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Hi, Doctor Nathan. Mhm. I think your meted me. Yes, I can. Okay. I think I can share my slides now. Oh, lovely. Please, go ahead. Okay. Um, I think we can get started by six or five. Just 30 seconds to go. Okay. Okay. Hi, everyone. My name is Michelle, Uh, surgeon. I'd like to welcome you all to this, uh, first session of, uh, arthroplasty lecture series. Uh, and we have the pleasure of having Doctor Nathan, uh, who is an orthopedic surgeon at Coptic Hospital Leaguers to get us started on total knee Arthroplasty, please. Um, guide Doctor Nathan. Hello. Good evening, everybody. I have the pleasure to join you today. Uh, I'm Doctor Nathan. I'm orthopedic surgeon from Coptic Hospital. Lagos. Uh, and I'm going today to have a short speech and in simple terms, about totally arthroplasty or totally, uh, replacement. Is that okay? Uh, it's okay. Shall I start now? Yes, it is. If you could just have your slides on a slide shape. Okay. Is it is it Is it now shared? Uh um, if you click on the slide show icon back, is it, uh is it shared now? I hope it can be shared. I think you may have, uh, discontinued. I think it may have stopped. Slowed share. Fine. Uh, so we can see your screen now, so if you just click? Yes, it is. If you just click on the slide show icon. Okay, that's it, right? Is it working now? Maybe if you move your screen, let's see if what should I do? I'm sorry. So if you look at the bottom of your screen towards the right and just to the just the immediate left of the high country lane, uh, like a positive and negative pole, uh, horizontal line. You see a heart corn that looks like a TV on the stand. Uh, if you put your clothes on right over it, it pops, it pops up with a slight show. Uh, so it's not shared now. The total knee or is a slide now is not shared with you. It is, uh, just that if you joint is for the screen, Sorry to make it a full steam. Exactly, uh, slide show. It makes it easier for you too more as well. Uh huh. So, when I choose screen was I choose the windows and choose, uh, the point and share. Yeah. So if you choose if you choose. Okay. So So the right option to choose one you try to share your screen is the one that says you're you're full screen. Uh, so it pops up with the options. If you click on the option that says window, you won't be able to proceed with a slight show. But the one you need to select is, uh, your screen itself. So you have to share your entire screen and then go onto the slides. And, uh, by doing that to be able to proceed, is it fine now? I'm going to slide through. Yeah. So if you click on your slides now, yes. You click on the slide show function. Is it working now? Wonderful. Uh, okay. Now. So yeah. Yeah, I think we can move on from here. Is it clear now with you? Yes, it is. Okay. Okay. So let's start. Okay, So now we are going to speak about total knee arthroplasty, which is in short term. We can call it t k. A. Uh so we have some items to share today. We have some short introduction and then we have five items to speak about. We will speak about indications of total knee and main principles for successful take A and also we'll speak possible complications how to prevent and rehabilitation, which is very important after the operation. And then we will finish by some common questions. So let's start with the introduction. What is the total knee arthroplasty? It's a replacement of the extremely painful and arthritic articular surfaces, so please look here at these pictures of the picture. On the left side, we have 44 needs. The very left is the normal need, with the referral service is smooth and card with nice scar tissue layer. With some arthritis, it becomes the next knee on the right side, and then the third knee has a severe osteoarthritis. We can see rough surface, and this is very painful to use wide walk. That's why we can do what what's called Arthoplasty to remove this rough surfaces and, uh, use a new artificial smooth services as on the force knee. So on the other photo, we can see some components of the knee replacement. We we cut this rough service of the knee of the tibia and femur, and we put these three components the tibial component and the femoral component or coverage. And in between there is what's called an insert. It's just a smooth surface between two services. So this is a simple picture of what is, uh, knee arthroplasty. Uh, now we want to speak about what is the goal for knee arthroplasty. What we do this operation. We want to get a new near, more or less natural need very anatomic and also with staying free. I mean, the patient can move freely after the operation without pain, and we have two more goals for this operation. To have a stable, knee stable knee means the vision can walk and run with it. There is a patient while walking and running. And regarding longevity, it means that it can last. We know that osteoarthritis all the need become aged. So we have to choose a new knee that can long last for many years. Uh, that we will not need to change it another time shortly. So longevity is one of my our main goals for totally Arthur Blast. As you can see in this picture, this is totally and brief with the three components of the knee. Well, now we want to speak about how, how frequent do you think total knee arthroplasty is performing? So I don't want to put a lot a lot of numbers, but I can take the USA USA as an example. So you have to know that about one million total knee arthroplasty procedures are performing in us A. Every year. Uh, and it's it's expected to be much more higher than this by 2030. So, uh, simply, I want to draw the attention for the difference between two kinds of knee arthroplasty. When we say totally arthroplasty, we mean that the one on the right side. But there is another knee arthroplasty, which is called Unique Compartment or unique compartment knee arthroplasty, uh, where we can change only one compartment of any. You have to know that the knee has three compartments, medial compartment and lateral compartment and patella femoral compartment, so total knee is changing almost the three compartments. But there's also what's called the unique compartment to change all these the medial side of the knee. Let's start with the first item, which is indication criteria for totally which patient I can choose to have this major operation. Any patient with knee pain know we have some criteria. The patient must have a pain with arthritic joint. And this pain must be not less than 3 to 6 months with intermittent or many times a week pain or constant pain. Uh, and also he is a patient must have, uh, severe arthritis confirmed by X ray or the radiological imaging and also confirm it. Clinically, the bishop must be old because we know that the new knee has longevity. As we mentioned, it has, like from 15 to 30 years of age. So we cannot do this operation like in 20 or thirties or forties. Usually this operation not be done before 55 years old and in some countries, not before 60. The Bishop must have a problem with the quality of life for at least 3 to 6 years, uh, to be chosen to have this operation. And also we have to try all the all kinds of conservative measures which include medical treatment, anti inflammatory and muscle relaxant, and local application of various kinds of modalities. Uh, the vision must have, uh, physical therapy and routine exercises for his need to strengthen the knee. Uh, we can try all conservative measures after failure. Of all of all of that, we can resort to our last resort, which is totally after August. Also, one of the indications is deformity, especially Gino Vera with with With any, uh, deformity, especially jeans over there. Um, and sometimes the gene a fungus, uh, and also and sometimes it's indicated for revision of total knee replacement or total knee arthroplasty. So we can have like, uh, pictures of patients with nipping on the Ortho right side. It's old age with arthritic joint and long term suffering. And in the right lower side of the screen, you can find a gene affair. Um, of both sides of the knee. Well, now let's have a look about what is what are the contraindications situations that we will never do totally arthroplasty the most important thing that prevent us from, uh, making this operation is infection. Infection of the knee is absolute contra indication to have an artificial object to insert it inside our body. So whether the infection is current, exacerbation has now an infection, or he has recently an infection of this joint or even exhibition has an infection elsewhere in his body. Like recurrent to re interacting fiction we cannot do, uh, totally arthroplasty at the moment we have to treat any infection. Uh, first, before we proceed to totally arthroplasty. Also, we will not do totally arthroplasty inhibitions with lower limb neurological problem like any paralysis or any weakness or any even other concomitant problem like sciatica or something else. We cannot do totally. We have to treat that first if it's treatable. Also, we cannot do totally arctic blast reservations with extensive mechanism dysfunction, extensive mechanism. You have to know this is very important to everyone. We cannot stand up without that. We cannot walk around without extensive mechanism. What is it? It's quadriceps together with patella patellar tendon. This is, uh, responsible for extension of the need. It is very important for you to stand up, to walk and to run. So if we have, if a patient has a problem with this extension mechanism, it cannot have this operation. Byetta. Also, we have to check ups. I lateral hip exhibition has a problem with the right knee. His right hip must be fine so that he can have proper rehabilitation after the operation. If he has osteoarthritis of the hip, it must be treated. So we also arthritic lateral hip is, uh, contra indication tha have totally arthroplasty also relative contra indication. These are absolute contraindications. But there are some relative contraindications, including exhibition has general wellbeing. Uh, general medical problems like, uh, anything interferes with anesthesia, so it must be treated first. Any metabolic problems that affect the wound healing like uncontrolled diabetes or something like that. It can be considered a relative contraindication also some other conditions, like, uh, through sclerosis of the same lower limb. It will affect the circulation of this lower limb. If there is venous Stasis, it will put a vision at high risk for, uh, DVT, which is very problem for him. Also, if there is another infection like cellulitis. Look at this picture. This patient has a problem with his right lower lip. We cannot do this operation for a limp like that because of infection because of venous Stasis because of inadequate blood circulation, because this could have, uh, neurogenic problem. Also, one of the relative contraindication is obesity. Sober obesity, like body mass index above 50 is contra indication to have this knee because the new knee maybe unable to weight bear this, uh, overweight. Also, any recurrent infection like to prevent infection. Well, now we can proceed to our second part of this lecture, which is six main principles for successful totally arthroplasty. I know not all of you are orthopedic doctors. So I will have just general look over these principles just to have an idea. An automatic. We have something called, uh, biomechanics of the lower length like axis of the lower land is different between anatomical access and mechanical access. So we have some, uh, important principles, including, like, first one alignment of the tibia. The tibial cut must be completely perpendicular with the mechanical access. What is the mechanical access you can understand? It is the axis of the tibia or the line over the bone marrow of the tibia. Also, it has it has to be three degree posterior slow. You know the tibia. The proximal end is not horizontal. It has a Steeler slope, three degrees. And also the reception must be between 8 to 10 millimeters. We will know that later on about this resection amount. The second principle is a line of the femur. You know, the posterior, the to condyles of the female posteriorly. They are not the same line. If you if you can look at this picture on the, uh, lower at the left side, the medial, uh, medial condyle is prominent more than the lateral condyle. So we have to do the distal cut. You know, to understand this operation, we have three important cuts. The TBS cut. You can understand it. We cut the TB approximately horizontally, and we have two other, uh, important cuts the femur, distal cuts and the femur posterior cut. So if we look at this picture, uh, when we cut the femur, it has to be in valgus 5 to 7 degrees. Why? Because if you look at the right side picture, you will find the femur has to access one access, which is called anatomical. Access it along with the bone of the femur along the middle dog. And there is also mechanical access. Mechanical access is the access that carries our body weight. It's from the center of the head of the femur to the center of the knee. So there are six degrees between these two axes, so uh, we have to make the total knee in valgus from 5 to 7 degrees. Usually it is six degrees, but sometimes it's different from person to person. Also, we have to do to do some external rotation about three degrees. And also the reception typically is between 8 to 10 millimeters. Sometimes it can be We can have two more millimeters if it's PCL sacrifice. So this is the second principle. Third one is medial and the lateral balance. Look at this picture. Um, look at this picture. Uh, you have media and lateral collateral ligaments which are responsible for the balance of the knee while walking and standing. So why we are doing this operation, we have to make sure that the media sign that lateral side are equally balancing. So I know you are a doctor and you can think about different cases like exhibition has a fungus or various various before the operation. So at that time, we have to do some interventions to make this balance. Uh, sometimes we need to do a release of some ligaments, and sometimes we have to do interventions to tighten these ligaments. But the basic idea you have to know that in this operation we depend on these media and lateral ligaments to give us some balance, and we have to check that intraoperatively. Uh, fourth principle is, uh, flexion and extension gaps. If you get this principle, uh, suppose you now our understanding this operation. As I told you, there are three cuts. The tibial cut. As you see it's a cut of the tibia, and the femur has mainly two major cuts. The distal cut, which you can see on the right photo of the femur. It is the distal end of the femur, and the other one is posterior cut, which we use on flexion of the name. So between the distal cut of the femur and the tibial cut, this is extension gap. It is the girl between femur and TV, while the limb is extended fully. But the other gap is flexion gap, flexion gap is the gap female and while the knee is 90 degrees flexing so this gap is flexion gap. So which gap is important for us? Extension gap or flexion? Gap? What do you think the patient uses the extension gap while he is walking and friction gap while he's climbing stairs, for example, or sitting down so both gaps are extremely important and enter operatively. We have to make sure that both flexion gap and extension gaps are perfectly, uh, equal, uh, to each other. So the fifth principal is the tiller. Tracking, uh, you have you know that the bottle has a track at the end of the femur. As you see in this picture, there is a track for the patella to run in a while, flexion and extension of the knee. Zeppetella must be centralized on this gap on this track. So in many cases, the patella is shifted to one side like look at the arrow. It points to the patella shifted, usually to the lateral side or outer side of the knee. Uh, this is a very big problem, and we can have a very successful operation. But later on, the patient suffers of pain anteriorly because the patella is not centralized in its in its track, so the patella must be tracked, and it's called someplace. It means you don't have to support the patella to be in. It's a track, so you have to check that inter operatively. And also if there is any mail tracking you have to fix that. And also the rotation of the tibial cut can affect the Q angle of the extensive mechanism, which can lead to patellar mail tracking so that you have to be make sure that you have proper but tibial cut. And also you have to make sure that the patella is properly tracking in in place. I know some of you haven't seen a total knee arthroplasty before, so I want to explain something to you. Enter operatively. After we have these cuts are done, we put a trial. It's very similar to the final implant of components, the same size, identical and everything. But it's not the final, totally so. We put this trial and we check all of these principles before we put the final knee. We have to make sure these principles are fulfilled. And like all in flexion extension gaps are equal. Media lateral are equal, all cuts are perfect and also the patella is in place. Last principle is low Contact stress, you know, totally currently is different from the totally like 10 or 15 years ago. We have currently modern any look at these two pictures the first on the left side. One, there is a small contact between the femur and the tibia and the one on the right side. It's a care of it. The answer this white, uh, pieces called insert. It's like a plastic special type of plastic. So, uh, you have you can see now a large area of contact. So when we have large area of contact, we have low contact stress, and we have high constraint forces. But the picture on the left side, we have low contact area with high contact stress. It means all the body weight are transmitted to tibia through only this contact small contact area with local strained forces. So what do you think? What you need is better. Yeah, I'm sure most of you are saying the right one. So this is one of the successful needs to have, uh, high contact area with low contact stress. Why? Because on the long run, after many years, if you check both of these, the right one will have less wearing this. It will be less, uh, turn. Uh, but the left one will be, uh, overused. And the insert will be, like, eaten up with frequent use of this knee. So now I can move to the third part, which is possible complications. What are the possible complications of the totally? Uh, this is a very important point because there are especially to complications that are like nightmares for any doctor which are infection and DVT uh, you have to know that they're not frequent like infection is less than 1% 1 to 2%. Some centers is less than 1% and some centers are 1 to 2. But generally speaking, this is not high. And also DVT currently is not high. So but generally speaking, we have to give the extremist attention to prevent these two complications how to prevent infection. It's easy, strict advance to accept it. Technique. Some operation rooms we prefer, like vertical laminar flow with air coming up down, uh, and distributed to the sides. It's better than the horizontal level of law, and also we everyone can know about aseptic technique, but we have to be 100% committed to this. Um, also, we have to early diagnose infection. It happened, so how to diagnose. It's easy, especially laboratory findings. Total extra kick counts E S R. And the most reliable one is CR be also a cardinal signs like swelling or erythema or, uh, redness. Uh, TC. And also, uh, the most confirmatory test is aspiration and send to analysis. If you, uh, diagnosed early, you can treat early, but it's better from treatment to avoid infection. The other, uh, important complication is dvt uh, before you read this slide. If if we have 10 100 patients with total knee arthroplasty without reflexes for activity, how many of them do expect they will develop DVT 10% more? It's about 42. 84% without reflexes will develop cavity. So to preventive itty is extremely important. You have to start on an anticoagulant chemical anticoagulant 6 to 8 hours. Post operatively. Never forget. Never forget together. Debatable flexes as soon as possible. After the operation, you can give the molecular weight. Heparin can give XY inhibitor, which is very common to use nowadays. Aspirin can be used. Warfarin can be used, uh, about any of them must be used six hours post 6 to 8 hours. Probably. Also, there are mechanical reflexes, like applying stockings, applying food bumps. There are many local. Uh, I mean, in the lower lands, uh, reflexes from DVT. Uh, some other possible complications include fracture many times during the operation or not many times, but sometimes intraoperatively fracture can happen, like pre prophetic in the femur or tibial fracture. Uh, if you are careful, this fortunately cannot happen. And also, it has very low instance. I remember from oh point, uh, point oh, 0.5% could be the fracture instance. Also, the Brazil arts injury has a low incidence of happening between large tendon injury of quadriceps, which we have spoke about. The extension mechanism is very important to keep in place during the operation. Uh, there is something called Byetta long syndrome. This is like a soft tissue, uh, formation like a bowl of soft tissue in front of the knee above the femoral, uh, insert. It can be like a liver over the expense of mechanism. It will be very painful, but it's easy to treat. We can treat arthroscopically and to remove it. It's not a big problem, but we have to prevent it. Intraoperatively, uh, very rare to have in baronial nerve ballsy, especially while treating a valgus patient stiffness. If there is less rehabilitation. Post operatively the patient can suffer of stiffness would increase and decrease the range of motion of the knee pain. Postoperatively has many possible causes and also sometimes happening loosening of the components either femoral or TB or now we can proceed to the fourth, uh, part of our lecture, which is rehabilitation. We have two items to speak in rehabilitation. What about the significance of rehabilitation? Uh, unfortunately, all over the wall. It Many people are very focusing on the operation itself the surgeon, the hospital, the company and all of that. But, uh, it is very, very important to focus on rehabilitation. It is as important as the surgery itself. If you have a perfect operation with poor rehabilitation, this definitely will lead to very poor outcome. So rehabilitation after the operation is extremely important. So what can we do in rehabilitation? We have a goal to restore the range of motion of the knee from 0 to 1 20 and the minimum range, except it is 5 to 90 in some stiff needs. Uh, we need to afford the vision full function of the knee by 12 weeks. Uh, so we asked the patient. Never put a balloon under the knee and leave the knee flexes for a long time and never stay in a recliner for a long time, especially during sleep. So movement of the knee after operation you cannot help is extremely important. Leavings. Any without movement after the operation is extremely hard. So I can simply speak about three phases of rehabilitation from day one boost after the operation two day three, there is what's called continuous passive motion. It is a machine. The vision can put his lower limb over and it can move the lower limb according to the range we detect. So usually, during the first three days, it's between 0 to 2. 90. The vision is not actively moving the lower limb, but the machine itself Move the lower limp to flex the knee and extend the, uh this is during the first three days, uh, divisions can apply some ice. I know there are some dressing. So, uh, maybe, uh, good to do that a little bit later, uh, to control the itching is very important. And also, to strengthen the head and ankle muscles during this time is very important. Also, this mobilization is very important to prevent one of the nightmares, which is DVT. Why DVT is nightmare because it can lead to a pulmonary embolus, which is a risk for the life of the bishop. So if we left the vision without movement, I have constipation at high risk for DVT and pulmonary embolism. So, uh, I have a few minutes left. So, uh, from day one to day three continuous passive motion, uh, from day 4 to 4 weeks, we have to prioritize the stretching of the muscles and help the vision to straight leg raising test helps the need to elevate the lower limbs like that by himself or herself. Um, and from week for two weeks at 12, we have to recreate athletes. We have to strengthen the muscles fully. We have to restore the, uh, muscle power of quadriceps to 95%. Insufficient. Has to do some resistant exercises to strengthen the, uh, muscles. So now I finished with some common questions When walking postoperatively When the patient can can work after the operation. Hopefully from the first day with constipation as as he can as as tolerable. He can wait like he can wait there from the first or second day according to the physiotherapy management. How long does the operation take? It takes 2 to 3 hours. Usually, uh, hospital stay. Usually it is three days. Uh, sometimes that's where we We have to uh, uh, full recovery happening. And the vision can manage few steps by himself or herself, or and can step up and down a few steps, uh, over the stairs. Uh, so the hospital stay? It could be three days more or less. Uh, what time? You can go to work back. Back to work. Like usually two weeks to 5 to 4 weeks according to the nature of the work. Uh, when can you drive? Usually we have to keep safety observation. So driving it can be, uh, delayed, like, 4 to 4 weeks. Uh, swimming by three months. The patient is able to swim. Supposed to be, uh, and traveling. Also supposed to be at three months, the vision is able to move and by himself without any support, without any crutch or steak. Uh, so this is the most common questions. Uh, finally, I want to give final messages to any orthopedic doctor there. First advice be a healer. You treat a human patient with an X ray. Second one, perhaps mental mental jogging before the operation. Every time you are going to an operation, Think about. Imagine it. Do the operation in your mind before you do it in the operation field. The Third Message Orthopedic surgeon is an artist, not a carpenter. Do everything meticulously. Look at things in three dimensions and you have not to miss this advice. Measure twice and cut once some surgeons cut and then cut again and then correct the cut. But no, make a good measurement. Take your time and then make one correct cut. And the last advice You have to remember that totally arthroplasty is a tissue soft tissue surgery with somebody. Cuts don't focus very much over the cuts and neglect the soft tissue of the name because it's it's very important for the outcome of the knee. Thank you. Thank you very much, Doctor Nathan, I think, uh, it's been a very delightful session. Thank you. Uh, I think I quite enjoyed every bit of it from the There is an academic to the technical, uh, content. Uh, I think it's very practical. One, uh, obviously the rehabilitation, which is quite key where, uh, especially gets involved in the care on the world. Uh, I think those are Those are very important point that you've raised. Uh uh, of course. The last bit, I think the one I found, uh, quite a bit amusing, but I think it is quite instructive. Uh, I mean, the caveat that orthopedic surgeons are artists and not capping, which is a popular balance. I think that's a very important thing to like. Thank you very much for that, uh, wonderful session, Uh, would welcome questions. Now, if anybody has a question, if you could kindly raise your hand, uh, we'll take the questions one after the other. Uh, you could also drop your questions in the chart section, if you prefer. I think the general hunts general. And yet I think while just while hanging around for a bit, um, market, too. Let me take the first shot with the questions. Uh, Doctor Nathan, your experience with Tony Arthroplasty in, uh, Nigeria. I mean, we've talked about the technical aspects of procedure what you experience in terms of the financial aspect. Uh, no. My experience, uh, back back home They are quite lots of people with their struggling with very severe osteoarthritis. And they just don't have the financial well with, uh too. I mean, pay for this service. And again, it's probably not a very common service in the law of public hospitals. Uh, you tend to have, uh, arthroplasty surgeries generally done mostly in private sector. Uh, I mean, Nigeria. Obviously. It's, uh it's not getting more traction, more momentum in government hospital as well. But it still remains that expensive. In my experience, what has been your experience? Uh, well, unfortunately, I don't have a long time experience in Nigeria for, uh, surgery. So, uh, I cannot give you meticulous information about that, but I can say, apart from the insurance companies which are supporting this operation, uh, some hospitals can afford this operation with, uh, could be affordable prices. Uh, so if if we can take only the price for the, uh, components itself from the company and reasonable for the anesthesia and the hospital, it will not be, like, extremely expensive, like it is in a very, uh, lovely Thank you for that. Um, well, so far, there's no hands, hopeful questions, uh, and There are no questions and charts log. Um, I guess if we don't have any questions, we don't want to keep you around, uh, any longer. Uh, once again, Doctor Nathan, thank you so much for, uh, with your presence. And, uh, we'll be reaching out to you for some other lovely sessions in the future. I hope you'll be glad to, uh, thank you so much. Uh, everyone, the, uh the feedback forms will be rolled out. Uh, shortly. Kindly take a few moments to feel the feedback forms. Uh, they're going to be very helpful for us. Uh, in terms of planning these sessions in the future and obviously to also give the speaker, uh, some feedback, Uh, in terms of how the session went, uh, I want to thank you all for attending this session. Uh, have a wonderful rest of the evening.