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Anterior cruciate ligament reconstruction (ACLR) failure is multifactorial, but it is known that increased posterior tibial slope (PTS) leads to a greater likelihood of ACLR failure. This technical note describes the senior author’s technique for performing an anterior closing wedge proximal tibial osteotomy, in which the osteotomy is made proximal to the tibial tubercle. This procedure is the first part of a staged surgery for patients with multiple failed ACLRs and increased sagittal plane PTS. Debridement of osteolytic reconstruction tunnels with bone grafting is also undertaken in preparation for a second-stage revision ACLR., Technique Video Video 1 Proximal tibial closing wedge osteotomy with tibial tubercle sparing and bone grafting. In a patient with multiple failed anterior cruciate ligament (ACL) reconstructions and increased posterior tibial slope (PTS) in the right knee, a proximal tibial closing wedge osteotomy is performed with bone grafting as a first stage to maximize the chances of success of a subsequent second stage ACL reconstruction. Examination under anesthesia reveals 3+ positive pivot-shift and Lachman tests. An anterior midline incision is made, and subcutaneous skin flaps develop medially and laterally. A scalpel and Cobb elevator are used to develop subperiosteal flaps laterally to the proximal tibiofibular joint and medially to the posteromedial aspect of the tibia. The patellar tendon is carefully outlined and protected, as the tibial tubercle will be preserved. Arthroscopy is then performed to address any intraarticular pathology and debride osteolytic bone tunnels from previous ACL reconstructions. Two guide pins are then placed parallel to the joint line at the inferior extent of the desired osteotomy. After confirming their position extending to the posterior tibial cortex fluoroscopically, two additional pins are drilled, parallel to the joint line, at the anterior extent of the planned osteotomy. These are angled such that they will meet the first two pins at the posterior tibial cortex, and fluoroscopy is used for verification of position. An ACL saw is then used to cut the anterior tibial cortex colinear with the inferior and superior guide pins, the desired wedge of bone is removed with curettes and rongeurs, and the guide pins are removed. To verify enough bone has been removed, a curette is inserted into the posterior extent of the wedge, and a lateral fluoroscopic image is taken. The wedge is then gently closed and a bump placed under the heel. The closed osteotomy is secured with several large staples, and anteroposterior and lateral radiographs confirm position of hardware. Bone grafting of the tibial and femoral tunnels is accomplished with autologous bones from the osteotomy and allograft bone matrix.

A middle-aged woman who was previously a long-distance trail runner presented with chronic right forefoot pain and was diagnosed with Freiberg's disease. She suffered from nonunion after undergoing a dorsal closing wedge osteotomy. The nonunion achieved full osseous union after treatment with abaloparatide. Patient reported outcome measures taken at 19 months postoperatively indicated good to excellent clinical outcomes and satisfaction. The aim of this case is to report on the effectiveness of abaloparatide to treat nonunion and support fracture healing., Highlights • Use of abaloparatide to treat nonunion in Freiberg's disease • Successful treatment of nonunion following dorsal closing wedge osteotomy • Role of osteoanabolic medications in fracture healing

Ray resections have been a viable treatment option for patients with tumors, trauma, infection, vascular insufficiency, or other abnormalities of the hand since the procedure was described in the 1920s. The creation of a functional hand after central ray resection presents unique technical challenges: insufficient closure of the gap between the metacarpals bordering the resected ray can produce an enlarged space between remaining digits and potentially cause digital malrotation, both of which negatively affect hand function. The goal is to make the space between resulting fingers as close to normal as possible. A number of procedures were described to address this issue, but unfortunately, they can be technically onerous and may require prolonged immobilization, the use of internal hardware, or the use of temporary hardware requiring removal.We describe a technique for amputation of the affected ray at the proximal metacarpal metadiaphyseal flare and a concomitant closing wedge osteotomy to allow superior gap closure between the residual fingers while maintaining the structure of the carpus and alignment of the hand. This improves functional and aesthetic outcomes after central ray resection of the hand. Key words: Metacarpal ray resection, Middle ray amputation, Ray amputation hand

Isolated lateral compartment arthritis or focal chondral defects in the setting of genu valgum in young, active individuals can be treated with a varus-producing distal femoral osteotomy with or without cartilage treatment. Both medial closing-wedge and lateral opening-wedge techniques have been described, with neither demonstrating clear superiority. The objective of this Technical Note is to describe a technique of biplanar medial opening-wedge with controlled reduction using an articulated tensioning device to achieve a safe, reproducible result.

Valgus malalignment can be corrected with a medial closing-wedge proximal tibia osteotomy in patients with symptomatic lateral compartment disease. Advantages of this technique include the inherent stability of the closing wedge with direct bone contact and reliable healing that enables early weight bearing and shorter recovery time. In addition, a tibial-based osteotomy alters joint contact forces in both flexion and extension versus femoral-based osteotomies. The purpose of this article is to present a reproducible technique for medial closing-wedge proximal tibia osteotomy and review the indications, preoperative planning, rationale, and clinical outcomes.

Freiberg infraction is a relatively rare osteochondrosis of the lesser metatarsal head. Operative treatment is indicated if conservative treatment fails to relieve the pain. Dorsal closing-wedge osteotomy is a realignment osteotomy of the metatarsal head and neck to redirect the articular surface, allowing the intact plantar cartilage to articulate with the proximal phalanx. The purpose of this technical note is to describe the details of arthroscopic dorsal closing-wedge osteotomy of the metatarsal head for management of Freiberg infraction. Although dorsal closing-wedge osteotomy has been proposed for the treatment of late-stage Freiberg infraction, we reserve this technique for early stages of the disease.

Increased sagittal plane posterior tibial slope has been identified as a risk factor for primary anterior cruciate ligament reconstruction (ACLR) failure. Although ACLR failure is multifactorial, correction of sagittal plane posterior tibial slope should be evaluated in patients with an ACLR graft rupture. There are limited technical descriptions of proposed decreasing tibial slope osteotomy procedures; therefore, the purpose of this Technical Note is to describe the current senior author's technique of performing an anterior closing wedge proximal tibial osteotomy to decrease sagittal plane tibial slope in patients requiring a revision ACLR.