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Lydia. Good evening, everyone. Um uh, welcome to this teaching session Organized jointly by Orthopedic Research UK and the Orthopedic Academy, the session is focused on, uh, teaching, uh, for the f r C s level. However, it's useful for orthopedic trainees and healthcare professionals. Um, interested in trauma and orthopedic specialty. Our guest speaker this evening is Mister J Malox. Um, Avala, who is a consultant, uh, surgeon at the Princess Alexandra Hospital. Uh, he has a special interest in hip and knee surgery. Mr. Malox Avala is, uh, well known, uh, speaker in the in the field. Uh, he speaks has spoken about this topics in the many conferences and meetings. Uh, he's also very well known for his, uh, as a trainer, um, in the region. He has been awarded the trainer of the in hospital rotation in the past. In addition, Mr Mark Zavala is the co founder and co director of the n f. R. C S course, a face to face course, which he runs once a year. Um, previously at the Royal College of Surgeons and now it's, uh, Sherman F R. C S course. It's a top course and were recommended for everyone, uh, to attend. It's a face to face course. Very interactive. Most importantly to us. Uh, Mr Maxim wallah has been the godfather of the F r. C s mentor group. His support to us has allowed us to continue, uh, delivering this teaching program. Uh, since January 2017, uh, this Webinar based F. R. C s teaching program has held many colleagues pass their exams, and we owe it to Mr Malik Sofala for his continuous support and encouragement and guidance for us to continue. So we're very pleased that he's with us this evening and and I'm sure it'll be a very useful, uh, session. Uh, my name is for us, are not. I'll be the convener of the session and we have with us a couple of, uh, faculty from the orthopedic academy. Uh, we have, uh, serum and Abdullah Gaber both ready with the Viagra questions. Um, the session will start with a lecture, Um, followed by some emcee cues. It'll be all anonymized, so encourage you all to try. Please listen carefully to the lecture so you can answer. The MCQ is correctly, uh, and then we offer hot seat Vival practice session. Uh, this has been proven to be very, very useful to all our colleagues going for the F. R. C s exam, you will be asked exam specific question and provided with feedback from the experienced faculty present this evening. So if anyone is interested, please encourage you strongly to express your interest as soon as possible. We only allow the maximum of three questions. Um, so please, if you're anyone interested in taking part in the hot seat driver, please let us know, you know, So it's not recorded. The hot driver is not recorded, but the lecture is recorded and will be available on our YouTube channel as soon as possible. So without whether I do, I will, uh, one more plug in. Sorry, We have an f R C s course, um, interactive intensive F. R. C s smoke exam course that we have been running now for over two years. Online, uh, is also very popular, and our next course is not Saturday, third of December and another one on 28th of January. In this course, we cover Vival for and clinical part of the exam and, uh, simulate the real exam scenario. So we cover the same tables as the exam with both clinicals intermediate and short clinicals as well as all the Vivat tables. And the candidates are all timed and they're all given structured feedback on their performance. Um, during throughout the course, very high faculty to participant ratio of 1 to 1. So on the day, we will have at least 16 faculty teaching each one of you. Um, and it would be just rotated through. So it's very nice interactive, uh, sort of put you on the spot and and give you a real feel of the exam and exam experience. So if anyone interested, please, you can scan the barcode or visit our UK website, uh, intensive intensive f R C s smoke examples. So that way that I do I will, uh, leave you now with Mr Malek's Avala over to you. Thank you. I'll share my screen first. Yeah, it's coming. Yeah, yes. Perfect. Can see your screen if you can just put it on a slide. Lovely. Lovely. Yeah, lovely. Just one minute. So Okay. So thank you very much for us for your kind introduction. As you know, it's my passion to be with you and all my colleagues at the Autistic academy and Lydia and Hannah. Thank you very much. From who are you, K uh, before the book on size orthopedic notes is what the book, which I would really not just recommend. It's a book which I also use in preparation of many lectures, which I give, and I must say, it's something which all of you all must have in the preparation as well as for the future. Okay, so that's one for us. Just let me is a second. I understand. The second, uh, edition is out or coming out. Yeah, well, thank you very much. Yeah, we are working on it. It might be a a year before, uh, comes out because, uh, so we'll use that. And so now, coming on to this topic of hip arthroplasty, I thought that I would use this talk as, uh, a talk, which for people to verbalize in the exam and not only for that or for all of y'all who are going to be hip and knee surgeon's like myself and for us, uh, to a certain degree, I It's a huge topic, as you know, and I'm trying to. I'll go away from doing a standard, uh, lecture. Like his talk about history, different types of the hips, etcetera, etcetera. I thought I would pick up because we have only half an hour to do, uh, topics, which I feel are difficult to understand, difficult to comprehend and what are commonly asked in the adult pathology Viber section. So starting at the end of my talk, I thought I'd start first with just talking about offsets, and obviously we'd have to talk about types of thr, and that would nicely lead to a common question, which I've talked in other lectures. But it always every every candidate is asked as to which hip you will use. And everybody's worried that Oh, he failed me because he's a cemented user and I months amended user has nothing to do with that. There's a way on talking and also in hip and knee arthroplasty. It's always a concern as to how many papers you need to know. Which papers do you need to quote. Are they relevant? Not relevant? You know, you don't you may not know that. So I thought I'll just introduce that and then talking on complex hips because when difficult X rays are shown to people, your first you get a heart sink feeling is, where am I going to start? Where am I going to end? So I just want that to be clarified. So that's all I think I could cover in three in 30 minutes. So what is set? The offset is the distance. Been the long axis of the femur? Yeah, so we all agree long extra FEMA and the center of rotation of the femoral head. And that's the word I want you to use. Most of the time when you're talking on adult pathology and hip replacements is what is the center of your, uh, femoral head or center of rotation. That's what you're aiming for and just keep in mind that changes with neck shaft angle. Yeah, and it changes neck length so you're thr offset is influenced by neck angle and by neck linked. The average offset is 43 we have a range, which is on 27 to 57 that's the reason why it is important to template. Okay, so that that that's there. So tell the examiner that then just keep in mind a various neck shaft angle. So if you're in various so you're like that, you will have a increased offset. And if you have a valgus neck angle, you have a decrease offset. Okay, so offset is influenced by your various or valgus, and therefore, as you know, all of us use any modern hip system. We'll have our options of a Cox Avera stem or a Cox of August, Um, but why is offset? Important is you need to tell the Examiner you need correct offset or optimal upset, and our increased offset is better and you get a better lever arm ratio. That's the word you have to use and you get optimal tension of your abductors, which gives you your stability of your soft tissues and less impingement. Okay, so why do you want correct? Offset is correct. Offset is optimal for the best abductor advantage. The best abductor lever arm ratio, the best tension in your abductors, which allow less impingement and less soft tissue problems. So the two words, which are important and hip arthroplasty, will be center of rotation to be restored with correct offset and hence that leads you the goals of Arthroplasty. And I would say my goals in Arthroplasty would be restoring hip center, restoring correct offset, equalizing leg lengths and having a hip which has the best long term survival. These are the four things which we all want in any hip we do. Where do we? What is the ideal? Thr So when you answering the question first say up hand that my idol thr is say you want to say you want to use a corral pinnacle? So say I use the coral pinnacle hip system or you say like me, I use the Exeter Trident hip system or any similar or any of the companies use the word, but you just can't stop them. Keep quiet. You have to justify as to why you're using it. So say I use this say, because my goals of arthroplasty have to be met and my goals of arthroplasty are such that I need a hip system which will reproduce my normal anatomy. And I need a his system hip system which will account for inventory for all the an atomic variants I come across which all the deformed hips I'm going to take on. Okay, so that's your one. I need a hip system, which would have a robust planning or templating kit. So now you can use your computer planning nowadays are using the acetate all over, so I use a robust templating kit. Then say the most important issues for me as a hip surgeon as to restore my offset to restore my neck angle and my neck length so as to get my correct hip center and therefore this system you can say Coral Trident. I'm Carides uh, exit er, or whichever you want to say gives me my commentary in to fulfill that, then say I do want and I do know I need ongoing, stable, hopefully lifelong fixation. I want a long term track record for survival studies, and hence I use it and then say this system, which I use has an optimal length stiffness and taper, which I don't do no has not caused any undue peak stress is, and it's not causing any undue increased moments, which may have resulted in predecessor stems or other implants which implant breakage, etcetera. Hence it got a long term survival. That's why I use it and then say, with cost an issue I do also want the flexibility of bearing services. I do know my default. You can say my default is ceramic on politically, but I do know and I want different Uh um, services available, and I want to optimize and perhaps the best head neck ratio. So see, in two slides, I've tried to put in the words where you will be asked in the vibe of anything. So keep in mind, just know about Head Nick ratio. Know about different surfaces, the where rates know about how stiffness and taper influences or increases the peak. Stress is you need to know about the lifelong fixation with H a coded implant or how crippled taper cement stem works, and you need to know the versatility of your offset. So in these two slides, it is something that you can cover most aspects of your heart's plasty and then say, without a doubt in my trust, I will need a adept high rating and a nice approved. And then there's always a controversy as to how which paper you talk about. I would say we need to talk about any paper in orthopedics. Only three types of studies, which we as automatic simple surgeons want to know about. It'll be long term implant survival studies. That's one patient reported outcome measures. That's the second type of big study, and third will be laboratory based studies. So whichever paper you want to keep for your, uh, to prove that you want to use an implant. So let's say you want to use the exited Trident. You can take one paper, which got a 25 year survival and say this is a long term survival studies. So when you're quoting that paper, I would say What you need to do when you quote papers is you don't you don't know every name of every author. You need to know what type of study it is. So say I do know this is a big, long term survival study or you say I do know it is a patient reported outcome measure study or if it's a little lab based study, looking at ceramic and ceramic, where lates where rates in a laboratory. Then you say I do know it's a laboratory based study looking at where it's so, introduce it with that heading, then always use the word. It's a contemporary papers The last 5 10 years of contemporary studies. If something historical say it's a historical paper, you don't have to know all the names. You don't have to know the exact month when it was published. But you need to know which centers compound and to be impressive to get a seven or eight. And even if I'm sitting on a panel or if we all are sitting on a panel to give an opinion, if you say that this is from a journal, which is the impact factor X, which you know is higher, then it sounds more impressive. And you need to know the level of evidence now in orthopedics for long term survival studies. It's very difficult to get the gold standard randomized studies, but at least you can say I do know it's a Level three evidence, but this is the paper is the best paper we have. So therefore, if you're talking about your hip, your knee, your, uh, implant, you use like a D. H s. Just keep one paper which supports its use, and try to use these three or four wordings, which impresses to get the seven or eight so moving on, Let's move on to how to talk about the difficult hip in Arthroplasty. And But before that, we need to know how to talk regarding a straightforward hip in in out the velocity. So, uh, let's first talk about his straightforward X ray, which is good for you now, when this X rays put up, uh, what do you want to talk about this X ray? So most people, when they say this X ray, will say it's a pelvis, both hips extra, and then immediately start talking about the pathology on the left side. I would say that you first need to say for me tell pathology via the question. Try to say this X ray is what? Okay, So if it's a what do you think this X ray should be in a hip? Now, me as a hip surgeon, I want an X ray called a pelvis with both hips AP view, and that's different from my chroma surgeons in the any who want a pelvic X ray where the entire Eli crests are seen. So I tell the Examiner, this is a A p pelvis of both hips. However, it is not correctly centered on the synthesis pubis. It should be centered year, while it's not centered there, and I need to see more of the shaft. Okay, so that's the first thing you say. The second you'll say, is that I want to know what it's correctly rotated, say the optical foramen. I cannot visualize because of the bled pad, but it may be some rotation on this film, so these are the two things I wanted to open to stay in a hip Disa pelvis. Both hips is centered correctly, or it's not centered correctly on the symphysis pubis and the opportunity for men appear symmetrical. Or they don't Sapir symmetrical. If they don't appear symmetrical, then say that there's there's some degree of rotation to this film. Next, I want you to say that describe the signs of Okay, So the first thing you say is I notice that on the on the left hand side there the classical signs of osteoarthritis, which would be sclerosis, the joint surface narrowing or near a bill irritation of the joint surface osteophyte formation. And I cannot particularly see cysts to say that and then say that I would therefore call this a straightforward Austro attic hip, and I do not see a gross abnormality of the hip center. All right, so make say that phrase. So we're going to say this is the signs of way. It is concentric away is the normal oa you see and mention there's no gross abnormality of the center of rotation off the head. Okay, then then say offset. I will. I will recreate, offset by templating or comparing it to the other side. So that's your straightforward interpretation of Austra arthritic hip. Now let's see what happens when we have a more difficult hip. So we all agree this is a more complex pathology, right? So where do we start? Where do we end? So the first thing to say is Start off by saying, This is the X ray, which is a pelvis turbo tips centered on the surfaces. Pubis? Yes. Now you agree this is a better X ray centering than the previous one. Then say the optic reform men are not symmetrical. Let me be some degree of rotation. Second, third, I want you to give the barn door of what you see. So say there's no doubt there's bilateral destructive arthropathy of both the hip joints with definite sclerosis of the joint services. There's no ability, Asian, any joint services. They are pasta fide formation and their market cysts or definite cysts with near obliteration of the femoral head. Now there are four points, which I've said so I've talked about the arthritic changes, and then the first thing you say is there's obliteration of the femoral head. So describe the head and then say where the center of rotation of the hip is gone and the next statement would be. And there's definite abnormality of the center of rotation of this hip, with definite superior migration of the CT of the head of the femur. Right? So what am I going to say? I'm going to say that's a hip center is grossly abnormal. And then I would like to describe the head more for pathology. And what did I say in this one? There was complete destruction of the femoral head. Then next I would describe that. Tell the Examiner, or just what I do in my when I'm planning a difficult hip is I describe or I divide the description into the femoral side and the assemble aside. Okay, so There's no confusion in my mind as to where my difficulty will lie. All right, from moving on this one, for example, this one. Do you agree again, that is, You're going to say the same thing is the a P pelvis with both hips sentence symphysis pubis up to reforming appear symmetrical. It is a correctly rotated film. There is definite signs of, uh, osteoarthritis in the left hip with complete operation of the joint space pasta, wide formation, cyst formation, sclerosis and the center of rotation is definitely abnormal with superior migration of the center of relation of the femoral head. And then say once again I noticed that there's a destruction of the femoral head. Now let's go on to what type of head shapes you can commonly have. So the Roman the first film which was our normal Oh a you're going to tell the Examiner the head scarcity is maintained. Okay, because it's a round head, Then you sometimes can have sectoral collapse. So the superior lateral quadrant, you know, the you know, when it starts hitting against accidental rim, it gets eroded there. So you see that on X ray, you call it sectoral collapse. Then you can have a completely misshapen or a dish shaping head where it's grossly, uh, distorted. So let's call it a misshapen head. Then you have, like, I showed you a destructive are through pity with obliteration of the femoral head. And then you have a cock so magna or a large head. Okay, so these are the all the heads you will see and I try to put it down. It's not going to be written in any textbook. It's just what I've picked up over the years. So do you agree? In this one? This ferocity is maintained. So you're gonna say the femoral head ferocity is maintained in this one? Do you agree? Is a distorted head? Yes, It'll be a distorted head of misshapen head over a year. We've already said it's near destruction of the femoral head over here. Coxon Magna. Yeah, So this is how you describe it, and I want you to move on to the neck area. So now I've divided it. So I've talked about the head and then I say on the femoral neck, which is this area I want to describe it. So I describe in my mind what has happened there. So in this case, for example, I talk about the length, so there's a definite shortening of the femoral neck. That's what I will say. And then in my mind, I want to know whether it's an excessive valgus of areas. And I say it is a normal values various orientation of this head of the neck. And then I not see whether there's any abnormality in the neck area, cysts, etcetera. All this is important. If you're doing hip resurfacing, the integrity of your neck is very crucial. So that's why it's important to know. And also, when you're templating, you need to know where you are with your neck angle. So let's go back to this. So what? I want to know in the neck. I want to know the weather is shortened. I want to know whether it's valgus or Berries and whether there any cysts or any issues in the neck area. After that, I go into, uh, centric area. So I say in the Intertrochanteric and the sub chromatic area, I notice that there's no abnormality or there's abnormality. And what are the abnormalities I look for? There's no evidence of the previous hospital. Me. Okay, Ostomies are normally done here, and many of the hips I see now which I'm operating at 40 45 would have some degree of osteotomy done when they were younger. So CNN is in the intertrochanteric subsequent area. I see. Not in this one. I'm just imagining that I noticed that is an abnormality with the previous foster to be done. We talk about whether there's any metal work there and if there's any remnants or attract of previous metal work removal. So see the phrase I'm using because very often you'll see in a X ray attract a screw attract of a D. H s. So all that is a word you can say. I see a previous tract of previous metal work. So let's see again in the intertrochanteric and subsequent area, I look for a deformity which could be your previous Oster to me. I look for metal work and I look attract of previous metal work and then I move on to the shaft area and the shaft area. I say in this limited film, the shaft of your satisfactory with good cortices with a good mystery canal with no deformity or previous fracture seen and no metal work. So what do I want to look in the shaft? I want to see whether it's normal. I wanna with the canal is patent and no fractures. Let's look at each one. Do you agree? In this one? The neck is normal. Uh, is the neck is shortened with definite cysts over there? But the valgus various angle is satisfactory in this one. Do you agree? We'll agree that this neck angle is in valgus. So you're gonna describe the head and then you're going to come into the neck. You say in the neck area? Yeah, it is in Vegas. You agree Here in the subq can trick area and the Trokendi area, there's a deformity. It's there on this side as well. But actually, as we picked it up, you see the pickup of the deformity in the true can trick and sub traumatic area. And on this side and then in the shaft you see this? You clearly will say my issue with this case would be that in the shaft area there's very thicken cortices. There's near obliteration of the canal Metric canal. So and but There's no fracture, see, So this is the way I would have talked on my femoral side. So just to recap before we go any further, in case it's getting confusing, I first start with the X ray. I start whether where it's centered or rotated. Next, I talk about the barn door, arthritic changes, which will be there in a simple hip or a complexity. Talk about that next. Talk about the center of rotation of the hip, whether it is near normal or grossly abnormal. Then describe the head of that femur and then move on to the femoral side, into neck into to Patrick Subtrochanteric and shocked. All right, so now we finished that. And now let's move on to the acid herbal aside. At several aside, I would say the first thing you want to look for is Can you see the teardrop? Okay, so if you see the teardrop, the medial Forsa or the floor is satisfactory or intact, so see the fossa and no in your mind whether the truth for is present. That's one thing look superior early and see whether there is any destruction of the superior lip of the acid. A Bill, Um, which is then I'll shoot you the cases, but that's a common thing. And then we never asked my registrars, My fellows, my, uh, people and courses describe a hip X ray and they see a very abnormal hip. They say it's arthritic changes. And they asked, What do you want to do? And immediately, The next question is, I'll do a CT scan now. I can't remember. I do a CT scan very occasionally, but a lot of information is actually got on your plain X ray and the plain X rays. You get that information exactly with the interpretation of your pelvic trauma. So, uh, from today onwards, I want every x ray to be looked at, like you're looking at it from a pelvic drama point of view that every ileo crystalline Elio pick penial lines are all have to be drawn, and that gives us the information about the columns and the walls. So let's go through some of them. So on this one, for example, let's let's put to you like this. What you're gonna say is, let's all say we can visualize the teardrop. Yeah, you can visualize the teardrop red so you can say. Therefore, the medial wall would be intact. Correct. Let's move to this side. Now you're gonna say there's definite destruction of the superior lip off the acetabulum with superior migration of the femoral head. Then you're going to say you're going to talk about your ileo picked any a while and you're ileo issue lines and you agree, at least on these X rays, the Tekturna. What would it represent and treat your wall? And the lowest pill will be the posterior wall. So you know, at least, uh, Scali the columns. So these two columns are intact and the walls are also intact. What may not be visible here is your Australia wall. So for that, you can say I'll need a lateral view or I'll need a CT scan. But most of your columns okay, you're definite. Anterior column and your posterior column and your medial wall is given me information from this plain X ray. So So that's there. Now look at this one. But this one you agree, is a pro to zero. But why? Because we know our line is drawn and the head and the acid before PSA is beyond the ileum pectinate line. Okay, so that's where you're so lines give us a lot of information on to where we are, and we need to know what it's called is the acetabular index. So if you draw a line from the teardrops and you draw another line to this edge of the acid, it will, um, if that edge suppose the edges destroyed and it's here. So let's go back to this one. You agree that if you draw a line at the bottom of the teardrops there and you draw a line from here to the lip here, it's a lesser. This angle is different from if the angle was there. So once you have this angle, that's your acid herbal index, and that gives you information that the superior lip is destroyed. Now that's the difference between calling this. This is not a dysplastic. It's dysplasia from the anatomy, but it's nothing to with dysplasia with the patient was born with. But it's destroying the superior lip in produce. Geo, I've said we need to know the lines to the head and the, uh, regular four. PSA is beyond that line. And look at this one. Now we're talking about this side. Yeah. When you're talking about this side, let's say you have this picture shown to you. So you've talked about the femoral side, which is grossly abnormal. So you're gonna tell the Examiner? I notice the femoral neck is shortened, I notice in the intro cantering subsequent area. There's a deformity. Look at the deformity. Yeah, you're gonna say my main worry is there's gross sclerosis of the femoral, uh, cortices. There's new ability. Ation of the canal. However, on my A suitable aside, more or less, I can see the teardrop. There's no really increased angle in the assessable index. It sclerosed, but more or less is a straightforward, a suitable um All right. And then now, after verbalize in the last five minutes, uh, I have five minutes. Is that correct? Yes. Yeah, that's that's good. Yeah. So? So now that I've made my, uh, entity as to where my issue is in all the cases that I've sold you, either the problem will be on the Activella side On the femoral side, it's very unlikely beyond both. So when you have to verbalize, how will you manage these complex cases? Say that I have taken a history and just immediately say, Don't say this patient can be treated conservatively and operator, you cannot. That's a destructive are therapy. There's no concept and management just say that assume have taken a history completely examine the patient and all concept with measures have been exhausted. And this patient obviously is in significant pain, and they're no contribution to joint replacement surgery. This patient merits bilateral complex hip replacement at a state setting. That's what he'll say and then immediately say it is complex surgery because part of your remit as your level is to identify complexities of surgery. And why is it complex issue is complex in hips because of either exposure, either because of hip center restoration to or there's a complexity on the femoral side and the acid a bill aside. So in exposure being difficult, I aim to get exposure and distribution safely. Okay, And that issue will be a worry in three types of conditions. One in produce, e O. Two in ankylosis and three in Concord, COXA. Magna. So we agree exposure is going to be difficult in this case where you have to institute it's gonna be difficult in this case and it's going to be difficult in this case now, once I've got my exposure, the s tableside restoration of my joint center is I have to localize the true floor and place my cup where the true floor is. That is always in theorizing. So my cup, whether it's cemented or uncemented, doesn't matter. I have to get it inferior where the true flu is, which means indirectly. Once you put your cup in fear early, then the superior part which has been destroyed has to be filled up with something okay. And that superior part which had been destroyed and needs to be filled up, has to be made from uncontained effect into a contained effect. And the areas in hip arthroplasty where we have going to have uncontained effects are most of times superior and immediately so this is the place where we need always some augmentation, and that augmentation could be in three forms. This remember this one is if it's contained, that's good. If it's uncontained, we have to make it contained. And then we can use impaction bone grafting. We can use structural bone grafting, or we can use augments like, uh wedges, et cetera, And the last thing you need to know in complex of surgery are the columns and walls intact. So in this one, do we agree that the superior lip migration I'm gonna place my cup in fairly. I'm not gonna put my cup here. I'm gonna put my cup here where the teardrop is, which means this area is going to be an uncontained effect. How do I get this uncontained effect? A. I can use a mesh with bone graft. Morselized at the back to I can use a structural bone graft over there. Or I can use a metal augment. Okay, which is trabecular metal. I can use all three. I've used all three. What do you think I've used in this case? So in this case, I go up in fear. Early this defect, I put a mesh bone graft and then screws and a mesh. And remember, I told you with the posterior wall wall, I had to put a mesh posteriorly as well. So this is complex surgery. But if you notice the hip center is being restored, the hip is down. Now he's got his length back. And this is not immediately POSTOP. But after a while, see how well all this bone has become like newborn. So this is what I use for this case. Same thing there. So imagine I got the hip centered down put bone graft there and a mesh and screws on the femoral side. All you want to know is will it be difficult? Will it will. I have to get the hip down so much there'll be a sciatic nerve issue. Will have to do a softly release or reception of bone and the femoral side. Just make sure that the canal is patent. The metal work is removed, the deformity is sorted. Or do you need a short stem? And this one? Do you agree? I would have struggled a on the dislocation. So I osteotomized there. The ast level, um, was straightforward. I would dream and get it out. My femur was a struggle. I had to really get my canal patent. And then this is what I did. OK, so so, uh, with this slide, because I think it's just 30 minutes. So what I've tried to do is I've tried to put through my own experiences, which I think will help you to talk in the exam and therefore look forward to adult pathology and hip and talk like this. It may impress the Examiner, and at least you get a confident of tackling any difficult hip, which is you've come across with the correct words. So thank you for that. That's wonderful. Thank you, Mr Malabsorb. Allah, for this, uh, concise but also very comprehensive lecture, uh, focusing on how to answer questions related to hip replacements in the exam. As you said, it's a It's a massive topic, and there's no way you can cover it in half an hour. But this is a very all right sorry. And, uh, very excellent recap of, uh, the main concepts of hip arthroplasty. And very interesting case is also thank you. Uh, so we have, uh, question uh, those, uh, from Asim. He asked about these destructive lesions. Can you describe them as a v n or or would that be committing yourself? No, that's a good question. I I mean, I, uh you're absolutely right. I mean, this is without a doubt, bond or opinions. Whoever says this is very correct. Uh, so just say that it's very likely significant oh, vascular necrosis leading to a destructive arthropathy. All I would say is that because it's bilateral, it's very likely bilateral ABN. However, if it was one sided and it we saw such a destructive are through party, all I would probably do, which I did in this case is just tell the examine or even in real life, we were tackling a patient like this. If your serial X rays before we'll say, Let's four months ago was relatively satisfactory, and then you had a very rapidly progressing destructive are through pretty like this. Always think of infection, right? So you would want to do a full account esr crp probably re safer to aspirate the hip to confirm it wasn't any infection. Now, bilateral, uh, infective arthropathy is near to zero. So in the case I showed I would not particularly say that. But even if someone said I would always worry about infection, that's something to think about. But the direct answer to the question is very correct. This was a B N, and I think that's right. Many people, when I asked this, they always say it's dysplasia. It cannot be dysplasia because it's A. It's a destructive arthropod E, thank you very much. And, uh, I had one other questions. And to me, uh, a lot of candidates, um, worry about answering this question about what's your favorite prosthesis or which What's hip replacement would you do? Uh, it's very common exam question. Um, a lot of the time is unnecessarily answered badly, because we worry that you always have to say Exeter or whatever, and we always have to say exactly. But, you know, you laid down very nicely the principles of how to answer this question. The Examiner is not really interested in. You could say any processes you want, as long as you can back it up with those principles of NGR or the patient reported outcomes and any published literature. Yeah, you could examiner really interested to know that you are using a safe, uh, procedures that has long term results. Um, that's That's our It has to be one of the top prostheses as well. That has the best results because there's no reason why you would not use it. A top prosthesis. So that's the interested in the principal's. If you tell them Exeter, that's you're not gonna score anything, Uh, very correct for us. I completely agree. And that's why please don't get stressed with this question. It's and don't just answer like virus has said. And if they want to use this as a setting question also to lead onto something, just all the points are there are going to be expanded on. So if they want to talk about bearing services, then you will know one or two points on the where it's right. If they ask you about head neck ratio, you know two sentences of that. So just expand on these, uh, phrases, Yes, virus A completely agreed. And Gotham is asking, um, how would the valgus or varus affect the ephemeral offset? It's a biomechanical now, biomechanics. Now we're moving basic experiences, but the way to uh, influence your offset is that if you have a various, you're because you're going down in your angle, right. The distance will be changed between your center of rotation of your head and the shaft of your femur, and hence you have what is called as an increased offset, but theoretically and even practically, you will not have an increasing limb length of that patient. So very often I've stopped using corral now. But when I used to with a lot of corral, it's excellent stem. My default was not the normal. I used to use the coq severa because that means that you can Let's say you've put in your stem right, and you're doing your final reduction with the trial, and it's still long. Instead of trying to get the lesser size, process it down further in. If you go to a cock cevera and then put your minus head on, you will be able to get your better correct offset will be. I mean, your limb length will be back. So the answer is that an increased a cock severa will increase your offset. Yeah. Thank you. That was very clear. Thank you. Thank you very much. Uh, we have another question from the career about what's your preference allograft or trabecular method to fill? Uh, yeah. I mean, in both the cases that I should practically I know, I'm, uh I use more of impaction grafting with a mesh because I feel most of the effects we get right, uh, are reasonable enough that we can't not use something and even the smallest. I find the smallest tropical metal, which is there may be too big for that defect, which we are trying to fill, so therefore, I tend to use the impaction grafting behind the mesh. So I put the mesh on, get it down to where I feel it needs the coverage, then impaction bone graft behind it, and that's what I tend to do. But there's no right or wrong answer. But if you use traffic color metal, keep in mind. Sometimes you have to re lean that defect a little more to get the smallest tropical metal in Okay, so that's what you have to do. But tropically metal. For most unscented users, that is their default, and they do it all the time, and that's a very acceptable way of doing it. I've done it, but, uh, this is where I found. Sometimes I prefer that the third one just to be on this topic is where you can Dec a structural bone graft from patient's. You can't use the patient's femoral head because most of the time the patient's femoral head is destroyed to use the allograft and use the number seven graft and place it the other way around and two screws to hold it there. So that's your structural bone graft, which can be used. There are three ways in the world of tackling this, but whatever it is jumbo cups, which is in the past 20 years ago, I know when I started, uh, people used to try to use a large cup. Okay, call it jumbo cup with screws. That certainly is now not acceptable. It causes all your problems of impingement. It causes buttock pain. It's not to be used. So let's say just saying, I'll go on expanding to the size of the defect and use a 60 millimeter cup or 67 or 68 millimeter cup that's wrong and superior. Rising your cup Just because you can't get your cup down is wrong. So whenever you remain normal hip whenever you remember, abnormal him your hand. Always down. Okay, so really, you'll never Your mistake. Always. We look critically at your X rays. You'll never get your cup lower. You'll always get it wrong by going higher. So the two wrong things are jumbo cups, and the second is to put your cup position higher because Well, you got it wrong. Yeah, Yes, thank you very much. That's very clear. I think we can move on now to the MCQ part of this, uh, teaching session. Um, so Mr Malik Savella has prepared some excuse. Please, guys, um, everyone, we encourage everyone to try to answer them. Uh, they are all anonymized. Please give them your best shot they presented to you. We'll give you around three minutes to answer all these three. Excuse, and we'll then go through the answers, please. Everyone try to answer, give it your best shot. Um, questions anonymized, uh, answered animals too. Um, just a reminder as well. You have two volunteers for the hot seat Vivat session. We We have a place for the third person. If anyone twisted. Otherwise, we will just do the two. So the two candidates interested in the Vival uh, got it? Yeah. Gareth Chan and Osama al Obeidi. Um, we have a third one now, so I think we Mohammad Mohammad Arafa is the third one. So that's it. So you have three now. You're coming in for us? Yeah, All coming in. We almost three minutes now. Um, a few more seconds Yeah. Um, yeah, I think that's it. Three minutes. Now, I think we can end up whole now and share the results. Um, that's good to get the results now shared. Uh, so first one first, Yeah, exactly. So, yeah. So with the various options and femoral stem cause lengthening very kindly, someone very ask the question and more or less for us. We discuss this, that the various actually is a better option because you can get your better offset, which is always good for your abductor functioning without compromising your neck length. Okay, so that was the answer for that. Uh, the second one is, will a various option cause a decrease in the bending moments? So now the answer is no, because a various option actually causes an increase in the bending moment in the proximal femur. And in the past, why stems were not made at less than 1 35 was because if they made stems at 1 27 1 30 which is actually closer to the normal population than 1 35 right, 1 35 is not the average population neck angle. The normal average black angle is less. It's about 1 29 1 30. So the question you have to ask yourself is, Why would DHS is? Why was the Charlie here? Why were they all made at 135? So the question is that in the past, when you've made your hips at say, let's 1 20 then the bending moments in the proximal femur were a lot, especially with stair climbing and getting up from a sitting position. And therefore, in the old days, when mythology was not very advanced, you had what is called as, uh, implant fracture. So that was very common in Charlie's when I was starting doing revisions. Now, if you noticed those of us too I mean, you don't hardly get stem breakages. So because of better mythology, you can go for your various options. Okay, so the answer is no. Actually, a various causes an increase in the bending moments. Okay, Perhaps I moved to the third one. Yes, please. Yeah. And will a various option of femoral stone improve abductor function? Yes. And the reason we should say yes is just keep in mind. Various increases offset and increases offset improves abdel function. So one leads to the other. Okay, So that's where where it is, the joint reaction force. Maybe more. But at least you're abductor function is improved. And therefore, I would say that a various option improves abductor functions, and the answer is yes. For the majority. So and why I put these three questions. I didn't want to ask the same questions I asked in my talk. I thought, I'll do. I'll touch on these three. Top this topic. So, in other words, I managed to give 40 minutes of something rather than overlapping it in 30. Yeah. Any questions on that? Now, that's wonderful. Wonderful, wonderful questions. Thank you very much. They're very important concepts. Uh, with the virus confuses people, isn't. Uh yeah. Just keep that in mind. Yeah, these these these praises and thoughts. Yeah, I think generally varices good general leaks. Making is good. Better offset gives you better offset better abductor functions. Yep. Generally it's good. Yeah, but not excessive. Aim for optimal. And I think you're right. Better or optimal. That really the best word to use for the exams? Yeah, correct. Perfect for us. Thank you. Wonderful. Thank you very much. Thank you very much. A game remarks, Um, Avala for this wonderful lecture and take us through taking us through this, uh, difficult topic. We go