(0:00) Okay, so I want to talk to you a little bit about osteotomy. And this is something myself and (0:04) Kristian, it's what really brought us together. I was doing live surgery demonstrating on Inside (0:09) ACL.
It was the second time it had been seen in Germany in 2010. And it was at Kristian's (0:15) boss's course, Philip Lobenhofer ran a live surgery course. We came together, (0:19) and we've been working in osteotomy, developing things like the care retractor (0:24) and developing techniques together since then.
And what osteotomy is all about is preserving the (0:33) knee. And you can see I was in Warsaw actually at a friend's meeting. I saw this guy doing some (0:37) beautiful roller skating.
He's not 20 years of age. And people are very active till very late. (0:42) And we can see this spectrum of disease as the knee gets arthritic.
And we want to keep people (0:48) in the green. So we want to be doing preservation procedures before we do joint replacements, (0:52) or the salvage stuff. And that's what osteotomy is all about.
Now, knee arthritis, the Holy Grail (0:59) was thought to be a total knee replacement. And we believe in these. And we believe in partial (1:04) knees on the inside, on the outside.
We get patients sometimes where we do both. But we know (1:10) from national joint statistics for total knee replacement, this was published in 2017, this is (1:15) 65,000 patients with a minimum of 10 years follow up. So they had to have had 10 years before they (1:22) did the scores.
And what they found was in the under 55s, 35% fail within seven years. (1:28) Mean time to having to have it redone, four years. It's a disaster.
So in certain countries, (1:33) you need two consultants to sign off before we can do a knee replacement in someone of that age, (1:37) because it's just such bad news. Now, we believe in knee replacements.
This is Mark. He's a (1:42) physiotherapist. This is his partial knee replacement. And this is him walking on the (1:48) day of surgery. He's done brilliantly. He got back to playing rugby. We believe in it.
(1:53) This gentleman here, he's a farmer. He'd actually had osteotomy surgeries, 55. We did both of his (1:58) knees at the same time. This is him a few hours after surgery. And you know, he's moving his knees (2:03) comfortably. He's not in too much pain. He's happy. And he went on to actually shoot this (2:07) lovely testimonial of him driving and being active. This is him.
(2:21) So we can get a great result with total knees. This gentleman here, day of partial knee (2:29) replacement. And this gentleman here is absolutely fantastic. He came to us. (2:39) So that's a revision knee replacement two weeks. (2:43) This is easier than the partial knee.
(2:49) Do you want me to do an Irish jig? Great guy. (2:55) So what is an osteotomy? And this is quite a nice animation that we can go through, (2:59) which shows a weight bearing line on the inside of the knee, which is most people are various, (3:04) the weight bearings on the inside, as opposed to being not need where the weight bearing would be (3:08) on the outside. There's disease on the inside.
And in here, this case here, we can see significant (3:14) arthritic change on both sides. And in grade four, which is makes up 35% of our cases, (3:20) we can perform this operation appropriate patients. And what we're aiming to do is to (3:25) move the weight bearing line from the inside to the middle of the knee.
That's what an osteotomy (3:30) is. And it can be done either in the femur or the tibia by either opening a wedge or closing a (3:35) wedge in the tibia or the femur. Everybody has a long leg x-ray calibrated.
And then we work out (3:41) whether they're suitable for this surgery by doing virtual surgery before we then go to execute the (3:46) osteotomy. We make through a very small incision now, a minimally invasive approach to cut the (3:52) bone and open. We pack that with borrowed bone and put the plate on and that's an osteotomy.
(3:59) Now, we've set up a centre of excellence with Ronald Van Heervaarden, who you see here as part (4:04) of this scientific advisory group. And we've taken Nuclip, which is the leading company now in (4:10) osteotomy surgery, from being not very well known to being number one. And our plate, (4:15) which we helped to design, is the most commonly used plate globally.
(4:20) So what about survivorship? This is my series. So I had a large grant, half a million pounds to (4:26) follow patients in Basingstoke. And I made it my, I suppose, my hobby from 2006 and collected (4:34) these patients.
And what we found was that at 10 years, 92% are doing well. We won the best (4:43) consensus when we set the consensus document in Europe with Matt Olivier and here Matt Dawson, (4:49) my good friends. And we won the best consensus in Paris for telling surgeons when, where, and what.
(4:56) Here's some pictures of rudimentary surgery. And now we have these sophisticated techniques.
(5:00) Look at this gentleman. He's 39, couldn't do any activities of daily living. This is him a year (5:06) after his osteotomy surgery, and he's walking. And in fact, he's running 30 kilometres a week now, (5:12) having not really been able to walk prior to the surgery.
(5:16) So these are the plates that we've designed. This one actually is my design. This is the (5:20) most commonly used plate, the type two active motion plate.
And we have a different plate (5:25) for a different solution now, which we've helped to develop with this company. And we're very proud (5:30) of this, the care retractor, which is a specially designed retractor that can slip in behind the (5:35) bone. It has a slot that receives the sore to make it very safe.
And this is to stop surgeons from (5:41) cutting the nerve, the vein, the artery at the back of the knee. It locks into place. It's been (5:47) very well received by the orthopaedic community.
And we're very proud of that design and of that (5:52) particular innovation. This is myself and Kristian messing around on another concept that we came up (5:59) with, which is the hinge screw, which we can place at the hinge and open. And without breaking (6:03) the hinge here, I'm sorry if that's a bit gruesome, but we can see a massive opening, which we can (6:09) achieve by stabilising.
Here we can see a hinge screw patient. And this gentleman has had a femoral (6:14) osteotomy, and this is him 24 hours, less than 24 hours after surgery, the day after surgery, (6:22) walking quite comfortably having had his femoral osteotomy surgery. So I'll just play that a little (6:28) bit.
And then on to this gentleman who's back now doing Taekwondo. (6:33) Here we are. It's not quite 24 hours since we did the surgery.
We've done an osteotomy. (6:40) I've got a nice straight leg here. And that was done relatively late yesterday.
How are you feeling? (6:45) How much pain are you in? No. No pain at all. Does that surprise you that you're going to be (6:50) straightened out in the next season? Yeah.
So no pain at all. And actually got back to (6:56) martial arts. Sorry, this is the same gentleman showing the preoperative x-rays.
And that (7:00) gentleman, 38, pain with activities a day, living, no sports possible. That's the before, (7:05) and then we saw the after. These are surgeons that we've operated.
Mark, a good friend from (7:11) South Africa, doing the little bit of shimmying after his osteotomy under our care. Zayed came (7:16) to us. He's the most senior sports medicine surgeon in the Middle East, from Jordan.
And (7:23) actually not our case here, but Anant Joshi, the father of knee surgery in India, who had this (7:28) performed as live surgery 20 years ago, showing that it's the surgeon's choice. So does it last? (7:34) This is Ronald, a bit younger, with his professor, Professor Marty. And this was a 20-year (7:40) follow-up clinic where patients came up to say farewell and to tell Ronald and Professor Marty (7:46) how good they're doing.
So Ronald, much younger, much younger. Back in 2006, we visited with (7:53) Neil Thomas, and we set up our master class in Basingstoke, which we ran in the North, (7:58) and then we ran in London. And we've moved this all around the world, training and teaching.
(8:03) And as I say, we've followed our patients. So 651 height of osteotomies, followed very carefully. (8:10) And what we found is 97% at five years, 91% of these patients doing well at 10 years.
That's (8:17) the largest series in the world for HTO. We then did, via a PhD, and this was done by James, (8:25) who very kindly did this PhD for me, showing fantastic return to activity after osteotomy (8:31) surgery, which really does outperform partial knee replacement on many different levels, (8:37) as shown recently from this data from Australia. This, again, the largest series for femoral (8:42) osteotomy, 89% survivorship at 10 years.
How good is osteotomy? Let's look at some cases. So (8:48) this is a chap that came to us, he's 58, he's an ex-professional, semi-professional, run a long (8:53) distance, best 5K time, 15 minutes. In 2021, was still running, but getting night pain, starting (8:59) to really struggle.
And when we look, look, absolutely nothing on the inside of his knee, (9:04) bone on bone arthritis. He wants to run again. So here we are at nine months, he's running 35 (9:10) miles a week, he's biking.
He wants to get a six minute pace after his osteotomy surgery. (9:16) And he sends us this lovely, lovely, or lovely picture of his first place. So he was in 80 (9:22) degrees in Florida.
First race, he did it in 22 minutes. He came first for the over 50s, fourth (9:28) out of 250 on his bilateral osteotomies. This lady is, this lady's just showing that this (9:39) works in elderly people.
This is about active people, not about age. Professor Takeuchi did a (9:46) brilliant study over 70, under 70. In fact, the over 70s did better.
So what about if we've got (9:53) someone who's got normal anatomy? So take this lady here, she's an ex-model, she's a very active (9:58) lady. She fractured her tibia and it was fixed. And the slope here is going in the wrong direction.
(10:04) It's going uphill instead of down. She can't walk. She's literally confined to a wheelchair. (10:10) And she came to us, she had a slope changing osteotomy to normalise the slope. She got out of (10:15) her wheelchair. She's a very, very motivated person.
And then got back to very high levels (10:21) of activity. And we can see during this little snippet, she's working out, she's working hard (10:25) on her bike, but she wanted to do more. So she actually started to, over the course of 12 months, (10:31) get back to a totally normal level of activity, even doing quite extreme climbing.
(10:36) This young girl here, now look, she's 17, five years on crutches, since 12 years of age, (10:42) three opinions. She finally gets to see Ronald van Heervaarden. Watch her walk.
So when she walks, (10:49) she's kneeing in. And the problem is most doctors aren't trained to assess this. And the problem is (10:56) not at the knee.
The problem is in her shin bone. So Ronald did the assessment, which found that her (11:02) foot was externally rotated. This is a 40 minute operation.
And this is her walking at three (11:08) months, completely normally, totally transformed her life. Ronald only does osteotomy, and he's (11:15) performing 10 of these sorts of cases every single week. And we're very, very lucky to have him come (11:21) and work with us as part of the London Osteotomy Centre.
So what would you want? So here's a lady, (11:26) bone on bone arthritis, both sides. So let's look at the case, 59, in 95 ligament surgery in New York. (11:34) Then she has bilateral HTOs under our care, the right in 2003, the left in 2004.
Then she comes (11:41) back in 2015. She has a partial knee on one side and a total knee on the other. And this is her (11:49) walking in Neil Thomas's office just prior to him retiring.
She just killed the volume again. (11:58) And she had both the hardware removed. She had this done as a simultaneous procedure, (12:05) and obviously doing very well.
What about if we overcorrect? So here's a difficult case. (12:13) And here we've actually gone in and we've done a partial knee with an osteotomy. (12:17) How many knees can we save? Every 10 seconds, somebody in the world is having a knee replacement.
(12:25) And one third of them are suitable for osteotomy. So think about it. This is actually an interesting (12:32) little video.
These are hip patients, but the chap at the back has had a double level osteotomy. So (12:37) he's had femoral and tibial corrections. And this is him hobbling slightly the day after his surgery.
(12:43) So we have lots of fellows and visitors. And we see Ronald here in the middle. We're very (12:50) proud of the teaching that we do.
This is a WhatsApp group that I set up. It has 115 members (12:55) in it, mainly experts, all sharing cases and asking, what would you do with this? And what (13:00) would you do with that? And videos are sent in and cases are sent in. And we look and we talk (13:06) and we chat and we plan.
I'm very proud of that actually as a thing that I set up. (13:11) So if you're interested, come and see us operating together, (13:16) generally at the Cromwell Hospital. We'd love to see you.
We're very proud of our centre. (13:21) And there are my details if you want to email me. Or if you have a problem, (13:25) you think you might be suitable for an osteotomy, get in touch.
