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Start. So, um thank you for the introduction with Spacey. So I'm Doctor Claire Blanford. I'm one of the consultant anesthetists down at and South Devon Hospital. So I'm from the other side of the drapes to talk to you today about enhanced recovery and tips. In terms of my background, I've been doing this type of work for over five years now and I started as the girth departmental representative. All right. And during the time I was in that role with basically launched Day Case Hips, which was back in September 18 day case shoulders in March 19 and day Case Total knees in June 19. And throughout that time, we have continued to refine what we've done had embedded, what we do now isn't a mile away from what we started off doing, but we have made some improvements in October 20. I took on an S T P Devon, the wide role as a clinical champion in orthopedics, which really was with a view to trying to unite what we were doing as a region. And then in May 2021 I was appointed to sway, okay, which some of you may have heard of it's the Southwest Ambulatory orthopedic Center, which is physically based on the site of the previous Exeter Nightingale. And I was appointed as their clinical pathway development advisor and I essentially wrote all the protocols for them for their hip and knee work that they're currently using as well as developing their patient information booklets. And then basically, this year's work has been working on the golf guidelines which are knocking on the door of being published. I've been told it should be any day now. But this is the 2023 updated hip and knee national guidelines for looking at how we can improve what we're doing in terms of length of stay for all our patient's the topics. I've been asked to talk to you today about our day case joints and enhanced recovery and rather than separate them into two talks, plan to fuse the two together and then take questions at the end in terms of where this story starts. I'd like to go through really a bit of a journey as to where we started back in 2018, how we've refined what we've done and then drawing that during that talk, basically, draw out the principles of enhanced recovery that I think are really important to apply to these cases. So let's go back to 2018 tour by hospital. I don't know if any of you have ever worked in the Southwest, but we are just an ordinary bog standard midsize district general hospital. We did benefit from a very well high, was well respected and very high achieving day surgery unit. We had over a decade of very strong leadership and a real willingness for innovation amongst the staff down there, which really gave us a great test pot. Should we say where we could do this sort of trial of change? We'd also had over a decade's experience of very successfully doing day case, a CLS and unique compartment or knee replacements with some of the highest rates in the country. So we'd already gone a little of the way towards doing total joints. At the time, I worked with a regular list with a surgeon called Mr Mike Kent whose um sadly now moved on to another hospital, but we did a weekly Friday list and one day he said, what do you think about us doing a day case total hip replacement? So we had a coffee and had a bit of a chat about it and we knocked the idea around and then drew up a bit of a plan. And then of course, once you start to do that, you move all of others and there was a bit of a mixed reception. So like any sort of change, there is going to be a group of people who are enthusiasts and a group of people who are resistors and none of these sorts of change. Sadly, our, as easy as one might like to think So there was quite a bit of resistance to us starting off with what we were doing. But my main advice would be to when I speak on any of these type of talks is when approaching any sort of change, my mantra would be D D D and that stands for data drives development. So first of all, in our case, where are the places doing it? Yes, not many. We were about the fifth in the UK to do day case hips but other places are doing it. Ergo. It is possible. What we really needed to know was what we were doing now in our practice and where we needed to make improvements so that we knew how to in a sense, fix what needed to be changed in order to convert. What was our previous length of stay on average for in patient's back in 2018 of about five days to being able to send them home on the same day. So I started off with an audit. Now as dull as the audits are they do provide you with some very useful data. And the really critical point of me doing this was when I then went to present to the anesthetic department particularly is if I'd have just started off this conversation and said, what your patient's look like after their operations, the answer almost universally would have been there. Fantastic. Everybody is great. I give a wonderful anesthetic. And if I had gone to the surgeons and asked a similar question. It probably would have been a similar bit substituting operation for anesthetic. But what's really useful to know is actually what's happening. And usually it's actually the ward nurses that know this stuff better than us. But following an audit that we did looking at hips and knees, as you can see, that's on the screen, it's not exactly a pretty set of numbers. We certainly had areas that we were going to have to substantially improve if we were going to be getting patient's home on the day of surgery. So we approached it as a mutual solutions. Now, for those of you who here at the beginning of the talk, I mentioned that we'd already had a decade's worth of very strong experience in day surgery. We were doing quite a lot of fairly advanced day surgery procedures, day case hysterectomies, day case nephrectomies. We've been doing day case uni knees for over a decade. So what works well in day case and we knew what our problems were in our inpatient practice. So we took what we knew and basically got a blank piece of paper and designed what we felt would be the best. So wrote a model day case pathway for doing hip replacement, we then trialed it by calling it a pilot. And if you're going to invoke any sort of change, saying you're going to do a pilot of something usually smooth. Some of the barriers along the way rather than just going out and saying you're going to change something. So we did a few test cases, saw how it went and then use that learning that we've gained to make a few refinements, but importantly, to take that work back into the in patient population so that all our patient's benefited from the best pathway, not that we designed some bespoke thing. And we kept it in a little cupboard that we wheeled out for the occasional person who met our criteria. But we applied these principles to every single patient so that they should all be getting the best possible standard of care. Our initial the day case criteria in terms of what we have put in as our pilot group for being able to be booked and managed as a day case. We're very conservative and we have considerably relaxed these now. But this is our 2018 criteria and the way we manage these was they were booked as day cases. They did not have an inpatient ring fenced bed allocated to their name. Therefore, if one needed to be provided, we would have found one. But it was really important that we made a success of this because the patient pathway was going to be discharged virucide room on our day surgery unit, not via the inpatient ward. So there wasn't an immediate backup plan for patient's that didn't go home in terms of our process. So this again is back in 2018 and I will talk about what we do differently. Our physical geography is that all our laminar flow theaters are in Maine Theater. So, although a high percentage of our work that it's day cases gets done in the day case unit, a lot of it also gets done in Maine Theaters, which means they get admitted to the main patient admission ward operated on in Maine theaters. Stage, one recovery, main theaters then go down to day surgery for their second stage recovery and discharge. We do have day surgery theaters and they're currently being upgraded and there will be laminar flow theaters going into those. But at present, our theaters down there do not have it. So all our day case hips when we started were booked as day cases and that's really important as well. Not only does it contribute to your data, but it actually helps manage expectation and that managing expectation is critical for both staff and patients'. So the patient's got a day case orientated pre assessment in it by a day case experienced nurse. The messaging was completely on point for day case. They weren't talking about three day length of stay, four day length of state. None of that topic came up. It was all about how we're going to get you home on this on the same day, how you'll be supported and what safety netting there would be in place. Patient's were booked first on the list, we minimize fasting. We held a sin. Him, Bitters and a two R B drugs for 40 hours. So the day before and the day of surgery and we also use water until sending. And I'd be really interested to know whether that practice is universal in the east of England. Because guidelines came out in 2017, that water should be freely consumed by patient's up until the time of sending. but it's been really slow to be adopted. So if it's something that you're not doing in your hospitals, I would employed to make that change and get patient's drinking water, no restriction, they can drink whatever they like up until the time of sending. And the rationale for that is that the amount of time it takes from water to drink that you've just drunk to leave your stomach by ultrasound assessment is 15 minutes. And I defy many hospitals certainly with the standard process of sending from the moment, the patient stands up on the admission's award to the patient is supine having their operation to be less than 15 minutes. There's certainly no way the Porta ring in our hospital would ever permit such a thing. So the water will be gone. We use a preop drinks regiment and that is three protein based drinks that the patient's have day before admission to carbohydrate drinks on the morning of consumed a minimum of two hours before the operation starts. So really, that's before half past six, they get told analgesia premeds are given on the admission's ward. And then we use an opiate free spinal technique, which is a short acting drug. So the one we use is called heavy prilocaine. We use surgical Lear and if we're doing any knees, then we add in blocks and then we use minimal sedation. We try to do no sedation and offer, offer patient's music, but any patient's that need some sedation. We will do that but try to keep it to a minimum. We use a blood conservation strategy with the routine cell salvage that usually raises some questions. So I've got a separate slide on that coming up and standard T T X A practice. The rest of the management in theater is fairly standard goal directed care aiming, aiming to achieve normovolemia normotension, normothermia, not flooding patient's with fluid using some vase oppressor drugs if necessary to keep patient's BP appropriate and really making sure they don't get cold, nausea and vomiting can be a problem, especially with early mobilization. So recommend giving to antiemetics routinely don't pick and choose, just give them to everybody. And then we introduced Protocol IZED T T A s. Now this is something we've had for a very long time. Every single operation, it is coded at our hospital and it has a package of tea to is attached to it. We built bespoke ones for our day case hips. We're recognizing that they would have a higher pain burden and many operations. But everybody gets the same unless they can't tolerate nonsteroidal type drugs. We give everybody unless they are the most brittle of diabetics, an energy drink in recovery and then they rapidly get mobilized as soon as their spinal is offset and is safe to do so. And they have physio input for their first mobilization stairs and transfers. But we also have up skilled nurses and HCHS who can help support this work as well. And then they have a supported discharge package where they have telephone numbers for access for emergencies. Physios do not routinely see again after discharge, but they will support on an S O S type basis just to rewind back to that original audit that I showed you. We had significant issues in these four areas and what we did was specifically target the design of our pathway. In order to address all of these things. We did a pilot group of 32 patient's which we published in November 2020. The numbers of cases that we did was quite slow to rise because obviously the period crosses into COVID times. But of our 32 patient's we achieved is 94% same day discharge rate, which is the highest in the country. Our pain scores were very much improved. We had none or mild as the communist ratings. So 70% of patient's and nobody reported severe pain and this was follow up across the first seven days are nausea rates were minimal. We had virtually no dizziness. Satisfaction rates were extremely high and we had a few patient's who actually had one joint done on an in patient pathway. And this was the second side being done on a day case pathway in the same hospital to direct comparator Xr's and they all preferred the day case pathway. So we published this work back in in jobs which is the journal of one day surgery in November 20. Now, by this time, we have gone on to do some day case total knees and also daycare shoulders as well. The biggest determinants of success. Sorry, I did have some slight animations in my previous slides which obviously aren't working on power points. So this is kind of overlapped a bit. But number one, the biggest thing is patient engagement and expectation setting. And I would say it outranks complexity of patient in terms of A S A grade. We had similar say three patient's in our initial cohort, we had patient's who had significant renal impairment. We had patient's who were on free of opioids. They all went home because they wanted to and because they believed it was possible. And actually that engagement is really, really important. The bit that you can't see is number two, they must believe it is okay to go home and that they will be supported and they're not being pushed out early. They're going home because they're ready. And actually getting all your staff on point is really important subject to are following onto our initial day to say that we had a couple of a day case hips that didn't go home. And when we finally looked at what was happening, there was actually a healthcare assistant up on the admission's ward that had said, I don't think I'd like that if I was, that was me and all it can take is one member of staff who isn't necessarily fully engaged with the process that can say something that shakes a patient's confidence. The third thing that's really important is protocal ized care and adherence to a protocol. So you need to write a protocol and get both your surgeons and your anesthetists and your ward nurses and your recovery nurses to all sign up to doing it and looking at our initial numbers, say our initial hips and knees where the protocol was followed. We had 100% discharge when the protocol deviated. I'm not saying this is 100% causative, but our discharge rates fell. And that's because people start picking and choosing what they do or start substituting in things. And that's obviously where the success margin will then fall. So make a protocol stick to it, sell salvage. We operate and continue to do so a default collect, decide to process strategy. We do this instead of a second group and save on the day which saves 20 lbs. The cost of a collection set is 20 lbs. It was a cost neutral introduction. We published our data of 324 patient's back in 21. And what it shows is if you go looking for it, there is a surprising number of patient's that you can actually transfuse back and you're the transfused back somewhere between 50 and 60% of your patient's with a decent volume. This is worth doing. And if you're trying to get your patient's home, why don't you want to optimize them to the absolute max and returning their red stuff to them is really important. Many hospitals have really strong preop pathways now and correcting anemia, but I don't think we're as good about making sure we keep them intraoperatively as topped up as they possibly could be. The protocol had several great benefits when we brought it through into the inpatient work. One of the biggest ones was, are a pain skit service. So they used to see every knee and then some hips, they stopped seeing them, they stopped seeing the knees as well because the pain scores went down so much. We introduced a functional pain assessment score, which is a real deal breaker because some patient's believe they should have no pain. And some nurses also believe patient should have no pain. And that's an unachievable goal. Patient's should have pain controlled to the level that they can mobilize. So looking at a pain score that looks at what they're doing, not what they were reporting their level of pain is, but what level of pain is actually impacting on their ability to do. They're, they're mobilizing their daily tasks. That's actually a much more useful way of looking and managing pain. So, we were in 2018, we've made a few little tweaks to our protocol along the way and then we obviously all face the pandemic and we now all have a massive problem. We have an absolute iceberg of waiting list. Patient's the ones we know the ones we can estimate and the unknown fraction is still yet to present in the community. We have deconditioning a dispirited group of staff, often loss of resources, fragmentation of teams, perhaps not all beds fully open yet problems with establishing and maintaining the ring fence and information that's been recorded historically, may not necessarily be reflective anymore leading to duplication of outpatient appointments, pre assessments and various input that otherwise would have all been streamlined. So is there are the opportunity for us to do more? These slides of pre COVID data has data from the country 2019 20. And the purpose of me showing this is that region by region. We're not that different. This was the average length of state for primary hips in the region. And it was basically bumbling around the 33.5 day mark for the hot for the country. As does it say, district distributed by region. And not surprisingly, as complexity goes up, length of stay goes up again. Nobody's going to be too, too surprised by me saying that. But what's interesting is where are the patient's? So if you look at where these patient's are distributed, 95% of our patient's do fall in the low complexity score. Yes, there are high complexity patient's, but 95% are low complexity. And the next thing that usually gets said is, but they're all in the private sector. Now, some of them are, but they're not all the blue bars on here. Our NHS patient's there is significant opportunity in the lower complexity patient's in the NHS for us to be doing more and for us to be really trying to get that length of stay down. So once you know how to do it better, you do it for everybody. As I said, you don't select I/O, you don't prejudge the person who's 85 who looks like they're not going to get up and move very well. You put everybody on the same pathway and give them every opportunity to successfully discharge. But if they're not ready to go, then they stay. So your safety at it. This is what we do now. So these are slides across the next few slides sections of our current protocol, which is the same protocol that is used now across the Southwest and is the same protocol that is used at swell expectation setting. As I've already mentioned, critical point, the admission side of things is very much unchanged from what I said originally, the only difference is we now use Celecoxib instead of Ibuprofen. The rest of it, the fasting, the warming, the protein, the carbohydrate drinks, the ace inhibitors. All as I've said in terms of what happens in theater, all patient's get the shortest acting spinal that we can and we judge that by the intended length of operation, we also supplement with leah with a surgical leah protocol for hips and except one for knees adding in blocks, both the stuffiness blocks. When a doctor canal block and an aipac block for knees hips, obviously get surgical infiltration, standardized antibiotics, minimize sedation, make sure the patient is warmed, etcetera. We anesthetist on the operating table and ideally if we have to operating tables, perlis, great. If not, then we'll, then we'll bring it through quickly and obviously, and then put the next patient on it. We request the surgical assistant scrubs with the scrub nurse before the spinal is inserted in order to help minimize the time that that part takes and to to improve readiness in theater. Because if you've got a shorter acting spinal, you really need to make sure you have no wasted time. So to that end, the operating surgeon is also requested to be present in theater as soon as the spinal is inserted, the rest of the management is, as I've said before. Still the same thing in terms of goal directed care used routine cell salvage, tranexamic acid protocal eyes management of V T A. In terms of what happens in recovery IV fluids come down, patient's get given all drinks, they get to build up energy drink including diabetics. Unless they are the most brittle of diabetics. We check their he mcewen pack you. So our primary uh post anesthetic care unit that's primary recovery. And if they're him A Q is greater than 99 they get no further postop blood's unless they clinically are not behaving as you would expect. So we use a clinical threshold rather than an automatic threshold. If your HB is less than 99 on he make you, yes, you do get a check bloods and we aggressively manage any symptoms that the patient's have so that when they get to the ward, they are able to be mobilised within two hours. And that's our target in terms of where we were at 2018, pre all our changes and where we are now, we have made considerable strides in the quality of what we're doing to our patient's in terms of the outcomes and how this actually translates into length of stay. Our length of stay was five days. It's now as a mean between two and three with a median of two and 30% are going home on day one. Our data at Torbay at the moment is very skewed in terms of were having low numbers. Some weeks, we're only getting 2 to 4 patient's for a hip and to, to, for, for a knee actually going through the pathway. And that's because of theater listing, scheduling all sorts of issues and a very large amount of trauma that is derailing the elective work, some of our neighbors. So our DNA as it was the world Devon and exeter has now emerged with Barnstable hospitals. So they've got very similar names. As you can see, they're driving down there lengths of stay sway. Okay. As I've already mentioned, this is a hub center. So they take their threshold for taking patient's as anybody who does not need a high care level. So an H D U level and art lines, metaraminol postdoc. So anybody who does not need that can go to sway look. So that includes a S A three that includes obese patient's, it includes diabetics. It includes renal impairment. It is not a highly selected unit, but by rigorously following the protocols. And most importantly, having an extra resource of staffing, they achieve incredibly impressive rates, 53% day zero, discharge, 99% home on day one. And that increased resource is really what I think is going to hamper some hospitals being able to take this to the max at Torbay. I think we could be doing an awful lot more, but we are limited by the number of physio hours we have at sway up, they stay till eight. The ratio of staffing is higher. Our physio stay till for it makes a big difference. It works though, as you can see, these are pictures of happy patient's undergoing their operations in a very slick service. So drawing all this together. What do I think really matters when you're thinking about designing your protocols for enhanced recovery, for doing hips, knees, any form of major surgery. So let's think about hips. What really matters, avoid excessive duration of anesthesia. If your operation takes x amount of time, your general anesthetic tends to proceed and follow it for a fairly short period. The trouble with spinals is historically, we used to put in really long acting spinals and it lasted at least twice as long as the operation, sometimes three times as long. So avoiding that is really important. So we need to tailor down our spinal dose to match the length of the operative period. But equally, we don't want any excessive operating time because we're going to have to put more stuff in the spinal to cater for that. So the more dead time there is, the more time scrub teams aren't ready, the more time there is wasted time in positioning. Actually, that really makes a big difference because your anesthetist will be putting longer acting agents and more dose in the spinal to cater for that and your patient's will not be getting up and walking around as quickly as they should. I appreciate. I'm not talking to a group of anesthetists. But even with our shorter acting drugs, it takes a long time for the patient's to be able to be fully able to stand and mobilize. So we converted over for all our in patient's to quarter percent. Historically, everybody used to use half percent. The half percent has a mean length of time of 6.5 hours from insertion before you can start walking your patient. Even the quarter percent is five hours. We really need to, as I say, be using the shorter acting agents and drive this time down keeping your patient's street fit. Now, this is a physical and a psychological thing. So physically, the energy drink really helps, it reduces their first mobilization. Dizziness. It's a simple thing to do. It should really be for all patient's self salvage. Why do you not want to get your patient's as topped up as possible, returning any lost red stuff to them? Warming. We all know that having patient's warm is really important for their onward. Well being they're healing their immune function. We just need to make sure we're really good at doing it. Psychologically, this is really important know pajamas, no beds, ideally, trolleys know bowls of fruit, get patient's away from the idea that they're coming into hospital for a long length of stay. And those patient sort of identifiable factors really do feed into that psychologically get your patient's dressed in their home clothes, get them up, get them walking, get meeting and drinking at normal times and mobilizing to the toilet, not using commodes and bedpans by decent pain relief. Now, often get some questions from the Iniesta's about our use of opioids. We do send patient's home with opioids for a time, limited 48 hour period. Pain control is really important if you don't get it right, you're not getting your patient's home. And it really does need to be a multimodal strategy, including your local infiltration techniques done by surgeons blocks, potentially done by anesthetists and various other strategies that you can use in terms of patient expectation management, distraction, ice various oral analgesics. The problem with opioids is unwarranted, unregulated continuation and that is where the addiction in the community problem comes from a short duration with a finite supply that is rigorously stewarded so that the patient's and the GPS and the discharging staff know this is a time limited non continuation prescription is safe. I would also caution against the use of Oramorph as a discharge medication. Many hospitals do we have a policy at torbay that we do not. There have been 13 NPS a related deaths due to Oramorph including in 11 in our hospital of a patient under 40 who had day case orthopedic surgery. Sadly, many patient's particularly post operatively don't seem to attribute value to a liquid medication needing to be dosed accurately and we'll just swig out of the bottle and regulated and that lead to respiratory depression. And as I say, deaths of over 13 patient's in the UK. So I would be very cautious about sending patient's home with Oramorph. We only send patient's home with tablet preparations, expectation management. As I've mentioned, it really matters both for length of stay, what process they're going to undertake and what pain it should be expecting and really getting the message out there that the patient's are not expecting no pain, they should be expecting moderate pain, use a functional pain assessment and we use the mantra of moving, makes it better. And all the patient literature help support that. But if the patient's move, it would use stiffness, they will ultimately get less pain and they would also get less side effects. But if they stay still for too long, stiffness and swelling will increase their pain, they're going to need more energy. Six and inevitably you're then side effect, burden constipation, nausea, dizziness, itching starts to become a problem. And finally, staffing, as I've mentioned, this really does link with your length of stay. How many hours of physio do you have available? How does your trauma work impact on your elective work both in terms of scheduling in theater, but the nursing input on the ward, more staffing means your theater turnaround times will be better your ability to take patients' into pack you without waiting your ability to transfer patient's to the ward and manage them on the ward effectively all improves and basically the better your staffing a resource. It's not rocket science, the better your outcomes, patient messaging. We have updated all our patient literature. We have dedicated booklets that really do try to pare down the information and give the patient exactly what they need in terms of patient expectation management. And we also send them home with patient medication charts which explains what medicines they should be taking when and allows them to accurately manage their analgesics. As I said at the beginning, there's barriers to any change and these barriers, maybe people barriers, practical barriers and process barriers, data will help as well as getting a group of people who are enthusiasts, start making some changes, audit what you're doing, refine it if you'd like any more information. There's a day case hip and knee replacement guide published by Bads, which is available from their website. There's an article in the World College of the STIs bulletin which talks very specifically about sway, okay and how they've managed to achieve what they've done. And there's also, as I mentioned at the beginning, the guidelines do to be coming out very soon, which I would encourage you to all have a good read through. Thank you very much for your attention. Thank you. You. Uh That was fantastic. Are there any questions to ask? Uh there's nothing that I can see uh in the group about the, in the group chat other than who have written the guidelines for the sip to send. Yeah. So that was originally published in the European Journal of Anesthesia. You're looking for mccracken and Montgomery. Thank you. Lots of thanks there. Um, I did have a question if no one else has got one. I wondered how often or how easy it is to find a bed that's ring fenced when the pathway ends up with an admission. Unfortunately, as I say, 94% go home, so it doesn't happen very often. Um, in reality, it does, it does work out primarily, I guess because our ward elective wards actually too big. I really wish it was smaller because the elective ward is too big. We tend to have clean trauma on there and as in MRSA screened, etcetera, etcetera. So that does tend to give them flexibility where they could move one of the trauma patient's back to the trauma ward or a another ward in order to re liberate a ring fenced. So that although it's a bit of a penance for us not having that dedicated elective because it means the nurses get sucked. Usually to the trauma patient's more, it does actually provide us with flexibility that we would otherwise not have if we had a tight say 8 to 10 bedded ward, our ward is 20 beds which as I say, it's, it's far too big. I wish they could chop a bit off. Uh There's a couple more questions just coming into the group chat. Um One is, are the patient's calling the ward or the S H O or a specialist nurse. Once they've been discharged, the answer to that, we used to have something called orthopedic outreach, which was a group of trained and healthcare assistant nurses that were primarily community focused but also worked on the ward. Patient's were given that number. The reason it's changed slightly is like everything COVID has disrupted it. They were completely pulled into the hospital. So the service was disbanded, 50% of that workforce has now either left or gone to retirement. So the service still runs and that is their primary call. But if that doesn't, if there isn't enough bodies to be able to run the service that day actually connects through to the ward nurse in charge of the orthopedic ward who would then direct it either to the secretary in order to get hold of the orthopedic surgeon or a junior, or it might be a nurse question or a physio question. So basically it's the ward. Okay. Um The next question is because I think you spoke about the first patient on the list are any done later in the day and if they, are they going home the same day or are they like an overnight stay and 23 hours day rather? So for us, it does seem to be first patient winner in terms of going home. That's due to the physios finishing at four at sway. Our patient's three almost university go home and patient's for about half of them go home. And that's because the video stays eight okay. And the patient for going home. Actually, it's quite impressive, I think because that also includes trainees doing surgery as well. These aren't just, this is not a non training center. I think that follows on to the next question which is other trainees still doing the arthroplasty cases, um, especially due to the shortest finals. But yes, it seems to be answered. Yeah, as I say, getting, getting you guys in theater out of the coffee room. Certainly we have a problem into all day with that. Um, is really, really helpful for us. Okay. Great. And I suppose the same is true of the other side of that, that the anesthetic trainees are also still being able to be trained with the pathway. Yeah, it's slightly easier for us, I think cause we can double up a little bit more as in, I can send the trainee into the anesthetic room while I'm finishing off the next one, they can at least check the patient input the drip, input the tiger plane in through. So I think it's possibly slightly easier for us than it is for you. Um And next question was how did you manage to convince the other anesthetist to change and get on board? With the protocol. I audited what they did. So I audited what they did and if they didn't do what I wanted them to do, I went and asked them why not? Okay. And then I made them all for the very ludicrously complicated foreman to explain why they've not done what they, you know, why they're not done the protocol overall. People change either if you make it really easy for them to do. and without being too tongue in cheek, actually, that makes a real difference. So I pre printed all the discharge medications. So it's a single signature. I've preprinted all the drug chart inserts. They just have to sign it. It's a lot less painful to just sign my form than it is to have to write everything out yourself. Yeah, perfect. Um Any other questions with Doctor Blandford from anybody, the local infiltration technique? So how do you judge if a surgeon's, um, another surgeon is better than the other? And how do you tend to tell them that they're not as good? That's excellent question. I can tell you which surgeons are really, I'm not gonna name names, but I know which ones are good and I know which ones aren't. Um, I suspect those surgeons may have less insight into the process, but that's one of the reasons why for needs which tend to struggle. I think more hip pain wise than hips, but we do blocks as well because you will get a variation of practice in any STIs and surgeons. And there are some surgeons who are great at Leah, some who aren't, there are some Iniesta's who are greater blocks and some who aren't. If you get both, you've got a better chance of at least one working and if you get both working winner um outcomes, I think, I think if there needs to be an appetite for information to be received and I think if patient's aren't doing as well, and surgeons and anesthetists are willing to hear that message. And that patient, you know, Mr Zohan says patient's are doing much better. And actually, I think we all have a duty to hold ourselves to account as to why do our patient's not look as good as our colleagues? Um That's something that is a very difficult, I think cross specialty conversation and it's better managed in specialty. So generally I will sort out the anesthetists and my counterpart in surgery. I will task with sorting out his colleagues is limited success because some people will not change and we have pockets of resistance. We aren't universally there yet. I wish we were. Is there anything in particular in the technique that you've noticed from the anesthetic perspective that that changes the way you deliver local? Do you mean in terms of the way the surgeon delivers the local infiltration? So I think, I think that might be, yeah, I think um some people don't follow the protocol and volume I would say is really important. So I'm I'm very happy to send you what we use. Um If you'd like, but uh you need a large volume of dilute stuff and it's not just the local, it's the dilution. And if you dilute, I'm down the inflammatory mediators in the space that really reduces your pain. So the surgeons that adhere to our protocol be giving 80 80 to 100 mils of which is by no means high. Some centers use 200 plus, but some surgeons only put 20 in because they don't like a boggy, particularly knee afterwards, those patients' don't do as well. So volume is important where you put, it is important. We found that by adding in the aipac block that helps target the posterior um compartments that really helps with pain because some surgeons were perhaps less judicious with infiltrating that part with knees, with hips. I think generally the technique I don't see so much variation in terms of the surgical technique on leah that then affects how the patient does. It seems to be knees and the other big one with knees is whether the surgeon tourniquets throughout or not. And actually tourniquet free surgery dramatically reduces pain afterwards. And so minimizing your tourniquet time and pressure and ideally, no tourniquet is a great thing from patient's anesthetists. We have to give more anesthetic, we have to give more sedation, the patient's more sore, it does actually have quite a bit of an impact, but I think it's careful technique and I think if you've got surgeons in your hospital that are doing it really well, then actually they're the ones that are going to be best place to teach their colleagues. It's not going to be somebody like me coming alongside just irritate you. Thank you. Lovely. Thank you so much, Doctor Blanford. That was a fantastic. Thank you. You're very, very welcome all the best for the rest of your day. Thank you. Hope you have a lovely day. Thank you. Bye bye bye. Uh Lovely. Hopefully we've got Mr Wimhurst in the house. Yeah, lovely mister Amherst is going to start talking to us about how you select your implants. The N J R and Odette, which obviously quite a common question to get in the F R C S. Mr Wimhurst is also uh an X F R C S examiner. So is coming at it from the type of information he would hopefully expect you to be able to deliver in your exam. Thank you, Mr impressed you happy with starting showing. I'm going to try and share my screen. So, uh huh. Uh let's see. Are you seeing that? No, no, sorry. It's not been a good morning with this medal um platform for me. Uh I'm on dodgy wifi because it's been blocked by the NHS wifi at the N N N um uh window. I'm not getting any, any option too. Share at all. I'm afraid. Uh Iggy. Uh So, oh Mr think uh my I T advisor here as well, but we clicked on that one already. That's what we were present. Now, if you do present now, does it give you the share slides? Share your screen option? Uh Hold on just a I can't let's just cancel this. Um So present now I've got share slides or share screen. Should I try share slides? Yeah, if you've uploaded the PDF, no, I haven't uploaded the PTS screen. Share screen. Uh Hold on. Mhm. Just like that. Okay. Um Have you got your uh okay. Yeah, I can't access that share screen and then you should have chrome window or entire screen option. I've got entire screen window or Microsoft edge tab. So go to wind window and Oh yeah, and it's not showing my power point which is your entire screen and then see if it shows up. Uh Thank you. Okay, let's try this. Can you see that now? We can see? Yes, excellent. Right. So um slightly drier presentation I'm afraid than the uh very entertaining. Um dake a surgery. Um I'm going to start talking about, oh dep first. So you do need to know about, oh, dep both for the benefit of your own practice, but also the exam. So, oh, dep is the orthopedic data evaluation panel. Um It was set up about 10 to 15 years ago, actually originally set up and still run by one of my former colleagues, Keith Tucker. Um it's a UK body. Um It has a panel comprised of surgeons who assess the data submitted by manufacturers to them. And then they assign a, a rating to each implant that is submitted by the, the companies that the companies then used to market their uh their wares. But also we can use to assess their, the value of that implant. So it goes number letter star. So the number just means the number of years that product performance have been available for analysis and it's uh they're 357, 10, 13, 15. As you'll see later, the NJ, our data now goes out to 18 years. But oh dep is at 15 years maximum at the moment, um the strength of evidence and that's basically down to number of centers that have produced the evidence. So if it's three or more, you'll get an A, if it's only one or two, you get A B because it's non developing centers is what you want to see um producing the same results with the same implants. Um And then you get a star for the number of revisions at each particular time point as long as it's below a certain percentage. So 80 at 15 years, you have to have less than 8% of those implants revised with more than 500 available for analysis from more than three centers to get a 15 a star. Um, there is a slight fudge that you need to be careful of. Um, this thing called beyond compliance. If you're introducing a new implant and you sign up with, oh, dep to beyond compliance, which means that that implant is analyzed a lot more regularly in terms of follow up an X rays, then you get awarded a star. Now, I'm not sure, I agree with that because that just means if you're being a good center and doing things properly, you get a star that suggests that your implant is good. Um I think it should just wait till you've got the longer term results. But there we are. So this is from the Odefsey um website. Uh and it shows you how you get your A stroke be straight star rating and you'll see uh down at the bottom. If you've only got one center doing the uh submitting the data, you're only going to get A B if you've got three or more, you're going to get an A as long as there are sufficient numbers. And then the star is given if your revision rate is uh less than 8% 15 years, less than 5% at 10 years is probably the key thing to remember. So, a 10 A star implant is more than 500 available for analysis, more than two or three or more centers and less than 5% revised at 10 years. If you just Google, oh dep and get onto the Odette website. It's a really nice thing to, to have a look at. Um, you can just bring up whatever company implant you want to look at, select their hips and it will bring up all of the implants that they've submitted to Odette and tell you what that the rating of each implant is. So you can look up your stems, your cups, it's the same for knees. So it's a really good resource. Um And that's basically all there is to say about Odette. Um You know, in terms of examination, you just need to know about it and know that if you mention a, I'd use a 10 A star or above implant that the examiner said will say to you. Well, what do you mean by that? And if you can then leave them off onto a discussion about Odette, that's brilliant if you know about it because your score ing lots of points in an area which you know, is very easy to know about. So the N J are, um, the N Jr's been going since uh 2003. It was started in response to something called the Three M Capital Hip disaster. Now, registry's have been going since the 19 eighties in Scandinavia. The Swedish hip registry was the first one. Uh And we've been trying in this country to start a, a registry for the hips and knees for some time, but it was only when a specific hip started causing massive problems in the 19 nineties that the government really got on board and funding was produced for this. So the three M capital hip was a Charnley supposedly. So it looked and smelled like a Charley. But actually the revision rate was massive and it was that stimulus that showed that actually just because one implant looks like another doesn't mean it's going to perform as well. Um When we first started the NJ, our compliance um was a problem. So lots of centers didn't want to submit their data. Um Nothing ruins, follow up, nothing ruins, good data, like careful follow up. So a lot of centers weren't willing to put their, their data into the N J R. It is now mandatory for uh to, to get your tariff. So um everybody is meant to do it but still only 95% get submitted for one reason or another. Um Up until the pandemic, we were hitting nearly 100,000 hips a year being submitted to the NJ. Our numbers dropped off massively during 2021 22. Uh They're now getting back to the sort of 90,000 ish again. But all this means that there are over a million hips available for analysis on the NJ are. So there's a lot of data out there if you read the NJ, our report, which again, those of you coming up to uh the exam, I would uh suggest that you do download the PDF, which is freely available online and just have a read through particularly the hip and knee sections. Um So that you've got an idea of what's going on. There are lots of interesting things other than what's useful for the exam in there. Like what happens with fixation over over the decades? So if you look at this slide um in 2003, the vast majority of hip replacements were uh so I'm just gonna, I don't know whether you're seeing this thing that says uh stop sharing your screen. I'm just gonna hide that because uh then you can see that the bottom of the slide. So the vast majority of uh stems uh and cups were cemented in 2003, then unscented became much, much more popular during the early two thousands overtook cemented. Um And then as just plateau, perhaps declined a little whilst cement has continued to be less and less popular and hybrid hips have become very much more popular over the decades and now are actually the most common type of hip put in in the UK. So bearing trends um again at the beginning and still metal on polyethylene is the most common, but you'll see that ceramic on polyethylene is gradually becoming more and more popular bearing trends. Um In sorry that last slide was in cemented hips bearing trends in hybrid and uh cement lis hips show similar kind of thing. But in hybrids, in particular, uh the majority have gone from being metal on plastic to being ceramic on plastic and a little bit of a mishmash with the un cemented hips. You can see it appears that people who do unscented hips are a little bit more prone to blowing with whatever the trend is at the time. But again, ceramic on Polly has taken over from ceramic on ceramic, metal or metal, had a little bit of a time and then declined uh as well. Head size trends. So over the decades, we've gone from 22 millimeters uh in cemented hips, in particular being the most popular uh 2 28 and now 32 is the most popular uh sized head in uh basically all three groups, cemented, unscented and hybrid uh revision rates. So what the N J R does is it provides a lot of information and trying to break down that information can be a bit of a challenge. So you'll get these sort of uh ballpark figures that the revision rate at 18 years for all cemented hips is 6.2%. Now, remember that's all age groups, all designs of cemented hips. So there'll be some good ones in there, some bad ones in there. But that's the average. Um You can see though that the trend is that cemented hips in general perform slightly better than unscented hybrids, perform slightly better than both reverse hybrids aren't bad uh resurfacing are over double the revision rate, 18 years to a stemmed. In part, it then breaks down those general all uncemented hips, all cemented hips or hybrids into age groups. And if there are more than 500 available at 18 years, you'll get a figure on, on what's happening. So, um and it will also break, break it down into two male and female. So in the over 70 fives, you can see that metal on Polly cemented, you've got about a 5% revision rate in men, about a 3.5% revision rate in women. Um Cement lis, other than uh metal on Polly and hybrid metal on Polly, there aren't the figures available at 18 years for many particular. But again, you can see that the revision rate for hybrids is about the same as um for cemented. The revision rate for cement. This is a bit higher. We then go into the 64 65 to 74 year old age group and it gets more and more complicated, but I've sort of highlighted in bold, the ones that are performing best in that age group. Cemented metal employees, ethylene tends to not be quite so good uh cemented. So, ceramic on polyethylene is pretty good. Hybrids don't do too badly, particularly um in the female patient's uh cement lis, there's an interesting blip there isn't there in that the cement lis ceramic on Polly's seem to be better in the, in the males, in particular, in that group, then we go to the 55 to 64 year olds. And again, you can see the trend of the cemented metal on polyethylene is not performing so well, but ceramic on Polly doing quite well. Both in the cemented group, the hybrid group and the cement lis group better than ceramic on ceramics, better than the metal on Pollies. And then you go into the youngest age group. Uh And again, in the under 55 you start to see this trend where actually the ceramic on Polly's in the hybrid group are doing particularly well in females. And interestingly in the males, the ceramic on policy, cement lis group are doing best. But again, remember this is all comers. So you may have some very well performing hips which are used by a lot of people that are skewing the data or some performing very badly that this is skewing the data. So when you look at impart combinations in all ages, uh all bearings, um the best long term hip replacement on the NJ are at the moment is an exodus stem. So a striker stem with an elite plus cup. So a dip you Johnson and Johnson cup that's called a crossbreed, which means that the implants come from different companies. And whilst that's the best performing hip, there are very few units who will be doing that on the basis that companies will not indemnify crossbreeding. So using the cup of one company with the stem of another, the reason for that is they say there is no guarantee that the tolerance is between the head and the inner lining of your either or cemented or um the line of your cement lis cup will match precisely enough. So if something goes wrong, you have used that those implants off menu and the companies will say we told you you shouldn't do that. So in terms of litigation, a patient with one of those in that goes wrong early, even if you told them, it's the best performing hip on the N Jr has a very strong case to uh to take you and your trust to the cleaners. So virtually nobody will do that. You can see that the uh C stem and Elite Plus performs very well. So that's a all Johnson and Johnson implant as does the Charley with the Elite Plus. Uh the extra trident, extra contemporary flange aged uh CPT trilogy are all pretty similar. So just to tell you what we do in knowledge, we have as our cemented option. The extra with the Contemporary Flanked Hip which metal on polyethylene at 15 years, sorry, 18 years is 5% and ceramic on Polly at 15 years is 4.2%. Uh the extra trident. Um The metal on Polly um is only available at 15 years with the number for analysis being over 500 that's 3.5%. The ceramic on ceramic is available at 18 years at 4.1%. Ceramic on Polly is outperforming both at 15 years, but the 18 year data not sufficient available to, to analyze. And again, uh currently, we don't have the accolade on the shelf, but we did use it for many years. And you can see that the metal on Polly uh considerably worse than the ceramic on ceramic and the ceramic on polly. So in the exam, if you get a hit case, uh it normally starts off with a discussion of the, you know, sort of the pathology that you're looking at on, on the X ray. Um It will move on to the, the technique of doing the procedure. It will normally be something a little bit more difficult, you know, Patricio or big big osteophytes or something that's just going to test your knowledge a little bit. You may be asked to consent one of the examiners for uh hip replacement. So you'll, you'll be faced by two examiners and one will say to you, this is, you know, MS is so and so who's going to have a hip replacement? Can you just tell her how you're going to go through the consent process? And it is extraordinary how many candidates are absolutely terrible at that. So, um you should all be able to nail a consent for any operation that you've done. Um And part of that you'll then get asked by the patient or the examiner. Um What kind of hip replacement are you going to use? Doctor? And I would suggest that if you're, if the patient you're being told to consent is over 75 you just say I'm going to use a cemented metal on polyethylene hip. What kind of hip are you going to use? Well, I'm used to using an extra with a contemporary uh flash cup or a CPT with whatever the Zimmer semantic cup is or a cease them with an elite. And you can say that most of them have got less than 5% revision rate at 18 years. Bang. That's done in the younger age group in the 64 to 70 fives. You can pretty much argue whatever you want. But if you're going to use all cemented, you probably want to say that you're going to go ceramic on polly rather than metal on polly in the younger to age groups. So 55 to 64 under under 55 the 55 to 64 you can basically use a bit like the slightly older race group, any of them. But you would go for a ceramic on polly because the evidence is that they perform better than anything else in the under 50 five's. Um, the evidence seems to suggest that you're better off using a hybrid. Certainly in women, perhaps a cement list. Em, in men. Um, the longest term outcome data is in the ceramic on ceramics because that bearing was available before crosslink polly came in. And it's only really since crosslink poly has been available that people have started to use ceramic on polly in the younger age groups. But that's the kind of thing to have in your head, this slide of what you're going to use on, on the age groups um issues as I've mentioned, um some of the best hips are cross breeds. Um, you know, not just in the cemented group. Uh, there are certainly some centers in this region that, that used the next to stem with a Trilogy cup for many years, which performs extremely well. Um But again, it's not indemnified poly figures as I've alluded to are slightly skewed and it's irritating that the NJ are, does not yet distinguish between cross linked and standard poly. So I think probably the cement lis and the hybrid data looks worse on the NJ are, uh, than it, than it really is. Even though some of it is excellent because up until about 2008, 2010, Standard Polly was still being used in a lot of hybrids and cement lis cups. And we know that, that, that wears out considerably quicker than, than the cross links stuff, um Moving on. So that's the stuff you need to know for the exam in terms of what you need to know for your life as a jobbing surgeon. If you do any form of joint replacement surgery, the rest of your career is going to be spent waiting for your consultant level report each, each year in slight trepidation. So basically your outcomes, your revision rate get analyzed and sent to you every year. You must sign on the NJ. Our website that you've looked at it, downloaded it and it will be discussed in your appraisal every year. It is strongly recommended that there should be an annual NJ are meeting where everybody in the units results are discussed and implant plant choices are reviewed. Uh We've been doing this in knowledge for a very, very long time and it's actually a really good thing to do. Um It helps support people maybe who's results aren't quite as good. It helps you to look at people whose results are excellent and say what are they doing that the rest of us aren't and uh it as yet that it just comes to you and it's not in the public domain, all that. If you Google a surgeon and uh N J are, you will be able to see how many procedures that surgeon does, hips and knees and what they're oh, dep adherence is, do they use all Odette rated implants? Um That's all it is at the moment. There has been huge pressure from certain quarters, particularly um as the cardiac surgeons um results since the Bristol inquiry have been in the public domain. For all NJ our data to be in the public domain. Now, the problem with that is that there are nuances to the data that the public will not be able to interpret. And if um for example, you are somebody who does a lot of fractured Neco fema's uh a lot of hip replacements for fracture neck, a fema, then your complication rate is going to be slightly higher than somebody who works in a purely elective unit. So there is some unfairness in there if it becomes in the public domain, equally revision rate for infection, for example, gets allocated to the surgeon rather than the unit. And infections tend to be a unit problem rather than a surgeon problem. So obviously, you know, at the moment, the profession is resisting it going into the public domain. But in your lifetimes, it wouldn't be a surprise if all your data becomes publicly available. When you do start getting this um information sent to you each year, you have to remember that the on the final plots which are called the funnel plot where your little dot appears as to where you are our confidence intervals. Statistically, as long as you're within the the standard deviations, you are no different to any other surgeon and there is a very distinct effect of volume on where you appear on the plot. So and your dot moves around by an alarming amount with one or two deaths or revisions attributed to you in each year. So don't get too worked up if your dot Moves, it can be quite disturbing and that's one of the reasons for having a unit meeting every year because we can reassure each other that actually this is normal and you can see everybody stops moving, you get your recording activity every year. Um And what you're doing in terms of cemented cement lis hybrid, etcetera. Um You can see, uh this data just shows that there's a massive drop off during the pandemic. You get to see what your bearing surface usages. Um you get your patient profile and again, this is going to skew your data. You can see that the majority of people in the N J are are going to be operating on A S A ones and twos. Unfortunately, the way we function in knowledge is um uh we will work on rather more of the essay threes and, and a few fours, you get your oh dep ratings from the NJ are now, this is a little bit interesting in that they don't always get things right. And we're not entirely sure why. Um This is my data from last year, this particular slide and you can see on my femoral construct. I only used extra stems last year. I didn't put in any accolades. Um And yet I've got 10 12% have been reported as being 13 A star stent. Um So obviously, there's a little bit something strange going on there. Um, my uh orange and red cups will be where I've used a, a revision cup in a primary uh for somebody with acetabular damage, etcetera. So you get your standardized revision rates and you get your dots moving over the years and you can, you're the, the green line is what's normal. If you're above the blue line, you start to get a little bit concerned if you're above the red line, that means you're, you're, you're an outlier and you can see your dot moves around over the years with very, very minimal changes. Um your mortality rate and this is the best uh one to show you how your mortality rate can change. So these are my mortalities in hips and knees for last year and you can see that that the black dot is last year. Um I was a getting towards being a low outlier for mortality on my hips. I had one patient with myeloma die and I suddenly become very average. Likewise, I had one patient, one knee replacement patient die at 89 days after his knee replacement. And my dot went from being uh below the line to above the line. So that's when it's reassuring to have your meeting with your colleagues and see that that's happening to everybody's dots. They jump about a bit each year. And what you've got to remember with your consultant level reports is that, you know, a Gandhi quote, you're looking at the quality of your work, not just the quantity. Okay. I think that is the end. I'm going to have to try and work out how I stop share ing here. Uh Okay, lovely. Thank you very much. Uh Any questions for Mr Wimhurst? Any exam based questions? Mhm. Stunned into silence by a whole load of data. Just those of you coming up to the exam, just get the N J R report downloaded and have a little look there loads of tables and you can just pick out what you want to use and you'll be able to say I would use an exeter uh with a contemporary flanked uh cup with a ceramic bearing and the revision rate of that in this age group at 15 years is 3.6%. Mhm Talking about mortality Abdullah, did you have a question or is that a song title Abdullah? Oh uh Dinesh is asking how do you know the answer on consent? Right? What you you do by consenting people? Okay. So um if you are going to consent somebody for a hip replacement in clinic, how do you do? Remember the exam is about assessing whether you are safe to progress to being a first year consultant? That's that, that is the the be all and end all of the of the exam. Are you safe to be a day one consultant as any type of surgeon? So you've got to be a day one hand surgeon, hip surgeon, spinal surge and everything. So if you were going to say to the, you know, the examiner, um I'm going to go through hip replacement with you. You would say um hip replacements are very good operation with extremely good outcomes. About 95% of patient's, you have a hip replacement are delighted with the the operation itself. It sorts out there, pain there, mobility. Um and the vast vast majority depending on age um will last 15 years or more. Um You talk them through how you're going to do the operation. You normally get a question about what type of anesthetic they're going to have, um which you defer to the anesthetist, but you say 90% will be done with a a spinal anesthetic with a little bit of sedation. Um Whilst it is a fantastic operation with great outcomes, there are risks associated with having a hip replacement. Now, everybody will get some bruising and some swelling of the leg which will go all the way down your leg to the ankle that can be helped with elevation. But the significant risk that we worry about are predominantly infection and thrombosis. We will operate on you in an ultra clean their theater. Um will where surgical gowns plus minus spacesuits will give you antibiotics during surgery to try and reduce that risk. But there is still about a 0.5 to 1% risk of you getting an infection, which can mean treatment with antibiotics, surgery, prolonged treatment. And in the worst case scenario that hip having to come out, potentially be redone or even come out and stay out. Blood clots are the second biggest thing that we worry about and patient's worry about. We give everybody some blood thinners for a month after surgery. But the most important thing you can do after surgery is to mobilize and get walking and pump the blood out of your leg to reduce the risk of surgery. And the earlier you get going to lower your risk, then there are specific risks around the hip such as the hip coming out of joint, which is called a dislocation. Now, our physiotherapist will go through with you what to do, what not to do. What you have to be careful with the highest risk is while the muscles are healing in the first 6 to 12 weeks. Then other risks around the hip are your legs not feeling exactly the same length. Now, that's very common, but most people accommodate any difference between their, their leg length as you're probably doing pre operatively. But sometimes people have to have an insult to wear in their shoe. And in very rare cases are build up on their shoe, on the outside nerve damage is very rare. Running at about a risk of about one in 2000. And the main risks are to the sciatic nerve at the back of the hip, which can give you weakness or numbness in your foot. The femoral nerve at the front of the hit, which can give you weakness or numbness in your thigh. The vast majority of those problems do resolve it can take several months, but occasionally the weakness or numbness can be permanent. And then the last thing we're going to talk about is risk to life. The standards quoted figures of risk to life of surgery of this magnitude are one in 300 to 1 in 500 which is actually significantly higher than most people realize. And that's why we are not putting every patient through for a hip replacement and why we need to tell you about the risks that entails. So you can make a balanced judgment on whether this is the right operation for you. Okay. So that, that's the kind of thing that I would expect you to say uh to, to an examiner to get, you know, sort of a 678 depending on, on how well you do it. Perfect. Good. I think that's kept in s happy. Perfect. Lovely. Uh, Thanos, are you? They're moving on from having chosen how your patient, what pathway they're going to be on, chosen your implants are going to have to make decisions about vte prophylaxis and Thanos if Thanos is there is going to talk to us about VTE prophylaxis in hip replacements. Yeah. Lovely. Thank you, Dana's. Uh I just need to find out How? Yeah. So, uh have you done, have you shared your window or? Uh so searchlights, isn't it? Or search? Uh You can do either. Have you got our point open or? Yes. Yes, I share your window then a minute. Yeah. Sure. Window. Yeah. Lovely. And then still shoot it. Uh Yeah. Hasn't started the slideshow though. Iggy. I have I given Thanos the wrong advice. No, just uh yeah. Go into full slideshow. Are you able to screen? You'll see that or have you spoke out of the slideshow? Yeah. Have you use like so yeah. No, I go to slideshow on the top of you. Yeah, I have clicked that. Yeah. Yeah. Mhm. Uh They were just cancel slideshow again. Yeah. Yeah. And then do that again. Yeah. So it's not. So um you can, you can convert it to a PDF or you can, you can use it as it is, we can see it. So if you just minimize that bar in the middle, we can see those lights like this I think uh put it down. Sorry about that. This will work, you know. So uh so just take, so go to go to present now again, go to share your screen and then go choose window instead of um entire screen, come back to the browse Yeah. So share your screen, share screen when we go. So we do. Yeah, and then choose the purple. Yeah. And then see if it's, if it's slightly different. Yeah, no, everyone's power points. But um one thing you could do is export it as a PDF. I mean, uh otherwise we can see it. So you just, just, just uh all through. Uh my present issue is not so impressive as the last one, I will go through the VTE prophylaxis um uh advising that it's our, I have gone through all the updated guidelines. It seems that uh everything is clear but everything is uh slightly controversial as well. Uh So the nice guidelines from August 2019 updated uh recommended for the vte prophylaxis to all the patients undergoing elective tickets are who's risk of vte outweighs the risks of the bleeding. And the advice are to use uh low molecular white separate for uh 10 days for followed by aspirin uh 75 250 mg's A for a further four weeks or low molecular weight heparin for four weeks. Uh Combined with Andy able is talking's or river oxygen uh is recommended as an option for the prevention of viti models that undergo elective states are or elective. Uh TKR also Apixaban is recommended as an option for the prevention of viti know adults after elective hip or knee replacement. And also they govern as well. Is recommended as an option for the primary prevention of viti in adults who have undergone elective thr uh Also from the review of the advice river oxygen in oxy paren vigadrone had very similar costs and also outcomes in the prevention of VT. The primary clinical outcome uh indicated that river oxygen is superior to enoxaparin and they've got the governor as well. The related risk for bleeding uh is actually in favor of enoxaparin and the big gallon as well. All administration of River oxygen without the need for hematological check reduces the administrator costs. So the river oxygen uh is actually the preferred one if we associate the administration costs in the thr uh So one of the, one of the trials that they were used in order to recommend what is the best uh for the V T prophylaxing dates are was the records dust daddy which actually was for randomized trials um that they compared the feces in the safety of oral river oxygen with subcutaneous and AQSA parent for the prevention of viti after it. It's a TKR and uh the participants were more than uh 12,005, 500. Uh patience Donald. You have slights advance, sorry. Uh because we're still stuck on the first one. Oh, sorry, I'm going through. So for that uh you see it now? No, just I'll go to the next one. Surely just click the manually on the Yeah. Mhm I don't know if you can see the slide from the record. Uh No trial. Why? Okay, we can see duration of therapy. Uh So here you can see the record uh which actually compared the X Xarelto with enoxaparin uh we have uh around 12,500 patients that participate in the study. And this was one of the studies that the committee that came out with the advice for the vte prophylaxis. Uh They thought that uh the record 12 and three can be implemented in that four was excluded. Um Also the advance to trial uh showed that uh non major bleed bleeding, a cured in uh 4% of the patients received Apixaban and 5% of the patients treated with enoxaparin. Uh The two groups of the study was almost the same 101,005, 28 with a picks abundant 15, 29 with enoxaparin. And the result of the advantage to was that uh Apixaban 2.5 mg's A, uh D D offers a convenient and more effective orally administered alternative to four times a per day with an ox a parent. So now if we look at the starting time when we can start the VT from prophylaxis, uh with all the medications that we have available, we can see that uh Apixaban had the longest uh time we window for administration after an operation and there's a, we know it's slightly increase the risk of bleeding. Uh So mainly 12 to 24 hours after surgery. And in practice, most of the people will start it uh 24 hours after the operation, uh river oxygen, uh 6 to 10 hours after the operation. Uh they began the government 1 to 4 hours after operation and Aqsa pairing 6 to 12 hours after the operation. And this is something that uh actually affected the way that the guidelines were introduced. Also, uh the majority of the patient's that undergo with thr do not have any major comp abilities, but uh uh good amount of them uh might have impaired function of the kidneys. So the renal function was something that the committee took into consideration. And they saw that Apixaban Rivaroxaban, so the potential benefit in the clinical practice and there was no need to modified. Uh those in people with mild to moderate kindle faction impairment show Apixaban Rivaroxaban head superior outcomes. And here also, we can see uh all the studies and the outcomes from A CCP and sign from uh 2008, 2012 and uh 2015 that uh most of the studies from the States, they recommend uh the use of uh low molecular weight heparin, Rivaroxaban, Apixaban aspirin. There is no significant differences um from the nice guidelines compared with the guidelines that they currently use in the States or in the rest of the U. Um and outcomes are more or less the same uh in the medication uh and also in the duration of the treatment. Um A CCP showed that uh the duration of the medication can go up to 35 days. Uh That's my, my presentation. Thank you. Very much. Thanks a nose and that any questions for the nose, really important that you've got an answer in your exam for what your prophylaxis is going to be. And any medication that you're going to use that you mention in the exam, you need to know what it's Axion is and how it works, what the complications of it are. Okay. So make sure you know where they work on the clotting cascade. Uh David is very kindly going to speak to us about preemptive anemia and self salvage. We've already heard today about the day surgery pathway down south using self salvage for every primary. Um She's not something that obviously we routinely do in our region. Uh Over to you, David. Thank you. Thank you very much. I'm just gonna try joining share ing screen. Uh mhm Yeah. Can you see anything from my end? Nope. Nope. Okay. Still nothing, I guess. All right, I'll try uploading the PDF. Yeah, I've been trying to anticipate what I was going to do based on what everybody else is probably were. But thanks David. Okay. Um So hello everybody. My name is David. Um Can you see that first title slide? Okay, great. So I'll be going over pre operative management of anemia and then uh intraoperative sell salvage. Um So like I said, we'll go over anemia, identifying it, treating it. Um And then strategies for minimizing inter operative blood loss. One of those strategies is uh inter operative sell salvage. So I'll go into a little bit of uh depth on that. A lot of the information that I gathered for this talk is from the UK organization called Center for Peri Operative Care. Um And their main statement was that anemia should be viewed as a serious and treatable medical condition rather than simply an abnormal laboratory value. So not just something that we see on ice highlighted as red and then pass over, but something that, that has a lot of facets to it. Um So background to it, the W H O and nice define anemia is less than 100 and 30 g per leader. Uh traditionally has been just in men um and less than 100 and 20 g per liter in women over the age of 15 who aren't pregnant. But more recently, there's been a consensus statement that was published that says less than 100 and 30 is for both sexes, less than 130 should be treated as anemia. And it's an important problem especially in orthopedics because about um there was a study done uh by Rocco said all and that was published in the BMJ I believe and that was looking at resuscitation of patient's with hip fractures. Um And that found that half of hip fracture patient's pre operatively were anemic. Um and one third of patient's having major surgery have been found to be anemic and that matters because it's um because of the association with poor outcomes. So, increased risk of poor wound healing or delayed wound healing, slower mobilization infection, there's an increased risk of death. Uh So 2 to 3 times complication rate in patients with pre operative anemia that was untreated compared to patient's that did not have anemia. And the B O A thinks it's an important problem as well. They've been involved in a, an initiative that has been started by Northumbria Trust. Uh looking at um uh it's called Quality Improvement for Surgical Teams and that was one of the components of it was preoperative anemia screening and they had improved outcomes as a result of this. Uh both in critical care, admission's length of stay readmission rates, transfusion rates. So it's important and it can be addressed. Um And the most common causes of iron deficiency is a sorry of anemia, is iron deficiency. Um but obviously chronic disease and B 12 folate deficiency or other causes. So, pre operative maximization of, of our patient's, the first step is identifying if a patient has anemia and um we're not going to do an FBC on everybody, but certainly if they're due to have major surgery, um nice guidelines says they should have it in FBC or if they're having intermediate surgery, but they have a higher A S A. And certainly if we expect the antis, if the anticipated uh E B L is greater than 500 mills or 10% of the circulating blood volume of the patient, then we should be checking their hemoglobin beforehand. And we might also consider checking if they have a bleeding disorder, if they're on anticoag or other medications. And if they have chronic renal disease or chronic liver disease disease can affect their bleeding times. This is from the Sea Park that this is the anemia pathway. So as I mentioned up top, you can see uh that the when would you check? Hb um And if the anemia is identified, what for the test? You need to do? A lot of the text is small, but I'll blow it up and further slides. And then after you've identified the cause of anemia, what are you gonna do about it? Are you gonna treat it? You're gonna go ahead with your operation. If you do, go ahead with the operation, how are you going to control blood loss, inter operative lee? And then what are you gonna do after the operation? This slide is what to do after you identify anemia, it's a bit busy, but I've just highlighted the 22 areas uh over on the left that in that yellow circle, that's the what extra tests are you going to do? So, uh hematinic, so you're gonna test the thyroid function and then on the right breaks down the different causes, you can see the majority of the causes come from iron deficiency. But then down at the bottom, it mentions if there's another cause suspected. Then are you going to refer, refer to another subspecialty? Um in the meantime, to try to treat that anemia or further investigate it, this is going back to their main anemia pathway. Um So again, it just talks about the tests that's in the top big box. What tests are you gonna do? But then in the bottom big box, what you gonna do about it, you're going to treat the anemia, are going to delay the operation. What is the overall aim? What are we trying to achieve? And that all comes down to share decision making with the patient. Um And, and you know, every step of the way you're going to involve the patient, obviously. So that's what that comes down to. So what are we going to do about the anemia if it's iron deficiency, which it usually is um you can treat with oral iron for 4 to 6 weeks, preoperatively, you can give them some vitamin C to increase our iron absorption as well. And then uh you can give Aretha a poet and it depends on what the cause is. That's fairly expensive uh intervention relative to oral iron. And so it's not come used as far as I understand. And then as I mentioned, the next step, so shared decision making, is there an alternative to surgery, other other considerations? Um Apparently there's a yoga that you can do to improve um your human globe. And I think it's just, it's just exercise, but they sell it as yoga for anemia. Which um, what steps can you take to minimize blood loss? Inter operative lee. So what you can do preoperatively is uh take some blood out of the patient, top them up with IV fluids and then give them the blood back, either inter operative lee or post operatively. So that accomplishes two things. One is uh autologous blood transfusion. So you're just giving them back their own blood. Um When you top them up with IV fluids, it then dilutes them. And it means for every mil of blood, they lose, they lose less, they lose fewer blood cells. So that obviously has an advantage. Other uh things that we do tourniquet, obviously, for, for some uh limb operations, there is the potential damage for nerves and other soft tissues that we have to bear in mind. So we use a wider tourniquet to distribute the force to distribute the pressure, put a pad underneath to prevent blistering. Um and lowest amount of pressure for the least amount of time we can use Tranexamic acid that reduces blood loss because it inhibits the plasminogen activation. And there has not been shown to as far as I understand from what I've read, no increased DVT risk. And then uh inter operative homeostasis obviously, and then we come to inter operative sell salvage. Um So that was a brief overview of uh preoperative anemia and how we identify and manage it and then how we're gonna minimize blood loss. Any questions about that sort of a whistlestop tour? Thanks David. Uh Any questions for David Iggy's asking what you're gonna do if you have a Jehovah witness patient. Yeah. Thanks for. That's a good question Iggy. Thank you. Um So there, it depends, it depends on the patient. Um There are some Jehovah's Witnesses who are happy to have any blood transfusion, any blood products and there are some who aren't. And then there's, we're not happy to have any type of blood product after it's left the body. And then there are people who are in between. So again, that's a conversation to have with them. Some people want to know the exact details of where the blood goes. What is it mixed with or how is it processed in something like in shop rite of cell salvage? Um So they might be happy with cell saver, for example, but for some people, they might not be happy if the blood has left the body at any point to have it put back in. So that's a discussion with, with them. It gets a bit more murky when you then have a child who is Jehovah's witness uh and whose parents are Jehovah's Witnesses because they might have different beliefs to their parents, but that I'm not going, I'm not going to that. Um So if I may, I'll move on to inter operative, sell salvage. So the history of this. Um The first recorded use of cell salvage was in 18 18 by an obstetrician. Um James Blundell, I haven't read his paper that he published on this, but he apparently what he did was he squeezed out some postpartum hemorrhage, sucked it up in a syringe and put it back in uh intravenously. Um I think it probably had there's some complications initially when he was using this technique. But in 1943 there was the first cell salvage autotransfusion device by a surgeon called Arnold Griswold. And he had collected it in the bottle, strained it through a cheesecloth and then re infused it. But in 19 seventies was the first sort of modern cell saver sell salvage device similar to what we use now. And there's three phases uh in cell salvage device. In the first is collection of the blood. Um And you want to optimize red blood cell salvage, minimize damage to the red blood cells, minimize contamination from other things in the surgical field. I'll get onto that in a minute. And then the next step is processing you separate it, you filter it, you wash it and then re infuse. And that's pretty straightforward. You put it back into the patient and there are advantages and disadvantages mostly from what I read. Um There seem to be advantages and that's that the red blood cells that you get uh have, have superior tissue oxygen delivery to say an allergenic or donor blood cell transfusion, they have better shape, they have higher concentrations of 23 D P G and 80 P. And then also there's no immunomodulatory response. So in donor transfusions, um there is a dose dependent increased risk of POSTOP infection, acute lung injury. Am I? And in patients who have had this done during some kind of tumor operation of risk of tumor recurrence, there's actually increased five year mortality um in using allergenic transfusions. So it minimizes that. Obviously, it minimizes transfusion reactions related to reactions against uh outside blood and the overall cost. So, if you're gonna minimize length of stay, minimize critical care, admission's minimize complications and overall, you're, you're reducing the cost. The disadvantage is it does alter the shape of the erythrocyte, it does alter the red blood self um and the set up. So it requires the equipment, it requires a trained staff and people associate uh sell salvage devices with the cost because they think of the cost associated with the device uh in that operation compared to not using it in that operation. And then obviously, if the patient refuses to, to, to have it done. Uh So there are indications and contra indications indications as stated here. So if there's a low hemoglobin or increased bleeding risk, if you know you're going to lose a lot of blood in a patient who has a rare blood type or, or lots of antibodies. So the blood is, is more difficult to come by the donor blood. That is and patient's who refuse blood blood donor products, but who would be happy to have cell salvage contraindications before I started reading into this, I I sort of thought that one contra indication or two contraindications might be malignancy and sepsis, but they aren't, they aren't contraindications. Um And I'll go into why, but the only hard and fast absolute contraindications, patient refusal, um a a sort of relative contra indication would be the lack of trained staff. If you can't set it up and use it properly, then you probably shouldn't be using it. Um But the only real contraindications, patient refusal, there are special circumstances and special things you need to look out for and cautions. So you don't want to suck up chlorhexidine. You don't want to suck up iodine uh skin preps. Um You also don't want topical antibiotics getting in there. If they're not licensed for intravenous use, you don't want any clotting agents. You don't want unset cement. So you stopped suction and then you would let the cement dry and then you then you can use it again. Um Collection can be direct aspiration. You want a wide board suction tip to minimize trauma to the red blood cells and a lowish pressure. And there's certain techniques. So you want to immerse the suction tip into the pool blood, you don't wanna skim across a thin layer of blood. So there's actually a bit more to uh sell salvage aspiration than I anyway, previously thought. And then the other, the other ways they take the bloody swabs soak them in normal saline and heparin and squeeze them gently into a vessel and then, and then put it all together for processing, um processing. So there's a few different types of centrifuges. I've just put this picture up as one example, but that central straw in the middle where it's white, that's actually the intakes, that's where the blood goes in. Um And it's filtered through um the, the best filters, the leukocyte depletion filter. LDF and that uses affinity separation. Um The red blood cells are then separated from the, the plasma, the supernatant which contains the contaminants and they are separated that way and then washed. A normal saline put into a bag with normal saline and some form of uh anticoagulate like heparin and then on to the next step, which is re infusion. Now, this should be done within six hours, usually done inter operatively or you know, immediately post operatively and all the same um cautions uh and precautions rather, it need to be taken for this blood needs to be labeled, need to make sure you give it to the right patient flush the lines. Um and it shouldn't be given under pressure because of risk of air embolism. Uh So, in conclusion, I talked about identifying anemia pre operatively and how to optimize appropriately and to consider alternatives, alternate methods, optimizing but also alternatives to the surgery itself. If that's something that the patient wants to consider and then finally, inter operative sell salvage. It's a useful tool. It can be cheaper overall because it reduces length of stay and complications. Minimizing red blood cell loss and minimizing side effects that can be linked with allergenic or donor red blood cell transfusion. This is a picture of a cell saver from the nineties, you could put coins in, it was like a piggy bank. Um But that's not the cell saver that we use today. Any questions anything anyone would like to ask? David Mike is asking, should we consent? Patient's to sell salvage. That's a good question, Mike. Thank you. Um I don't know. I don't, I don't think so, but we do consent patient's for blood transfusion. Um And this in a sense is blood transfusion or we, you know, we usually mention are you happy if you needed want to have a blood transfusion? I think that would, that would fall, but this would fall under asking that question. Yeah, I mean, I you always have the blood transfusion box to tick, don't you on your consent forms? So I generally say to them that might be your blood or it might be somebody else's blood. If we're doing a revision. For example, if you know that the patient is Jehovah's witness 100% you need to check with them whether they're happy for cell salvage to be used. So some sell salvage setups, used a closed circuit and therefore some Jehovah's witness will accept a closed circuit, sell salvage, but it's not a purely closed circuit, it won't be accepted. So, um it's going to be very trust dependent how this set up is, but there's often a lead for cell salvage and that person often phones uh first witness patient that's coming from major surgery and they will discuss through what they have and what they can offer good. Any other questions from anybody? Thank you very much David. Um Perfect. Have a coffee or tea. Um and we'll come back at 11 were running a little bit behind only 15 minutes, but I promise I will make it up this afternoon. So we'll see you at 11. How much I miss p see. How are you doing? I'm good. You're right. Yeah, I'm fine. Thank you very much. Thanks a lot for giving Superteam to present this. Thank you. Okay. Hopefully everyone's back, John, are you screen sharing our med? Uh Lovely. So our med is going to talk to us about a paper on vte prophylaxis as part of a journal club. Hopefully you have all had a chance to read it. Um And I think he's gonna lend a hand as well. Potentially. Lovely over to you our med great. Can everyone see my presentation? Yeah, perfect, perfect. So uh this uh paper about the mice control trial, um checking the effect of aspirin versus enoxaparin on symptomatic venous thromboembolism in patient's undergoing hip or knee arthroplasty um crystal randomization. Um So this is an Australian people, Australian people um which includes our city single blinded, published in 2022. So I'm going to talk quickly about the introduction uh objective of the study methodology, inclusion exclusion criteria, outcome measures, results, limitations. And finally, the conclusion, parting with a little bit of introduction and background, around 1.5 million total hip and total knee replacements done in the States per year. 2% they get VTE even with prevention. Um chemical perplexes, aspirin has been used more between 2010 to 2021 because it has got low cost, easy to take with evidence of observation studies that attracts well. So the objective of this study is to check the aspirin is non inferior to enoxaparin in preventing symptomatic vte after total hip arthroplasty and totally arthroplasty. In terms of methodology, they have included all the hospitals which were doing more than 250 total hip and totally per year, all adults more than 18 years old. And they have included the patient's who were on single anti platelet agents before the operation um like the aspirin and we'll talk about that later in uh in the actual methodology. Um They have excluded all the patient's who were on preoperative anticoagulants like Duac Warfarin or dual anti platelets. Um it's a single blinded study. They have unblind ID, the hospital and the patients', hospital, staff, doctors and the patient's and they have blinded the investigators and the uh data and study measurement board. So um they have used the the intervention as aspirin 100 mg per day, which was given oral for 35 days for a total hip and 14 days for totally within 24 hours per stop. And enoxaparin was 40 mg per day, subcutaneous, same period for hips and needs and, and half those if the patient's got to wait, less than 50 kg of Egypt are, is impaired, less than 30. Um And we talked about the patient's who were on aspirin, preoperative if they already on aspirin and they have been on the minds to the aspirin arm, they continue on aspirin. And if they have been in the minds to enoxaparin arm, they are, they have been given the enoxaparin in addition to the aspirin looking at this flow chart, um they've identified 37 hospitals were performing um more than 250 hips in needs for um osteoarthritis or in general. Uh per year six hospitals declined to participate. 31 hospitals they have agreed to participate and they have been randomized. Um 16 have been randomized on the aspirin arm and 15 were randomized onto the enoxaparin arm as we see here and there was some something like cross randomization. So, um on the aspirin on five of the hospitals, they have made the target and they have been crossed over to the enoxaparin. And on the enoxaparin, there were 11 who made the target and they've been crossed over to the aspirin arm. And finally, they have managed to include 5000, 400 patient's on the aspirin arm. And um on the enoxaparin, they managed to include 3000, roughly 700 in terms of outcome measures. Primarily they were looking for and symptomatic vte e um incidents within 90 days. And they didn't do any screening for the a symptomatic vte secondary outcomes. They were looking for joint related readmission, joint related re operation measure bleeding events which led to readmission, re operation or death mortality within 90 days or joint related re operations within six months. Moving to the results. Uh, 31 hospitals have been advised between 15th of April, 19 to 12th of August 19, around 13,000 patient's were enrolled 9700 patient's who have been selected because they had total knee and total replacement for osteoarthritis. And the others have been excluded. The aspirin on the, uh, they have got five, roughly 5600 patient's mean age of 67 years old. Um, 57% roughly where females BM I uh, was mean of 30 and 5%. Um, had a history of DVT on the enoxaparin on the managed to get 4000 patient's with the mean age of 68. It was almost 57% females and the same mean age of uh sort of mean be MRI of 30 and 6% history of DVT. Looking at this table, um looking at the primary outcomes in the Aspirin arm, enoxaparin arm. So they found uh significantly statistical difference between the aspirin and enoxaparin with the value of um not 0.7 with a high rate of um VTE VTE incidents in the Aspirin are, as we see here, 187 patient's out of 5400 they have got a DVT which was symptomatic within 90 days in the aspirin are in the nooks. A parent was only 69 out of 3700 which is roughly 3.5% in the aspirin on and 1.8% in the enoxaparin are uh looking at the secondary outcomes. There was not any statistical difference or the P value were fine moving to the limitations. Um There was a few of them, uh starting with lots of follow up in 5% of the cases. Some hospitals had low recruitment because there was possible bias, they might not be recruiting. Um because of high risk patients' with DVT hospitals were on blinded. So more, they have done more diagnostic investigations in the aspirin arm. Um It was limited to only patient's with osteoarthritis. They didn't include any other um, patient's who've gone for replacement like fractures or trauma. Um Aspirin group, they have gone to monotherapy. However, the enoxaparin, they continued on Austrian postal. So they were almost on dual agent and only 5%. You could argue that only 5% were given both in the enoxaparin arm. So not much in in the enoxaparin. Um think that they didn't look for the cost effectiveness measurement and they didn't record the race and ethnicity. In conclusion, Aspirin has significantly high rate of DVT uh in experience, significantly superior in uh good perplexes of V T E. Within 90 days, post up further cost effectiveness analysis would be required or recommended the future studies. Uh Did this change my practice? Yes. Uh understand that aspirin was recommended by nice guidelines in 2018. But from now, I'm definitely not go for aspirin for um thromboprophylaxis reflexes, post operative for hep a knee replacement. Thank you. Sorry, I realized I was talking to myself. Thank you, Ahmed. Um Lovely. Any questions that anyone wants to ask our med to begin with? But so your this happened to us. So your department wants to change from Aspirin to from uh low molecular weight heparin aspirin. Too low molecular weight happened. And some people still want to remain in aspirin based on this paper based on one paper alone, would you, how would you change your practice? So some, some people still want to remain on aspirin uh question for me. Uh So I could see that question again. So, so the question. If some people, they want to remain on aspirin, how could argue based on just one paper? Is that the question? Um Well, so yeah, I, I talked to this and so I'm, I meant this is my personal view on, on this paper. Um, understand that it has got some limitations, especially the cost effectiveness. They didn't look at this because half of these hospitals were private. Um Two apparently they didn't care too much about the cost effectiveness. Yes. Uh, some of the limitations showed that it could be some biased. Um, patient's were on dual agent. So if someone would argue that they won't still give aspirin based on the nice guidelines, especially there is good evidence saying that aspirin is good in from reflux is, I wouldn't argue too much to be honest with you. However, there should be like local standards or policy in each trust where everyone should stick to read here too, which shouldn't be, um, totally different from the national guidelines. Mike's asked a question Ahmed about, did they comment on patient compliance in the paper? Yeah. So they have actually, uh, audited the utterance to, um, uh, to each arms by the patient's and by the doctors as well who were prescribing with your reflexes. Yeah, they were auditing most of them. What are you going to use? Ahmed. Uh, personally, um, I don't believe I'm not a believer in Aspirin two months with you. So I would, uh, I would like to use the lawmaker Weight Heparin personally. The one thing that this, this paper did talk about was that, um, if you're on the aspirin arm, the issues is that you, whether you've, you were across over a group and then if you're on Aspirin, you were screened more, you were perceived to have more screening for symptomatic vte. So, whether that led, that has led to an increase detection of V T E, um, because you want aspirin because people have prejudiced against aspirin. And that's for the, uh, exactly. And that's one of the limitations actually. And they have, they have admitted this in, in their conclusion. And then, yeah, there was some hospital buys. Exactly. Especially with the aspirin. Um, it's a single blind study. So it's, yeah, Scotty. Even though it's a jam. Okay. Egg. Exactly. Yeah. Yeah. Lovely. Thank you very much. Ahmed. Much appreciated. Uh, Mr Wimhurst is going to talk to us about how you go about templating for a total hip replacement. It's not very often someone sits you down and explains how to do it if Mr Wimhurst is there. Uh, hi, I am here. I'm just going to see if I can, um, share my screen. Can you see that? Yes. Excellent. Right. Okay. Can you still see that? And just tell me if the slides slides don't move on since coming because he doesn't know how to templates. So he's, uh, he's just come to watch. So, what is templating? It is fundamentally preoperative planning on radiographs. Um Traditionally, it was done on uh hard copy films with uh acetate. It's that you stuck to the film to once you've decided on, the size is, um, it's now done digitally. Um It involves sizing of the implants for surgery where you're going to put the implants. What you're gonna do with leg length and offset and just one of the most important things is that the knowledge of the magnification of your radiographs is essential. So why bother? Uh the most important thing about templating is it makes you think about the operation in advance. Everything else I think is uh is secondary. Um but you can decide on your cut positioning and the position of your cup will tell you how much of the cup is going to be uncovered laterally. You can decide fairly accurately on size of components. You can look at where your neck cut is going to be. Um You can measure what the preoperative leg length discrepancy is and therefore plan how much you're going to lengthen the patient. Um You can look at offset and the size of the femoral component. Um It is known to reduce peri operative complications such as fractures and there is evidence from the state's in particular that having documented preoperative templating and preoperative planning reduces your risk of litigation or reduces your risk of successful litigation. Um It also helps theater staff in terms of planning and ordering implants. Uh Not just because you may telephone them and say, oh, I need a particular thing tomorrow or next week. But also if you have staff are a little bit proactive and look at your templating in advance, they can go, oh, gosh, we need four size 52 caps tomorrow and we've only got three on the shelf, right? Um Magnification is really important to accurately template and it is quite nicely an East Anglian story in the, one of the early papers on uh how to assess the magnification on your X rays came from Kevin Khan, who was a registrar in Ipswich at the time. And they basically showed that if you stuck a 10 P peace with a little bit of op tape onto the patient's greater trochanter before you took an X ray. Um You could then measure the size of that Tempe piece on the post operative films on the uh the pre op film, sorry and decide on what the magnification of your X ray was and that made your templating more accurate. Um My Qadhi who was my registrar a few years ago, I took this to uh the next level with measurement of objects on digital radiographs and showed again that if you had a marker of known size on the radiograph, your templating was much more accurate when compared with what you actually used inter operative, Lee. Um the guys in Colchester uh did a fantastic piece of work where they showed that you could assess the magnification on a radiograph digitally without the need for a size marker. Um And I'll show you how they did that in a, in a little while. And we then showed with, with Christendom here that actually your leg lengthening or leg length correction is very accurate if you have digital templating and measurement of preoperative leg length discrepancy. So magnification options, um so you can stick, as I said with a bit of tape, you can stick a coin or a size marker to the most prominent area of the greater trochanter. Um or you can use obviously, if they've got a hip in the other side, you can and you know the size of the head in that you can use that. If you're gonna use coins, then you need to know how big they are. And at two p pieces, 26 millimeters in diameter, a Tempe 24 millimeters, there are commercial discs which are normally 25 millimeters in diameter. Uh But what we found with all these things is they disappear. Um Also, if you've got a larger patient and you stick a markup over there, what you think is there greater trochanter? Um Sometimes that doesn't actually appear on the radiograph because it's off the side of the film. Um There is a thing called a hip scaler which was quite popular when Ortho view first started to become used in a lot of trust. This is a perspect block with a 25 millimeter disc in it, um, that you put over the trick Ansara on one view and then in between the legs on another view to give you a, give you your size. The problem with these things is they're quite expensive. Um, you have to have one in every X ray room. And interestingly, the radiographers don't like using them because they have to stick them up into people's groins and then clean them in between patient's. And they, it's quite interesting. Radiographers don't actually like doing that. Um So um we, we tried these for a while and they weren't very popular. Then there's a, the bendy arm option which basically the perspective it goes under the patient's bum and you can then bend the ball into whatever position you like slightly less concerns about intimacy and sterility. But they are again expensive and you need one for every uh X ray room and sometimes the placement isn't that perfect. So the uh technique that they developed in Colchester, which we've used for many years here is the F F D F O D measure. So F F D is focus film distance. Now, in our outpatient X ray, in knowledge, the distance between the camera and the film is set at 100 and 15 centimeters. The radiographer then takes the tape measure, which is, I didn't know this until we started doing it. There's a tape measure in just about every X ray machine and you can pull it, pull it down and measure to a point on the greater trochanter to the radio, radiographer then puts F F D equals 115 F O D equals X on the uh radiograph for you. Then by a little bit of mathematics, you divide one by the other multiplied by 100 and you get the magnification percentage. So pounds a template um we have author view in knowledge. There are various other uh there's uh there's a foreign E A one. Uh There's a third one. I can't remember um uh which is quite widely used, but I'm just going to take you through how to template on also view. So at the top of our pack screens is a little uh doctor's bag um that you can see I've put an arrow on there, you click there and it brings up a login screen. Um You then decide on the side of the operation you're doing and click the add procedure tab, then highlight the radiograph or radiographs that you want to template and start plan. The next thing to do is to assess the magnification. Now, this patient happens to have a hip replacement in the left side, which we know is a 32 millimeter um uh femoral head. So you can use the three uh handle circle marker which you click on there on the left hand part of the screen, it brings up a circle which you can play with until you get it to the size of the head. You then click on the question mark in the middle of the head and type 32 into the. Please enter the size click return and that will scale it. This patient has also had F F D F O D done which you can see documents on the screen at the bottom. And if you're just using that and you haven't got the anything to measure you type it into the magnification percentage and click apply. Okay. So you then use the smart hip wizard which is in the box of hip replacement wizards on the left hand side of the analysis screen. Um The first thing to do is to measure the femoral head that you're operating on. And again, you have a three tab circle that you increase in size until it matches the size of the femoral head. And then it tells tells you what size your femoral head is. Um I've said the four millimeter rule there. If your cup that you template is more than four millimeters bigger than the femoral head size, either the head is collapsing or your cup is too big. Okay. So as a rule of thumb, your cup size should be about four millimeters bigger than the head and no more than that. So you can see this one measured 45 millimeters. I then measure the leg length. Now, the leg length, the most accurate thing to base your leg length measurement on is the inter teardrop line, not the trans ischial line, not the trans obturator line. And people often use ischial a obturator. Um They are much more affected by pelvic tilt and rotation. So if you can see the bottom of the tear drops, you put the two little squares on the transverse line on the tear drops And then you use the drop down line to measure to uh common points on the lesser counters. And I tend to use the most prominent point of the lesser counters. And this then shows us in this one that the leg length difference is about 4.5 millimeters less on the right than the left. So in our inter operative uh operative procedure, we're going to be planning to put between four and five millimeters of length on this hip. If we can, we then start thinking about canal diameter for femoral size and offset. And there's a, a device a tab that says find femur and it will give you this four point um measurement device which you then put to the inside of the cortices. Sometimes in author of you, if it can see sufficient femur, it will automatically do it for you. Sometimes you have to do it manually and that will also give you your offset. So you can see now on the left hand screen, it's saying that my leg was 4.5 millimeters short, my head diameters 45 millimeters. My offsets about 33 my canal diameter is 15 and my distal canal diameter is 10. Um You then go on to the template screen. We don't tend to use the reduced screen in green in hip replacement. That's mainly for when you're doing hip fractures. And when you click template, it will bring up the images that you've pre selected in the system. And in this case, I'm templating a trident cup. Um And by right, clicking your mouse, you can just rotate the position to get your cup inclination. And I tend to, to go for an inclination of about 42 degrees, 40 to 42 degrees. And you can see I'm sitting that just lateral to Cola's line, which is the I LEO SQL line, which if you draw a line up from the, in a sort of the lateral aspect of the obturator foramen through the teardrop vertically, you can see a sclerotic white line. Now, that is the medial extent of the acetabulum. In this one, if you look carefully, you can see a little bit of a white line bulging beyond Cola's line, which tells you this patient has a little bit of protrusion. So I've got my cup angle there at about 42 degrees. I can tell my cup is going to be pretty much buried. If I go on to Cola's line, sometimes you'll have a little bit of your cup showing laterally on your templating. And that will tell you that you're allowed to have that. When you're inter operative, Lee, you're going to see a little bit of the superior aspect of the cup and then size my, move my acetabular component out of the way and size my femoral component. You're looking with a cemented stem to get at least two of the little tabs outside of the the stem template within the canal. Now, that's what I've highlighted with the two red circles. I'm sorry, on my screen, it's not showing up very well, but basically in a, a cemented component, you don't want your stem filling the canal distantly, you want about three millimeters for cement and then head center. I'm looking to get my head center, my new head center in the middle of that femoral head. Now remember that if you've got gross external rotation of the hip, the uh the uh the offset is going to be affected. And sometimes if they've got a normal hip on the other side, you need two template, the normal hip if they are grossly externally rotated. But this one you can see is telling me that my head center is pretty much uh the tip of the trochanter. If they're various, the head center is going to be below the tree can to, if they're valgus is going to be above and I will then often use the reduced tab now, which just shows which then cuts the femoral neck and positions your hip where it's going to go in terms of offset. Um So you can see this one is, oh, I'm sorry, I've I've got a menu overlying the my wizard telling me what my stem sizes, but this is a 37 5 offset. Number one stem with a 48 cup. I'm correcting my leg length as you can see if you go down from the top um leg length before and after that change is going to be four millimeters. So that's going to give me about an equal leg length. And I know what my femoral component and my acetabular component sizes are. If you want to go to to really the next level, you add report to the screen and I've circled at the top there a little tab which looks like a page of word. If you click on that and then click on the screen, it will then give you all your sizes and your leg lengths on the screen. In writing, you have to make sure you put that away from the bit that you're operating on. You then click save. And what then happens is a report is saved two packs which not only is useful for the theater staff to look and see what you're doing because if they just bring up the images, it is there on packs. Um You can print it out if you want to, but it's, they're saved impacts as a medical legal document that you have thought about this operation in advance. So to summarize, you should do this well in advance for every hip replacement, not just in the wild patient's in the anesthetic room, do it in advance. That way, you're going to realize that you've got a really tight canal or a really small cup or a really huge offset and actually you may need something that isn't on the shelf. Um You should be assessing your implant sizes, your offsets the positions and your leg lengths. Um You should always save your templating two packs. Um I, even though it's safe two packs and it's on the X ray, I don't know what your patches like, but ours has a tendency to log out after a while when you're in theater. So I always write the sizes of the femoral component, the acetabular component and my leg length discrepancy on the white board before I start the operation. That way I know what I'm meant to be using. Um My advice would be if you've got off the view or another system in your hospital, every hemiarthroplasty that you do, you can template. Um Centrax heads are available as a cup option uh in author of you. And just rather than using an Acetabular component, you select Centrax head and that will then give you a head that you can size. And actually if you in this hospital if you go through a magnification of about 100 and 17% on our A and E X rays, you are rarely more than two millimeters wrong on your Centrax or your unit tracks or ETS head size. Um If you become a template, er, which I would really encourage any of you who are going to be hip or knee replacements to do, you will find that there will be colleagues of yours who are a little bit more artisan and like to sort of hold the thumb up and say, oh, you know, that's a 44 and they will take the Mick out of you, but I promise you it is worth it because you will save yourself from getting into a hit replacement where you suddenly find you need a 56 offset femoral component and there ain't any on the shelf and if that happens to you once in your career, it's too often. I'm happy to answer any questions. Thank you. Any questions for Mr Lim past. Mhm No, lovely. Uh In that case, we've had a slight shuffle around in how we're going to deliver the afternoon just to accommodate uh somebody who's in clinic this morning. Uh So Iggy's going to talk about STEM design now and then we'll finish up before lunch. Mr Women just talking about how you go about um choosing implants in the NHS and how you might change, implants, procurement, etcetera over to E G. Well, So I'm gonna try to keep it simple. Um So the femoral stem side as design is roughly divided uh simply into cemented and un cemented. If you look at most textbooks, that's how they start off. And I'm going to focus on cemented first, then we'll talk about uncemented stems. Um The cemented stems are divided into composite beam and taper slip. And um before when I was core training, I still remember one of my friends said one's rough and once shiny. Um And that's not entirely true. Um The composite beams are tend to be mattered with a collar or collarless, but it's a cylindrical beam where the nickname for it is set up and stay so it stays where it is when you implant it and you can have taper slips that are mattered. But typically we now talk when we talk about taper slips, it has to be polished because of the biomechanics of taper slip steps. So if you compare like for like taper slip is polished, it is colorless, it has tapers or taper and it is a force closed design or a slip and slide design. And that's the, that's the broad um categories in the cement in stem category. And um the stem on the left is a composite beam where it stays where it is the um the cement is well fixed, it has a color to help fixation on the antral medial side of the femur where as a taper slip over time due to the properties of cement and creep. As the pay the, as the patient has constant walks on it and constant load, the stem will then dissipate its forces evenly through hoops, dresses into the cancellous bone, uh evenly, distributing the load over time. And thus, with um uh the broad, the broader um types of some composite beams would be safe. For example, arguments sake would be a Charlie and with rough surface and it's bonded between the implant and the cement interface. The exeter which is a double taper and the C stem which is a triple timber, the mechanical properties then translate. Where if you have a fixed stem for a composite beam, uh the proximal femur when it loads, it has a stress shielding. So there are, there are stems typically, if the stem is well fixed, this li you will see historical X rays from Charlie's that it has antral medial stress shielding where um there's increased bone resorption because there is no weight bearing on that medial car car. So that when the load is transferred from the stem to the bone, it is sheer forces because it's well fixed, it does not tolerate sheer and the stem is well fixed distally. So we'll talk about stem um failures later on, it's well bonded due to the surface roughness. A table slip relies on hoops stresses as the patient weight bearers um distributing the using the viscoelastic property of cement, which is creep and is a controlled substance and it converts the forces into a compressive force, distributing it evenly. Now, it took, it took me a while to learn what a taper is. Um But essentially uh the first taper of the taper slip stem is as you look at it A P is the medial lateral. And then the second taper will be if you look at it side on, that's the curve taper of a second taper. And that's typically your exeter, CPT and your third taper is if you look at it from the front, so that would be a third taper um as you're holding the stem from, from the top. So if you, if you look back from the slides, especially um looking at exeter where it doesn't have the third taper and then the C stem has the third taper where it's triangular shaped and there are papers out there to suggest that the see stem or C stem uh the CCM classic. Then the C S M A M T where it says annual media Tabor um is what I am T stands for is to load onto the proximal medial femur to allow to reduce the risk of share shielding. This is, this is one of the pictures lifted directly off Charlie where this is tape. The taper slips is designed that relies on the viscoelastic property of cement where if you load it long enough, the cement would then deform uh or conform into what the shape of that canalys. So Iaea Gonzalez bone. So now broadly speaking, that's cemented. So cemented, relies on early fixation. So the patient doesn't complain of thigh pain as previous talks. Mr Wimhurst has suggested that N G R revision rates are better, especially that the patient's that are above 65 where that's about biological reasons. It has bone cement disease uh when you're cementing and it's cheap, it's a cheaper stem to run. In terms of if you're taking, taking into account, cementing, taking into account pulse lavage and everything is still cheaper than an unscented stem. And uh NSA mentis them relies on bony in growth but no risk of bone cement disease, which if you speak to American surgeons, they will argue about bone cement disease and how it's a nasty thing. Uh But they don't really do pulse LaBarge. Uh in the way we we've been trained to use cemented stems. It is expensive and the people will argue that it's a quicker operation. But in this day and age with four hips on the list is that 10 minutes of cement setting with risk of intra opposite fractures. Um worst N G R rates uh complications. So, a cement lis stem relies on the coating. Traditionally, it's a fully coated stem with the material of stem made from titanium. And the, the key word here that people mostly uses press fit. It is a slightly larger implant and broached. It depends on each and every manufacturing, what, which one you use and what um what stem you particularly use. Most people are press fits or plus two or plus four depending on what the make is. So, always read the ob tech calcium hydroxyapatite is typically the courting. Um mcq question's always ask you about what they, how, what the chemical composition is and there's the rules of 50. So I know it's not Kate's rules, but Kate always talks about this in the auto club. So the rules of 50 where you want to reduce the amount of micromotion of less than 50 microns, the thickness is 50 microns or slightly thicker. The poor size is 50 microns and it has to be 50% porosity. If there's two little porosity, it's a week fixation. If it's too much porosity, there will be sharing of the metal. And it also relies on titanium plasma spray for bone ingrowth. And we'll talk about, we have bone graph later on in terms of how the bone ingrowth happens. Coating. Typically, if uh we used to be fully quoted stems, then we know from composite beams is that if it's distally fixed them, then the stem can fill in the middle, then we move towards approximately approximately fixated stem. And with uh that's particularly bony in growth with a taper profile. And in the middle of the distal portion, typically a distal portion that is not, is unquoted and it's on growth on the middle section and that reduces the risk of a typical, uh a typical un cemented stem. You will see that it's quoted in the middle and there are even some names that have uh that has suggestions that they're, they're approximately quoted stem in terms of the eponymous uh company name. So my choices then um in the exam will be an exeter V 40 femoral stem, which has a 10 year old debt rating fits nice guidelines. So more than 10 a star, the offset choice is easy to understand. So it comes in 35 5, 37 5 44 50 55 even higher comes in short stem options. So standard long stem, so you can have a 1 to 5 mil option. You can have 1 50 option, you can have long stem option. The only thing about the V 40 that we always have to remember is that the V which is a five radiant or 40 degree. So that's the reason why it's called V 40 trainee in in revisions is that if you keep the stem, uh you have to have the head that is a V 40 trunnion or a taper, which if you were to want to build up onto it, increases risk of trichinosis, multiple adapters is that you, you can have a V 42 a 12 14 taper adapter. But why would you so just make sure that you have the femoral head that is a V 40 trunnion taper. And that's for the afternoon. Thanks, Icky. Any questions, uh, figgy about stems? Really common case to come up in your basic sciences? I think even in the past, they'll put a couple of stems out and ask you to pick one up and describe it. So you need to be able to talk through the anatomy in the shape of that stem and then talk about how it works. Um And then fixation methods. They could easily then take that on to talking about cement. They could take it on to talk about the uh environment that's needed for in grow, things like that on growth. Um Great. Any other questions? No. Uh Mr Wimhurst is very kindly going to speak to us just briefly about how you introduce the implant that you want to use into a department. So many of you will get consultant jobs you'll arrive and they'll be established kit on the shelf. But how do you go about introducing something new? Hello again. Um Hopefully, I've now got the point where I'm doing this properly. Can you see that? Yes, good, good. Just a couple of comments. You saw that excellently. Um cement disease, bone cement disease that Americans referred to. That's quite an old term. And actually what they were referring to as ostial isis and Americans went away from bone cement in the 19 eighties because they thought all osteal isis was caused by bone cement, not by um polyethylene. Where so that, that's where that that term was coined. Um And the other thing is a 56 not a 55 on the extra. Thanks, that millimeter makes all the difference, right? This is really brief because um this is purely for when you become a consultant to understand um what's going on about why departments have specific implants and what happens if you try to introduce anything new? Um Maybe it's got stop screen sharing. I haven't. Um Are you not saying that I can't see it but I don't know if it's just me, Iggy. Can you see it? No. Uh Hold on, let me just try again. Um on, I thought I'd do it right this time. That's it was working shash screen to shot. See that? See that's still Yeah, perfect. Okay. So um basically, um when you're deciding on implants, um the you use or you should use NJ our data and Odette rating. So uh you should do your own analysis as a unit um and decide what you're going to to use and that's based on uh the experience of the uh surgeons in your unit. Um The how well implants of performing on the N Jr. Um And also there are there are other influences that come into this um such as the service provided by the company. Now, some uh implant companies provide a fantastic service and if you need additional implants because you've got more than the number of cases you have on the day, uh, on the shelf or if you need a specific unusual revision implant, they get it in for you rapidly and other companies, um, rather drag their heels and that is actually a factor you need, um, you need a good service from the company that's, uh, that's looking after your, your hospital, um, gift over the last decade have had more of an influence and goof would like everybody to do um cemented hips for all patient's. And it's really interesting that gift have been really pushing that agenda for a decade. And as I showed you on the NJ, our slides earlier, cemented hips have been going down during the same decade. And actually hybrids have now taken, taken over as the most common implants. Um You should take into account with gift in mind the cost of implants. Now, the difference between a cemented cup with the bone cement and a cement lis cup is probably 2 to 300 lbs. So if you're doing several 100 of those a year, it it all adds up. So that's why here we tend to try and follow the what's going on in the N J R and say, well in our over 70 fives, there really isn't an argument not to do a semantic cup, but in the younger patient, in terms of outcome and longevity of the implant, you start to get into the decision. Well, actually in the slightly younger group, I'm going to use a semantic cup, but I want to use a ceramic head uh which again is more expensive. So, you know, you just have to balance cost against what's the best thing for your patient. Um in terms of getting the best deal for your hospital, it it depends very much on your usage. So hospitals that do an awful lot of operations get better deals off the the companies. Now, this is actually now being balanced out bit by the I C E S s. So if you're in a group of three hospitals and you all agree on the same implants, you get much better buying power. So my recommendations are that actually all units should only have one cemented stem and cup and one cement lis stem and cup on the shelf. If you've got more than that, then your department needs to get together and discuss why and what's the best option. Because if you've got to cemented stems coming from different companies, you will not be getting the best deal on those stems. So you are costing your, your hospital money and your local health economy money. Um Ideally, revision implants should come from the same manufacturer as your primaries come from because if you have a peri prosthetic fracture or recurrent dislocated that you need to revise, it's much better if all your implants match each other and you're not having to go to off license cross breeds. Um It gets slightly more difficult now that we've got the I see S s and, you know, my personal view is that actually if you're in a spoken hub system with uh smaller hospitals, relying on the central unit to do their revisions, actually, the central unit dictates what primaries you use to match in with what the revision equipment is. Um decision to change, implant manufacture at the end of the contract is interesting. The contracts tend to be three years in general and quite often your operations manager will come to you and say, oh, you know, the contract's up for negotiation, we're going to go out to tender and then they'll come to you and say, oh, actually, if you change and do all Smith and nephew hips were going to say 300,000 lbs next year, now you have to balance that against are those implants as good as the ones you're using or better. In which case, if they're cheaper and better in terms of outcomes, it's very difficult to say. No, there are training issues in terms of uh you've got, if you change implants, you have to change, you have to train all your theater staff to use the new kit, as well as your surgeons and your surgeons will have a learning curve. So you have to think quite carefully about changing implants as to what the long term benefit is. Um you as future consultants need to be robust and evidence based with your managerial colleagues because I can promise you they will come to you and say, oh, we can get this um extra copy from, you know, Wimhurst Medical who have now started making them and they're undercutting striker by 50 lbs a hit which will save us 250,000 lbs next year. Uh And you could say, well, you know, what's the NJ our data on the Wimhurst hip? Uh It's a pre entry implant. No, we're not using it. Um If you are, if you do bend to pressure or you are somebody who wants to use something that is shiny and new, then just be aware if you're using a non 10 A star rated implant, they need to be followed up more and they shouldn't actually be discharged until such time as that implant has gone 10 a star or beyond. So that has implications on the cost to your trust in terms of follow up appointments. And if you're using the earlier implants or implants, which have recently been introduced to the market, you need to be doing beyond compliance submissions and getting consent from your patient's to do so on every single hit that you do. So there are quite a large um implications doing something new. I would caution you all in your early days as a consultant against being uh seduced by implant companies saying, oh, we've got this fantastic new shorts them that only occupies the meta fossas and it's going to be absolutely brilliant and that, you know, five years it's outperforming the exeter. So that's absolutely fine when it's got a 10 A star rating, I'll look at it. Thank you very much, but I'm not being your guinea pig. Um, so, you know, do not get involved in that kind of thing later on in your career, particularly if you've got a research interest, uh, you might want to get involved in introducing new implants that might be better in the future with the correct kind of follow up and beyond compliance, but do not get seduced into doing that early on. Um, I'm happy to answer questions but there isn't an awful lot more to say about this. I suspect lovely. Any questions for Mr Wimhurst or for anything from this morning so far? Nothing quick question. Of course, you can believe. Um, so it's sort of related about the use of reps. So you said about training and, uh, I've been in a trust where they seemed to call in the rep at the drop of a hat to support the theater staff with Arthur plastic cases. Is there any downside to having the, well, other, other than another number of people in theater, which is a consideration that the greater the traffic in theater, the greater the infection risk. So you want to minimize traffic through theater. So the more people crowding in perhaps not good. I mean, in Australia um where I did my fellowship, if the rep wasn't in the theater complex for every single operation that was using their kit, they changed to a different company. That was the level of service that was expected from. It was Zimmer where I worked at the time. So it, you know, in knowledge because there are so many theaters going and we have a sole supplier for Hips and there's only one rep for this whole region. And he's frequently in the Paget and vary in various other places. We don't see the reps that often, but I don't think there is a major downside to having the reps in theater if it's for the right reasons to support the theater staff with use that next etcetera. Um It's, it's, there's really a problem with them being there and it's often positive and, you know, when Ben Lemon is here, I'll always have a chat with him and, you know, we'll say actually we haven't got enough of this, so we haven't got enough of that and I'll sort it out and, you know, it's having a good relationship with your, your local rep is really, really important. Thanks. Just add in, in other countries where I've experienced, they, they, the reps have to open the implants. So, so I think from our point of view in the UK, there's a consignment rule where we are allowed to open the implants, but not other countries. Interesting. Every school opened by. Yeah. Yeah. I'm even more time consuming. I mean, just, just a word on reps just do be always take what reps tell you with a pinch of salt and do your own analysis because you will get reps telling you that. Oh, you know, this is the best implant and the NJ, our data is skewed because actually people are only using our hip stroke knee in younger patient's therefore it's failing earlier because it's only used in difficult cases, etcetera. That's normally balls. If something is performing badly on the N J R don't use it. We stopped using the contemporary Hooded cup, the extra cup, which is actually a 15 a star cup or 50 and a cup, I think. Um because we noticed on the NJ are that the revision rate of the contemporary flange aged at 15 years was 3% and the contemporary uh hooded was almost 6% double the revision rate from the same company and same price. So we just stopped using it. So, right. We're just going to use the flanks one instead. So, but the company didn't tell us that Ben didn't come knocking on the door saying actually, you know what, you know, all these cups you got, they're not as good as our other ones. So you've got to do your own analysis. Lovely, perfect. Any other questions?