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I recognize that uh one of the things that is very, very clear to me is when we do any of our camps, any of our team team uh outings is you need to have gophers, you need to, you can't go as a surgeon and see um a surgeon, you have to go there and do everything from prepping the patient to get in the case notes out to checking the equipment before the, you know, they're putting a plaster on and having people who provide this generalist uh input is incredibly valuable. And you know, one of the things that was mentioned is, you know, anesthetics is really difficult to support many of these environments. And I travel with uh my general dogs body who can assist in theater, resuscitate patient's do all the paperwork and support the staff to learn whilst I'm doing other things. And it's this ability to everybody to teamwork together that the team is actually much more than the sum of the parts. And this is actually something that then comes back to N H S. And why the Scottish government is keen for people to be involved in work in the mid countries because it makes the team as a whole better. And we, we've got ample evidence. Now people have deployed abroad, coming back to the UK are better. NHS staff for the, for the purpose. And that's why we really have a lot to gain from our limit colleagues and environments. OK. Okay. Now, one of the, one of the things I found can go into the next slide, holding side please. One of the things I found really difficult in all my travels and all my work of the years is when faced with a terribly destroyed young hip, either from a neglected hip fracture and neglected Osteomyelitis. Uh CDH that's been untreated or in many parts. I work the neglected sickle cell crisis of avascular necrosis. The completely wrecked hip in a young person for me is a heart sink. And though I've been taught these techniques by some of my, my, my consultants over the years who have experience of working, I've never found a good solution until recently. Uh That is I came across some solutions actually are a potential solution for that young hip patient. That's too young for a hip placement that they'll never get anyway. So very lucky to have at er from uh Siddiqui from Oxford is going to show you a solution which I think we need to teach our trainees, not just for working abroad, but I wonder if it has a role in the UK as well. Having done a few revisions of young hips over my career. Thank you after. Thank you so much. Everyone have two slides up, please. Yeah, there we are. Thanks so much, Alberto. And I think this talk originated from that trip to Kenya, which is really memorable. And by the way, fish, I did find that fold and I'll forward it to you some really memorable pictures, photographs from that trip where, where I was asked to present on the Eliza of hip reconstruction. So I currently work as a sarcoma surgeon in Oxford. And a lot of you will be sort of wondering what am I doing with the Lazarov. So in my previous cat life, I used to be a Limerick concert and as well prior to moving to the, to the UK four years ago, and I've been teaching this technique uh mostly around Pakistan, but also in Iraq and North Africa. Um over five years. Uh I think it, it's not my technique. It's been there for, for a very long time. And every time I've spoken about this with hip surgeons being around, they look at me as a crazy person. But luckily I've got to Limerick on um surgeons in the room today. So hopefully, uh I'm not going to have as many eyebrows raised. So, um yes. So I come from Karachi Pakistan originally and I work, I used to work at like at National University uh National Hospital Medical College, which is one of the premier uh medical colleges in the country. Uh Karachi Pakistan being the six most populated country country, Karachi being among the top five most populated cities. Uh My work in this particular hospital was I had set up the Limerick con uh Ortho plastics and Sarcoma service probably see by the number of career here. I've got not that old if I would say. But anyway, that was a lot of work load because setting those services up and then also running them uh singlehandedly for up to three years until I was able to find a colleague to support me. At least in the limerick on work, we used to get a lot of war zone injuries. But it's interesting. So besides having a catchment from all of the country, Karachi Sindh is the capital of Sin and Sin itself is so different from the rest of Pakistan. You go to Punjab, which is the seat of power in Pakistan. It's really got well double up D G H s and sort of, you know, you can have a lot of procedures being performed there. But Karachi go for 50 kilometers out of Karachi. There's nothing, absolutely nothing. You won't find a C arm, you won't find people being able to do intramedullary nails. They everything will be either X fix or plates. It is sore oral. Uh If you go 50 kilometers out of Karachi until you reach, until you really hit the border of Punjab and then you realize that you're in a different country. Uh Anyway, so I've got no, nothing to disclose as far as this talk is concerned. So essentially as Alberta said, what do you do with the pediatric septic? It, which is where this technique essentially originated from, which is completely destroyed. Hip, it's been neglected for many years. And you see this so many times in the Ruhr a population, uh whether it's Africa, whether it's uh you know, uh far East Asia, especially the neural populations where these people do not present to hospital in time, either due to pure neglect or due to social stigma of, you know, being in a hospital and there's a girl child and you know, what's going to happen to them. Interestingly, the precise reason for them presenting an adolescent life is also social stigma, which is when these female kids reach marriageable age and with a limp, they're not acceptable members of the society to be married into a respectful uh sort of, you know, married draw. Uh And that's what we, we, we've, we've come across time and again, when we see these patient's. However, what the problems are. I think if we can just so if you look at different pathologies, but the problems here are with this destroyed hip, you've got a lower extremity, leg length discrepancy and you've got a complete failure of the hip articulation with an absent or a non existent hip. Sometimes what you do have is a residue all thermal head, but you have pressure sort of support point arthros iss which can be really painful. So, yeah, we've been taught as medical students or as in my early orthopedic carrier, we were taught bilateral dds symmetrical. Don't do anything, just leave them alone. But does that really work? Sometimes those patients do not accept it as I will show in one of the cases that we did, which was one of my first cases when I was learning this technique, uh this particular patient had significant pain from her wobbling gait. And that's when the indication becomes relevant when, when they have pain. Yes, you can do hip arthroplasty. Uh You can't always get away with it. There's a PFFT. Uh So you, you have to think of, you know what other options you have uh in in certain situations. So the treatment goals are pretty simple. You want to relieve pain, you want to get, you want to balance the trend and gait to as much as possible. You want to address the L L D and you want to make the hip as stable as possible. Uh There are a number of surgical options described and literature. You can go back to your textbooks and you will find that there are a number of surgical procedures that have been described to address this really challenging aspect of orthopedic surgery. So scenes actually came up with the original P S O, the proximal thermal subcontract support osteotomy. Uh where he suggested a proximus, a proximal femur val defying osteotomy uh to get the proximal femoral segment to align next to the pelvis and provide better support. But at the same time would lead to improving the abductor arm by tension in the abductor musculature. Uh So essentially, that's what you achieve. You bring the central floatation more medial you tension the abductor muscles and you improve the lever arm by medialize ing the central rotation, which is what's happened here. So uh if you look at just these two pictures, that was the classical technique of using the proximal thermal osteotomy with the plate, it can be done with virtually anything. You can open it up, do an osteotomy value fi it and fix it with a plate. The problem is now you've got a valgus extremity and further limb land discrepancy. So you've actually, you might have improved the hip biomechanics and you might have provided the, the support to the pelvis. But you've got to other problems to deal with right now because you don't have an aligned limp and you do not have a limb that's long enough. So, uh the other problem with the classical technique was also support point arthros iss because of the abnormal way they would walk, they would start getting arthrosis from uh sort of rubbing against that valgus angle. Uh And then, especially if you do it in really young patient's, they would be remodeling. Uh and they can sort of, you know, get back straight uh without uh achieving the target. So you will lose what you've achieved anyway. So if you just look at the history of the public support osteotomy, the first it was done by uh sir Barton, more, more known for the Barton Bulla Barton Fracture uh to a sailor as far back as 18 26. Uh it was further uh sort of, you know, modified by grant in 18 72. Then the two Germans who actually came and modified it further. Uh So Lawrence did his bifurcation osteotomy trying to stick the distal and into the acetabulum, just try and support the pelvis. But the P S O was then described by Shan's in 1921. What we do currently is probably a modification of Milch which is essentially resection arthroplasty, not so much on the established site. Uh But I would also want to mention girdle stones work on girdle stone arthroplasty because I come from Oxford. But anyway, so currently, what we, what Elizabeth has suggested is modifying a girdle stone arthroplasty to provide pelvic support with a pelvic support osteotomy with Shan's. And then it is Ross contribution was introducing the virus lengthening osteotomy, which was a distal osteotomy completely separate from the public support osteotomy to try and get the alignment right, and also increase the length. The more important contribution was he did it all percutaneous. And that thought he preserved the biology. That sort of a schematic diagram of what he introduced. Um the dis lost artemis can be used for distraction, osteogenesis to uh get the length back, but also uh get the alignment right again. So what are the indications? It's usually if you look at the hook classification, it's usually for the four and five of pediatric uh neglected hip uh situations, but you can virtually do it for post traumatic uh sarcoma resections, uh even arthritis D D H uh that's been neglected. Uh And re reconstruction after resection arthroplasty is this is a list of indications, but you do have to select your patient's wisely. I think there are papers and if you go and read up, you would find that the best patient is probably uh an adolescent patient with flail hip. If you try and do it in uh in an Carlos tip, it's a completely different ballgame uh because the outcomes are really not so great and you have to have extensive physiotherapy and there are complications, risks. Uh And as I will describe in a couple of my cases when I take you through some of my cases. So anyway, so what we do is provide front plane alignment, sagittal plane, alignment, axilla plane alignment, and obviously length, which is, which are the principles in any limerick on uh procedure. So in the front complain, you want to get the alignment right going through this uh sort of pseudoarthrosis right down to the knee, right down to the ankle, getting the mechanical alignment in place. That's your pelvic support, which is the new center of rotation, which needs to go through the physiological uh mechanical access. Now, this is not my patient. Uh I would want to thank professor, both Rawi, who I will show you on a photograph who was sort of my original mentor uh in learning this technique is it very famous Egyptian um prominent Egyptian limerick concer Gyn. Anyway, so you can see that there's a pelvic tilt and that has to be corrected with, with, with a couple of blocks. But that's the final sort of outcome when you get the alignment right, and also get the length right. Uh And the improvement in the Trendelenburg gait is also pretty visible. Uh They get good abductor retention ing if you, if you perform the procedure, well, the other thing is the spinal pelvic angle. Again, that's a normal. Usually you would find with these cases, you would have uh flexion deformity at the hip and compensate ori low doses of the spine, which you can correct by doing an extension at the proximal osteotomy to get your psa agitate alignment, right. And that can be seen on how this patient stands after completing the procedure, excuse me for the scars. But that's part of the whole thing, the external irritation, which is also part of this pathology can be corrected acutely or gradually through the frame. Uh I like to do it acutely because it just takes care of one problem uh in the same setting. Uh And normally the patient's find it quite easy to walk. It's easy to rehabilitate them rather than walking. Having a Charlie Chaplin walk immediately with a, with a big frame on uh uh length obviously has to be uh corrected uh sort of uh gradually. And you can see that's the external rotation. You can see the position of the foot uh before and after. In this particular case, I believe he had done it gradually over time. So that's the virus lengthening astronomy where you can get the length back. So in summary, you're trying to achieve a soft tissue interposition weight bearing surface between the apex of the proximal formula, cystotomy and the pelvis. That's your primary aim to restore the biomechanics of the hip, the residue all valgus and the length is corrected at the distal osteotomy just to take you through a few cases. This is a young girl. She was actually from Karachi. So she didn't come from a lower and middle income background, but she actually came from fairly effluent family. She had uh sort of dds that was neglected as a child, um never got to treating it. She came in really a lot, a lot of pain. She was seen by my hip colleague and given her age, my hip colleague was not keen on offering her surgery. However, she underwent extensive counseling. I offered her hip replacement. She didn't want to take it. The other problem with certain societies is, for example, in Pakistan and India, we've got a problem with our toilets. A lot of people sit squat in toilets. If they're coming from neural areas, they do not have commodes and they will not have commodes, they do not have chairs, they sit on the ground cross leg for eating. So as a hip surgeon in that sort of a community, you always worry about the risk of dislocation, especially when they live in, in sort of neural areas where they might have to walk a few kilometers on foot, upper hill to get to their place of living. So imagine having to do that. And with a hip replacement in what are the risks of, you know, dislocating? So anyway, so she chose to have this procedure. Um that was sort of an initial scan, a gram, I believe. And these are x rays where we did the astronomy, there's a slight bit of translation. That's just because of the internal sort of recoil from the, from the frame application. Uh And that was when we uh consolidated all the offset autumn ease and we took the frame off and that's her final alignment. She was pretty pleased. This is actually six months after the frame had come off, she still has a slight. So if you can see that she's doing a trick movement to get up. So her hip is not fantastic and she has a residue limp. But remember she's still having rehabilitation, her knee was quite stiff. That's another problem with these techniques. They all get some sort of, you know, limitation to your knee flexion. And we have in our experience found that almost 10 to 20% of them might need quarter steps, plastys later, especially because they're not fantastic with their court's rehab when they've got the frame on. So, um this is another case, this was actually the first case that I performed with my boss. Uh Again, bilateral uh destroyed hips. Uh lady came from uh kid, came from uh Gilgit Baltistan which is in the foothills of the character. Um uh very, very strong kid. She made the decision of going ahead with this operation. Uh had it and there's a 13 year follow up which was sent to me by my boss uh on, on a whatsapp group. She's got three kids now, happily married. I'm really pleased with no problems at all with the hip function. And these are sort of final 13 year follow up X rays with absolutely good looking alignment. This was a gentlemen with multiple proposal dysplasia with cox Avara, uh severe cox Avara, severe arthros iss and pain, really brave guy who wanted to have bilateral simultaneous frames uh because he just could not bear the pain. And this is what we achieved with him. You can see it's really, it's a problem doing bilateral at the same time. It's remarkable that he was walking with the frames. We told him not to, but he, he sort of, you know, pushed on. That's his five year follow up on the, right. So he's done really well. He came back to me four years later in my clinic asking me for a cosmetic line thing. And I said, just go away. I'm not doing it for you. That's it. You got good hip. So that's it. Anyway. So I think it's a good solution if you select your patient's wisely, if you counsel your patient's well. And if you take them through a good rehabilitation program, it does provide reliable pain relief if done for the right indication and the right patient, it can be a lifelong solution of the 40 cases that I personally have done. There's only been one conversion to a total hip replacement and that patient was a doctor who traveled to the UK and was converted to a hip replacement in Oxford. And after, you know, traveling to Oxford, I met her in the cafeteria at the Knock where she was there for a visit to her hip surgeon. But anyway, that's the only person I know who's done who's been conveyed to him. So it can be converted to April placement. Although it's very, very challenging. Uh I think uh she was presented on one of the clinical pathological conference at the Knock saying somebody in Pakistan had done a very funny astronomy. Uh and we did not understand what this was. So that's why we gave her a hip, but that's the story. Uh So it does correct all of those problems. It has relative, less complications and you can probably uh use it in those low and middle income countries where you can't really give them a hip replacement. But I think with the current uh modalities of, you know, the current designs of hip replacements, there are, there are solutions within the arthroplasty world. Um So it's your choice and I think you have got to select your patient's right. Thank you so much. Fashions that, that picture is professor of a throwaway and you recognize him holla and this was three days before we flew to Kenya and we were surprised to find ally in Kenya and we were at the dinner table three only three days ago in Tunisia in question. Yes. Uh I just wanted, was there an actually up there with hinges than sort of mid diagnosis of the femur? Um So do you, do you do an acute correction at the top with framing and half pins? And then you said a court in the mid femur osteotomy? Is it a gradual correction with hinges followed by lengthening or is that, is that the order or, or yes, there was a whole segment on this talk about the technique which I've taken away because this sort of beyond the scope of this uh this group. Yes. So it couldn't be done. So the virus on the distal osteotomy has been described both gradual and acute initially. I think it is a cough started acutely. But then he realized that, you know, sometimes it's not tolerable so you can do it both acute and I've done it both ways does really matter. There is an advantage of doing it acutely because you get the alignment back straight away and your patient has got external rotation and virus acutely, they get a straight limb and then all you got left is uh lengthening, but you can do it gradually so you can do it both ways. It is a just lost charge me. Yeah. Yeah. The hinge has to be placed when you do it right. So uh you can build a hinge and a distraction mortar or you can uh distract only and then place a hinge later, I've done both and it can be done whichever way. Thank you. Thanks. It is a very useful technique in the right patient, as you say, do you find there's any major difference between those that are what I'd call virgin uh surgical cases? I have not had operations before for their hips versus so does scarring make a big difference? Yes, it does. So I think the worst patient, as I said are the ones who have got um ankylosis and previous surgeries. They are really difficult to get in and I have had to go back in to, to do an interposition with a fascia lata graft again because they just would want to fuse again. The other thing that people have done is done it in stages. So do a girdle stone first. Leave them, move their hip because with the heavy frame, they can't really move their hip a lot and therefore they start and coloring again. So leave them with the girdle stone, let them move around, get them back after six months and then do the rest of the astronomy's. The other problem has been the concepts and we all know that the concepts, any femoral lengthening has a problem with the concepts, contractors. So, uh, the publication that we did in 2014, I believe was with our 1st 40 cases, we had about a 15% quarter septoplasty rate, uh, in all of the patient's, I think we've now done over 100 cases between me and my sort of, you know, mentor. Uh, and I think we still stick that, you know, they, they do need 15 20% of them would need, uh, Carter Septoplasty. And, uh, and the younger they are, the better, but the older they are there the worse. So if you go any, anywhere near 35 40 then you're asking for trouble that your definition of over. I think the oldest I've done is 38. Can I ask how long are you leaving a plain one in general to do the whole thing. So on average, it's about three months. Uh sometimes it's, it can take up to six months depending on what length you're gonna achieve. And again, if you've got problems with regenerate, then then you can have problems. But I think on average it's about 3 to 4 months and in the unsupported limit environment where they come from a small village in the middle of nowhere. Do you keep them in the hospital or near the hospital that time or are you confident enough to let them home? And I think we're confident enough to say that we do keep them around the city for the first, you know, until we are sure, absolutely sure that they can do the distraction. Uh I've had one case that I remember who came back after lengthening it over lengthening it. And then you got a problem because now you got a longer limb and now you want to verify it. So we had to obviously reverse it. Luckily, he did not come back after stopping and consolidating, but he could have uh I haven't had a patient in my hr group, but I have a patient in other settings with Eliza Rov when we were lengthening and they came back to us because the frame had run out of space to lengthen and they just could not afford to come back to the city and they stopped there and they consolidated with a limb that was now longer and that's a really challenging situation because now you, now you scratch your head. What do I do now? I've been taught lengthening. But how do I shorten? Because now I have to go back and, and, you know, do an open procedure maybe. Thank you very much. Indeed. Thank you.