Good morning. It's a good day to be a Hans Society member when you have a nice program like this. My charge is to talk about a kind of a concept, more of a preoperative planning, and how to tackle these complex cases. You saw Jesse's cases in regards to form defects. And so I'll try to just get a lay of the land here. This is nothing new. This is Milch, who I recommend you read most everything he ever wrote because he's just such a smart guy. And in 1953, he really talked about the basic elements of radial malunions, and he broke them down into four basic defects, and that's angulated around the longitudinal axis, collapsed or telescoped just in a linear fashion, rotated around its longitudinal axis, and then translated parallel to its longitudinal axis and offset radius. So we've been still battling the same thing since the year I was born. How do we get there? So we'll kind of break this down into how to orient yourself to the form and have some landmarks that you can always rely on to go back to. These are complex. Many times it's both bones. Sometimes it's multiple angles that you're dealing with. Sometimes multiple segments that you're dealing with. And so you've got to go back to the basics. And then we'll talk a little bit about map making and how you plan your preoperative experience. And then the journey and how you follow the route and make your plan go into effect. And so any of you who do any orienteering, you know there's a lot of symbols, but mostly you've got to have your landmarks. And so here's the landmarks I always rely upon. When I start this process, remember in the anatomic plane or the anatomic position of the human body, the form is supinated. So it's an AP of the ulna and it's an AP of the radius. But that's in the supinated position, which we don't do much planning in, at least in form understanding. It's mostly the zero rotation view. So in pronation, you've got a PA of the radius and a supination AP of the radius. But you always have an AP of the ulna, the stable axis of the form. And that axis translates from the radius to the ulna, from the foveus centralis distally to the center of rotation of the radial head approximately. And that's within three or four millimeters of each other. And it's a forearm joint. And it's truly just like doing an articular fracture. And here's that bicondylar joint illustration that Haggart has really cleverly shown us. And it gives me a better understanding. And the space between those condyles and the space between those concavities is really your length relationship of the radius and the ulna. And they're so intertwined that you have to have them fairly exact. So that's another big thing in osteotomy of the forearm is get your length relationships. It's almost as important as getting your length of your tibia so you don't limp around after an osteotomy. But length relationship of those two bones is critical. And so the linear malunion, as Milch described, is another huge problem distally, not only for the forearm but for the wrist joint itself. And here's that. Always remember you're doing a PA and AP. And then in a neutral position, you're really looking at a AP of the ulna and the lateral of the radius. So here's the zero, standard zero rotation view. And you're looking at a lateral of the ulna. So goes the humerus. Always goes the ulna. So always check your humerus and make sure it's a lateral. And then you know you've got a lateral of your ulna with your posterior border bone from ulnar styloid to tip of the olecranon. And your radius has always got your sigmoid notch distally lined up with your biceps tuberosity. And your 11-degree offset here from your biceps tuberosity, kind of 11 degrees of valgus, but it's actually 11 degrees of apex posterior angulation in this neutral view, corresponds nicely to the slope. So really your lunate fossa and your radiocapitular joint are fairly parallel. And so those are the goals you want to get when you're doing these complex osteotomies. Not only do you want to restore the radial bow, but you've got to deal with flexion extension. And we know a lot about flexion extension of the DRUJ and how it limits pronation and supination with distal radius osteotomies. But more than anything, we've got to have this joint surface right here as this fulcrum and the joint reactive force of this huge forearm and this giant load in the hand be stable. And most of what I'm going to talk about is based on a stable form, that we may have deformity with instability of one or more of the joints, but most of the time we have deformity with stability and loss of motion. As Dr. Goldner used to say, you know, Tom, instability is not going to be this guy's problem. So for the most part it's that. And so you have to really talk a standard nomenclature. And so I like to talk about apex radial, apex ulnar, apex anterior, and apex posterior. And that helps us all to remember, for me, it's better than trying to say it's extended or flexed or it's radially deviated, ulnar deviated. You just look at the apex of the deformity and do your corrections off of that. And then you can all talk the same language in the frontal plane, the sagittal plane, the transverse plane. And here's that, you know, how the setting or the rising sun, you know, rotates around the axis of the ulna. And so Randy Bindra and a couple of fairly famous guys like Lou Galula and others put together this torsional angle of the radius. And Richard Gelberman is on this paper, too, and they talk about having this angle between this line, which is in CT scans is fairly reproducible, and this line, which is very reproducible. And it should be somewhere around 30 degrees when you put these two lines together. And a decrease in the angle means that you're really, you're supinating the distal fragment and the proximal fragment. And an increase in the angle means that you're going the other way, according to this paper. The radial bow was first described by Robin Richards and Emile Shevitch from Ontario. And they really showed that you can determine what the height of that radial bow is and what position along the radial bow it is determined. So X over Y gives you your linear position of the radial bow, and it's usually in the 60% of the length of the forearm from distal to proximal. And then the height is determined. And you can measure the height in millimeters, and you can locate the radial bow along a percentage of the length of the radius. And so we've come a long way in our mapmaking from, you know, these sweatshops putting maps together to now 3-D printed maps that you can get everything you want out of them. And so 3-D printed bones and 3-D reproduced images are really the new norm for understanding these deformities. And so you can go back to the plane radiographs, and I still do it this way, just as long as you've got a good normal side tracing, which sometimes isn't the case. You have to then do an abnormal side tracing. And then you cut out your tracing paper and match and measure the length, the rotation, the angle. And you do it in two planes, and you can come up with a fairly good sight of osteotomy as well as direction of osteotomy just based on paper. You can do 3-D reconstructions, and this is in the AO surgery reference. And I find that it's a good practice to do this in your preoperative plan, especially if you don't do it very often. And I still do it to this day because I think it's a good practice run. And it's the old carpenter's saw. You know, you measure twice, cut once. And so you're measuring this out. And to me, I like to write stuff down, and my images are stuck in my head once I've written them down. And so I go through this exercise. You can do it electronically, but I find doing it with a pair of scissors lasting in my brain. Nonetheless, however you want to do it, you can do the 3-D reconstructions with just images only. And you can just look at your... This is the medium-priced, you know, way of going about this. And you can just take your models and not necessarily manipulate them, but just manipulate them by your measurements electronically. And then your 3-D models... This is a fracture, not necessarily a deformity, but your 3-D models can overlie a normal bone and give you the zones where the abnormal bone lives outside the normal bone shape. And you can figure out your site of osteotomy and your angle of corrections based on these 3-D images. With 3-D models, you can also create drilling and cutting jigs. And you can use... There's a number of different companies that can create these jigs and these models for you with 3-D printing. And hopefully soon we'll be able to do our own 3-D printing in the office for making these types of cutting jigs. And so when you're lost, you can always go back to your 3-D model and have it sitting in the operating room and go back to figuring out what's your next step or what's the next part of the cut you need to make. The COC, the center of correction... We started talking about the COC when we had the Eliserov technique. And Lotti Nagy from Balgris Hospital in Switzerland and Christian Gerber and a number of other really bright engineer-type orthopedic surgeons have created a methodology. You can look up tables to take the cosine of the angle and know how many millimeters to cut. Or you can let a computer do it. It's like having a difference between using a magnetic compass and a GPS. You let the GPS do the work for you. And so in this case, the center of correction will give you a computation that will take every angle that you want, put the cut in a single plane, and you can cut through your center of correction and take out both your varus valgus, your flexion extension, and then slide it out to the appropriate length. And so you can do your preoperative planning through a computation with these tables embedded in the program that you create your algorithms with. And you can come up with fairly good ways of creating two single cuts, closing-wedge osteotomy, opening-wedge osteotomy, angular cuts that correct in two planes without length changes, and then create your plate and your cutting jig all out of the same program. And there's three or four out there that are available both in Europe and the United States for this type of work. And they've now applied it not only to tibias and humerus, but complex shapes of the form also. If you want to go back and basically the Primer 101, I recommend this instructional course lecture that was done by Najee, Jupiter, et al., and Wysocki. And this primer, I commend to your reading from 2009, and it's a great way of just reintroducing yourself to forearm plating. Since that time, we've gotten locking plates, and the locking plates are a great boon to our work because we no longer have to pull the bone up next to the plate. In other words, we just had it just right, and then we put that last compression screw in, and the whole thing changes 5 degrees, or the whole thing changes 10 degrees, or you shift your osteotomy just off itself. So with locking plates, you can leave it where it is, put an interphrag screw across the osteotomy, and then lock it in place. And this is a giant neutralization device, giant external fixator that sits effectively right on the surface of the bone. With these longer plates, though, you have to have some ability to change the torsion of these plates. As you go down, the length of radius is not all radius or bowed the same way. And if you have a nice locking system at the end of the plate, it helps you do your osteotomies way out towards the joint. And so it's important to have these tails, and you get your French benders and your old recon plates. The problem is the recon plates just aren't quite strong enough for many of these constructs to hold. So remember, your radius is like a bucket handle that's going around the ulna. You keep your ulna straight, and you restore the bow of your radius, and you have your bow of your radius in the proper location. And so in summary, you make the ulna straight, you restore the bow of the radius, you equalize the length of the two bones. In other words, you do a forearm leveling operation. You correct the rotation using CT scan orientation. You use anatomically designed or adapted long plates, and you find and use a computed correction system using 3D models. Get used to one you want to use and use it regularly, or get used to the one PAC system at your hospital and use it regularly. And you can come up with these corrections of complex shapes. So with that, I'll leave it. And one thing I want to also add, just listen to Marco Rizzo's talk. Bob Winkus, when I was a resident, taught me to always open up the medullary canal and let those stem cells... We always open up this medullary canal and chant, release the stem cells, release the stem cells. So Marco's talk just kind of reinforces that, too, to allow the medullary cavity to communicate back with your osteotomy once again. Thank you very much.

preoperative planning

radial malunions

forearm deformities

anatomical landmarks

3D printing technology