteotomy and this is some of the osteotomy is plant I'm planning to do distal to the tuberosity away from the effects so I'm going to use osteotomy rule number two

and that is the hinge that is placed see the osteotomy is lower down but my hinges exactly at the effects of the deformity now I rotate and this is the

correction that I am planning to do so everything is in your hand before you go into the operation theater so only the thirty percent of the work is left in the operation theater breast is done

outside so once you have this picture once you have a printout of this and you're pasting it on your x-ray movie things become much more easier so just

to summarize that's a mechanical axis deviation medial mechanical axis deviation there is an abnormal MPT a as well as an LED effects so there is a femoral deformity

as well as a t-bill defaults for approximately bilko hundred distill fungal Cora both are very close to the joint lines so here this is how I planned the correction and planning to

correct a tibia by doing an opening wedge it's distal to the tuberosity so I'm going to use a ring fixator here that's my personal choice you can use any implant which you are comfortable

with you can do a closing method also disturb femur I am trying to do an opening wedge but here since the deformity is at the level of the epiphyseal facial plate I'll be doing a

guided growth here if it was still open she is only 13 years and that's the final correction I used a ring fixator for the distal tibia I mean proximal tibia I uses x-axis correction system

gained a little bit of length and corrected the deformity for the distal femur I used Italy the femur is a little bit under corrected but that is fine like axis is

perfectly at the center a little bit of joint obliquity is a so now the question arises once you are done with this the question arises whether you want to go for an acute or a

gradual correction the gradual correction is if the advantages of doing a gradual correction is you can correct the exact degree of deformity and there is always the perfection of correction

because you have the option of fine tuning in the post-operative period once the correction is done you can go to the x-ray room take a full length weight-bearing x-ray and find out whether the axis is aligned and where

the whether you have joint or interrogation angles are restored to normal and any limb length discrepancy is there you can correct it with a fixator acute Corrections are personally I perform it very less frequently very

small children we prefer a closing which and an acute correction and led cannot be corrected that is limb length discrepancy cannot be corrected when you are going for an acute method the choice

of hardware it's a surgeon's preference none of us like there are many of us doing al Israel ring fixated Liz Rome is our personal choice but we never recommend will is zero people to Bowie

listen Oh for every case Liz Roe definitely has its own place in deformity correction surgery but if they are not comfortable with eligible you can use plates or nails whatever you want whatever you are comfortable with

but do it in the proper way like if you are doing a plate or if you are doing a nail if the deformity warrants some amount of translation your Hardware choice has to be depending upon that so

lot of things depend upon the patient as well as the deformity parameters the type of osteotomy whether you are doing an opening wedge or a closing which and the level of the osteotomy also certain deformity is like if you if you are

dealing with very deformities that are very close to the John sometimes you find it difficult to fix with a plate or a nail in that circumstance you will have to use a ring fixed set of that you

would be left with only one shirt so lot of things depend upon the deformity parameters as well as the patient parameters but ultimately do

whatever is comfortable in your hands thank you very much so this is a nutshell how to deal with coronal plane deformity especially that of the tibia

and if you have any queries you can mail me at any time you want Thank You Krishna that was an excellent

presentation thank you thank you very much for the presentation and the concepts are being very very clear and

couple of queries yeah one is can you explain what is the alignment test should I go back to that slide

right so malalignment test is is to find out whether the receptive for meteora not so that is the first step in deformity correction you can take a full

length x-ray you draw the axis of the limb that is the marker point on the center of the head of femur and mark a point on the center of the ankle joint

then you connect these two points and normally if your alignment is normal it should pass through the center of the knee so if this is passing away from the

knee that is enviros it passes medial to the John Kline and if it is while this deformity passes away from them that is a lateral to the knee joint so

that is something from the mechanical axis deviation now once you are done with mechanical axis deviation you have to find out which is the which bone is deformed that is whether it is the femur

or is it the tibia that is deformed so for that you do a you draw the joint orientation lines you mark up the axis of femur and access of tibia

so axis of femur is from the centre of the head to the center of the knee you find out the joint orientation handles whether that is normal or not the most commonly used things are the lateral

distal femoral ankle and the medial proximity so if there is an abnormality in any of these samples that means that particular onus deform like if you have an abnormality of the ladder of the

still femoral mantle that is that is a femoral deformity basically and if it is a deviation if it is a variation of the MPT that is a medium approximate again and it's a t-bill deformity so this is how

you do the malalignment is the next part is to find out the orientation that is the man orientation test now once you find out that there is a malalignment

you plot the proximal and distal axis of that particular book and you check whether these axis are for correct

angles to these joint orientation lines and if these axes are at correct align or orientation to these joint lines then your ultimate aim is going to be your correction of the axis alignment of the

axis so that is malalignment test and the second part of my after you do a malalignment test you do the Mallo equations okay so that is pretty clear thank you

very much and the other question was see suppose you have multi apical deformities right whether there are more than two abbesses

yeah outside the bone now you have two options there like when you're dealing with a multi Imperial deformity something which you get in these many of

these congenital anomalies like osteogenesis imperfecta and out you gain these uniform going of the tibia femur where you have got multiple effects pieces so in that situation what you do

is you plan properly that is you plan according to your normal thing itself like you draw a proximal axis line it is relaxed this line it will usually intersect outside the bone so that is

something you called the resolution kora so either you can what you can do is you perform an osteotomy at the level of the kora and correct it but what happens is ultimately like you have a banana like

you think about it you have a banana you cut the banana and the center and straighten it out you get two curvatures but ultimately it's going to be a straight line through the center so that

is one way of doing the correction the second way of doing a correction is like the classical seekh kabab uh straight where you do multiple osteotomies at

different levels and make it straight so what do you do is you pass your suppose you are correcting you with you with a nail you pass a reamer pointed which the reamer touches the bone you do an osteotomy there straighten it out go

through the second again cut it again go through the third fragment so this is this similarly you do on an x-ray also you draw the

proximal line it means at one point so proximal line is easier you can draw it using your joint orientation length then what you do is you draw the distal one also and draw a third line through the

center of the book which is going to be which is an arbitrary line which passes through the center but connects both the proximal and distal axis the easiest way to understand this is the seek of a

busted passer Riemann that's the proximal axis but it correct that deformity pass it through the second fragment again that becomes access so these two axes are now wondering now you

go to the third part so that is what you do when you are dealing with a multi apically okay so that's pretty yeah the

other thing was someone got confused with the Fugees ava's point and the mid

part of the knee so this our point is something which you often hear when you are dealing with ITB loss strategies

cassavas point is actually lateral to the lateral tibial spine so that is something which is when you are doing a high tibial osteotomy what your your

ultimate aim is your axis passes through the fuji service point but what we usually do is we nowadays we are not bothered about fields is our spot we aim

to get her HK axis that is the hip knee ankle axis at one to eighty three two one nine to six degrees that is moving effectively three to six degrees of validus that is ultimately what you need

you just reverse finders lateral to just lateral to the lateral tibial spine that is something which many textbooks and many literature tells about few G's are your ultimate aim of getting the axes

around to the fugitivus fine but if you are treating osteoarthritis the best thing is always aim at a hip knee ankle axis of 183 to 186 buildings the center of knee is different like if you are

talking about the normal axis it usually passes between the boot EPL's pants so that is a difference between future sagas point at the center of the that's

clear so a normal axis goes between the spine yeah I mean the tibial spines and the 50 service point is immediately lateral to the level of the bills matter

okay so that is some people get confused with that boogy service point comes in the y-axis yeah fugitivus point is is what you ate when you are dealing with

osteoarthritis most children right yeah so I think there are no more questions Krishna so that was the real imposition thank you very much for sparing your time with us we look forward for more

lectures from your side because of the crystal clear nature of your presentation thank you very okay I'll end the meeting [Music]