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December 2024 EOA-OrthoBEMA Journal Club (Foot & Ankle)

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Summary

This on-demand teaching session by the Monk City Journal Club in collaboration with the Egyptian orthopedic association and the Ortho Bema focuses on the implications of Vascular Thromboembolic Events (VTE) in foot and ankle surgeries. In this session, medical professionals will examine two important papers in the field. The first one will reflect on the frequency and severity of VTE in patients undergoing foot and ankle surgery within the first 90 days of post-operation. The second one will delve into the relationship between Vitamin C and CRP S in ankle and foot cases.

Throughout the session, participants will explore how VTE protocol varies across different medical entities and how crucial it is to identify specific risk factors including certain injuries and specific patient groups. The presenters discuss the need for a standardized, evidence-based guideline to handle VTE for foot and ankle surgeries across the NHS and UK. The session ends providing key takeaways such as the necessity for doctors to assess VTE risks particularly in patients with achilles tendon rupture or with higher SA grade and the significant contribution of the UK faith study to our understanding of VTE in foot and ankle surgery.

This session is highly recommended for medical professionals interested in preventive care for foot and ankle surgery patients and

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Description

Date & Time: Friday 20th December 2024 at 9:00 pm Cairo time.

Venue: Online

Chair/Moderator: Prof. Mohamed Elashhab- Dean of Benha faculty of medicine

Mr. Mohamed Hashem- Consultant Trauma and Orthopaedic Surgery- UK

9:00 PM – 9:20 PM :

UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE): A Multicentre Prospective Study of Venous Thromboembolism in Foot and Ankle Surgery

Jitendra Mangwani, Lyndon W Mason, Karan Malhotra, Linzy Houchen-Wolloff

Presenter: Mr. Mohamed El-Shial, Orthopedic Registrar, Swansea, UK

9:20 PM – 9:30 PM

Discussion

9:30 PM – 9:50 PM

Vitamin C prevention of complex regional pain syndrome after foot and ankle surgery: a prospective randomized study of three hundred and twenty-nine patients

Jacques HernigouAdeline LabadensBarbara GhistelinckEmilie Bui QuocRenaud MaesHarkirat BhogalAntoine CallewierOlivier BathEsfandiar ChahidiAdonis Safar

Presenter: Dr. Hatem Hussain, Senior Clinical Fellow (SCF), Southend Hospital, UK

9:50 PM – 10:00 PM

Discussion

10:00 PM

Closure

Learning objectives

  1. Understand and interpret key findings regarding VTE complications in foot and ankle surgeries, especially with regards to frequency and severity.
  2. Analyze the variations in VTE prophylaxis protocols and risk assessments across different hospitals and trusts.
  3. Learn about high-risk and low-risk procedures impacting the occurrence of VTE, such as Achille's tendon rupture and elective surgery, respectively.
  4. Identify the key factors contributing to the high risk of VTE complications, namely high ASA grade and a history of previous VTE complications.
  5. Discuss strategies for standardizing prevention protocols and risk assessments to reduce variations in practice and improve patient care, including the development of evidence-based guidelines and tools.
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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Uh Good evening everyone. And um welcome to the second uh session of the Monk City Journal Club in collaboration between the Egyptian orthopedic asci and uh the Ortho Bema. Uh Today, we have to uh interest papers to be appraised by um to eminent speakers. So how much will take us through the fake about the reflexes in foot and ankle uh cases? And the question will be a, a bit bit about the relation between Vitamin C and CRP S in foot and ankle cases. So the main theme of this, this time is foot and ankle. And uh I hope you will, you, you, you will enjoy the two papers and get a message from both of them. So how much iron will be in moderation? You push. And um I share, we start with the first presentation. So if we can all um both all your question, the question answered uh box or a section and we'll be having a discussion after every paper presentation uh answering all your questions. So if we get all the cameras off on the chair and how much please present your uh both your came on. Yeah, good evening, everybody Uh uh I'm Mohamed Shell. I'm also in South Wales. Uh today we are speak, uh we are speaking about UK, foot and ankle uh faith study. Uh It's a very interesting uh Multicentric topic, uh prospective study uh of V VT E reflexes supervised by uh Mr Mango, one of the pioneers in the foot and ankle in the country. And uh I have a, a chance to work uh with him uh in Leicester University Hospital. Uh So, first of all, uh we are exploring VT E in the foot and ankle surgeries through uh UK practice. Uh this presentation uh criticized the UK, foot and ankle thromboembolism highlighting uh methodology, key finding clinical significance. Uh what is the strength of this study and how uh can uh make it more uh profound uh and take it uh to other step. Uh So, first of all VT E uh complication, it's uh one of the serious complication in the orthopedic field, especially when it comes to lower limb uh surgery. Even with a simple cost, it can cause uh problem and it can cause major consequence. The main uh consequence of the uh VT E here, DVT and B DVT is simply as a float which uh can uh arise in the uh lower limb. Uh Sometimes it's uh um detached and make significant uh close which uh transverse and tracking up to London cause major consequence. And sometimes it can cause this. Uh here, we can, we will speak how that correlated in foot and ankle surgery and how can, uh we, uh, uh prevent this major consequences and the objective of this study. First of all, uh we, uh, are uh studying the, uh, 1st 90 days most of, of the uh, foot and ankle surgery, uh, focusing and stressing on the frequency and severity of VT E in a certain patient, uh group. Uh, we also, we will speak about how it's differ and the valuable uh from trust to trust and from hospital to hospital uh the uh VT E PRO protocol and even the uh risk assessment control, which is different and varies from trust to trust. And we need to highlight and identify the risk factors especially in a certain uh injury and a certain patient groups here. The design of this, sorry, share your screen. You haven't shared your screen. It's not to share until now. No. Sorry. Bear with me. Yeah. Yeah. Is it now? Yeah. Yeah. So again, sorry for technical issue. Uh Again, here for uh are you choose no from down, no, no, from the right side from your presentation itself. Point. OK. Yeah, perfect. Yeah. So uh we speak about the uh complication of VT E uh and objectives. The study uh about the first uh POSTOP uh 90 days uh and how uh it's uh cause a significant uh event of the uh VT and consequence of the uh surgery itself. Uh And we speak about how it's differ and uh uh variable from just trust to trust uh to give a chemo uh thrombo uh prolex and also the risk assessment differ from trust to trust. And we uh here we are uh studying the risk factor identification in a certain uh patient group and certain operations. And here this is a Multicentric prospective National collaborative uh audit that uh mean uh many uh hospital included uh about 68 site and hospitals through the UK. So that's uh why this is a uh study is important to ensure that diverse geographical representation and part the inclusion criteria. All the patient who under uh went uh uh foot and ankle surgery, uh plus uh tendon achilles uh rupture uh management is a conservative or surgical uh uh from June to November uh 22. Uh only the excluded patient who uh have um injection of uh chemoreflex in, in theater room. And that collection here, we uh demographically, uh we are speaking about the uh age uh six essential background, medical history, uh like comorbidity, previous uh uh VT E uh incidents and also uh medical uh history uh procedure details include the time of surgery, time of the anesthesia. Uh if the tourniquet uh been used or not unhoused uh uh duration uh of the tourniquet. So, uh reflexes how and for how long and outcome if there is uh any patient uh had developed any kind of VT E or uh pulmonary iol. We uh highlight them the key finding of this uh study. Uh It's about, uh, fortunately it's me, uh good result as roughly we found one in 100 patients were affected in the 1st, 20 days POSTOP mortality. This is rate less than uh, 1%. It's, uh about 0.03% shows that the VT E uh complication seldom lead to this. Uh, and we found out there is no standard across the UK hospital. This means that every trust have their own policy in management of VT E and also they have uh own uh risk assessment for school. And, uh on uh chemoprophylaxis uh treatment, uh, we found out, uh about 30% of the patient received no chemo reflexes and most of them, uh, got low molecular weight which been given to about uh 56% of the patient procedure impact on VT E high risk group. Uh, uh, was, uh noticed in achilles tendon, uh, rupture. Uh, about uh, 4 4% of VT E incidents were, were with non operative treatment. Uh, while, uh, 2% of VT E incidents was surgical treatment of the, um, tendon achilles low risk, uh, being noticed in elective foot and ankle surgery. It's, uh, uh about 4.3% and uh, major risk factors. Uh, uh, does, does that make sense? The patient with high SA grade had, uh, high incidence of developing a VT E prolex and patient with previous uh episodes of VT E uh complication. Uh also been noted to uh have a higher risk of uh VT E uh incidents. Um The interpretation of this result, this is uh finding have important implication. First of all, uh it's the result matching with uh being noticed in the previous research. This is add further support to uh understanding the VT E risk uh and make this um paper a very strong uh position uh in uh support the evidence of uh incidents. Second, need of standardized protocol here, we highlight that uh different protocol in giving uh reflexes uh uh of VT E uh pre op and also the risk assessment is differ. So this is a uh urgently need uh to have evidence based guideline uh to globalize the VT E in foot and ankle all over the NHS and UK. And we need uh to target prevention uh for a certain uh patient, especially who uh got achilles tendon uh rupture and also patient with high sa grade. And uh this has been uh noted to be the uh key risk factors in uh management of VT E in an patient. Why is this uh study? Is this strength is, first of all, as we said that it's large number of patient representative sample as it's multi centric. Uh So this is the size and the geographical distribution of this um hospital uh give the strength of this study. Uh Secondly, prospective design, the study minimize the chance of and give a clearer picture of how the VT E developed after surgery. Comprehensive data collection. Uh this is allow for a analysis of potential influence so on the VT E risk. So the main strengths here, large number uh prospective uh and also comprehensive data. Why this study is uh limited. First of all, some uh data uh been missed during uh uh a light duration of prevention uh uh preventive treatment. We noticed that when uh we uh study this is uh uh paper, they didn't uh give a clear uh information about how long the chemoprophylaxis should be uh given pre op or POSTOP to prevent the uh possibility of vte uh risk. So we need something uh more clear about the duration of preventive treatment. Second, l uh lack of risk, uh assessment details. We don't know based on what criteria that has this patient being uh uh to have uh reflected uh VT E uh chemical uh low molecular weight or other type of uh VT E reflexes. We don't have any clear answer about what is the risk assessment detail of this patient. Uh Third limitation, it's observe uh observational nature uh of study. Uh It can only show association like it's, it was very interesting that we found uh that the patient who received uh chemo reflexes the uh for a long time uh before the surgery uh had higher uh risk of developing VTE POSTOP, which it doesn't make sense as it's just observation. Uh No uh clear uh justification of why this patient and why is this patient who get uh VTE reflexes develop uh VT E uh after that? So what we are uh what we need to do. First of all, uh this is a mini area. We need to uh work on it to make, this is a uh a global and make it uh in higher level uh of evidence based. First of all, we need to arrange randomized controlled trial uh to uh compare uh variable methods of chemoreflex, preventive, chemoreflex, uh medication wise duration doses and to see what is the outcome between all these uh medication and uh that will give uh a clear evidence and support our uh results. Uh Second and most important development of risk assessment tools and it should be uh globalized and uh widely spread all over the uh UK and the niches uh which uh will be make sense and make it the safe practice for every trust uh to uh deal with the VT E uh complication. Uh take home message here. VT E is a real but generally low risk complication of foot and ankle surgery. Uh doctors uh need to be EENT in assessment of VT E uh risk, particularly in patients with achilles tendon rupture or with higher is a grade. Standardized call and guidelines for VTE prevention are necessary to reduce variation in practice and improve patient care. And UK uh faith study is a sig uh uh make a significant contribution to our understanding of VT E in a foot and ankle uh surgery. Uh And also uh this is to optimize uh the patient. I would come. Uh We need a, a further study uh for uh risk assessment uh tool and uh how long it should be? Thank you. Um I uh I can't see any question and the answer uh question from the participant. But if I can ask hammed just one question regarding the achilles tendon. Yeah. Is it uh acute rupture? For example, in our trust, the policy is for conservative management for all achilles in the rupture. Yeah, it is, uh it is uh either uh acute rupture or failure of conservative management. Also the, the age of the participant, we notice uh more than 16 years old. What about the high, high elderly people who has, have other high risk factor for VTE reflexes? Yeah. So first of all, this is study stress. Uh not on the way of the treatment. They g uh uh globally speak about the uh outcome. They didn't uh specialize the outcome coming from uh the certain surgery uh over the uh other methods of treatment. They just mentioned that it's higher with achilles tendon, higher with conservative management in Achilles tendon. But to elect some patient to have a surgery or not, it's not for this study. But uh again, it's something related to long duration of immolation. If we treat the uh patient with conservative measurement for achilles tendon, the, the chance of developing uh VT is higher as uh the longer duration of immobilization, uh uh again, is needed. So, uh I think this makes sense. But if we uh elect the uh surgical management, I think the duration of surgery will be uh less which uh can cause uh at some point improvement in the outcome uh in term of VT was of uh complication. So uh I might be not clear. So for example, if patient for conservative management of achilles tendon rupture for like six to week to eight weeks before starting mobilization. Yeah, and then fail the conservative management and then go for surgical intervention. Hm Is it higher risk as a patient who is going for surgical from the first day? They didn't highlight that they didn't highlight that they speak about is a conservative. The outcome of conservative but bridging from conservative to surgery, they didn't highlight anything about that they just uh speak about is a conservative. The outcome of the conservative is that uh 123 and the uh patient who uh treated surgical uh uh incidence of uh outcome uh is uh 123. But again, if you speak about the risk, I think the risk is higher as this patient will go for longer duration uh of uh uh embolization which uh is the most important contributing factor in developing VTE. You can imagine this patient being in the cast for 68 weeks. And after that, he didn't ha uh uh uh good uh full uh union or healing of tender achilles again. He will go for a surgery and we will start to count from zero again and he will be ili for some sort of 34 weeks. So if we say that 68 weeks of uh immobilization and the treatment conservative again, and after that, we will add the duration, it will be about now, uh reaching about 10 or more than uh 12 week plus the incidence of the surgery. So it, he will be the highest risk factors. Uh I think Mister Hashim can uh agree or disagree with my point, but it didn't mention clearly about the bridging between conservative to uh uh to uh surgical management in this study. So, first of all, thank you Mohammed for uh for the nice presentation and um the good appraisal of the paper. So I was a part of this trial and uh we have um remember the number exactly, but we have a very good chair in the number of the patients. So um answering your question, how much I learn. So this is an observation study. It hasn't interfered at all with any variables. It just have a look on the va prophylaxis in foot and ankle cases, including the achilles. Um it's checking if the patient has been assessed or not and if the patient hasn't been assessed, they just highlight that and what the patient, what V flexes did the patient receive? And who is a patient who had an VT E event? And how this event was? And was was it wasn't the what, what was the Communist VT E um Prophylactic um uh type of treatment had the patient received. So it's just an observation study. So answering your question, the this study came with a few findings which were just settled and few surprises. First of all, um the the the the few surprises is 32% of our patient does not receive a chemical um thromboprophylaxis based on uh decision of the surgeon or the decision of the of the treating doctor. The second surprise is most of these patient doesn't have a formal assessment, which is according to the nice guidelines should for every patient coming with a foot and ankle injury should receive before he go in the hospital, that should receive formal VTA assessment to stratify the risk if this patient is at VTA risk and how, how much risk is low risk, moderate risk or high risk. And based on that he should start be starting on uh treatment. The difference, the the month surprise or the, the, the sub the changes which was covered is the achilles one we understand that the achilles in itself as a as as an injury is a risk for VTE and why the VTA uh event is more in the oper not operative versus the operative. The answer basically that most of them will wait there. They want both of them goes in an uh uh uh uh rehab protocol. We, we follow most of the UK follow the smart protocol, the Swansea Morrison protocol for accelerated rehabilitation of the ait tendon injuries. So this patient stays for two weeks in an equinus cast. And from two weeks onward, starts to go in uh back route and start weight bearing. The difference between operating and and and repairing the tendon versus non operative is with operating. The patient have the option to do aesthetic contraction or what we call isometric contraction. This is our understanding why the VTE events is less in the surgical group. Both of them were there, but one of them has a tendon injury. There is no option for the muscle to do an isometric or uh uh static contraction. But with the bad, there is an option of static contraction or isometric contraction. But both of them has a higher risk of VTA reflexion rather than any other foot and ankle surgery. Most of our VTA, most of our foot and anchor surgeries, they are now weight bearer from day one. Even the surgeries which doesn't allow weight bearer, there is no increase in the VTA risk in them. Uh So basically with weight bearing, we understand from this study that the main factor contributing to VTE event is the weight bearing. Once your patient is having is weight bearing, the risk of VTE is low. And the second thing we understand from this study that the event which will happen will happen. So by VTE prophylaxis, you save the low risk patient, the patient who is at high risk of having a VTE will have a VTE whatever you do for him. This is the second point but the good news is it's not fatal. So even the people who had the VTE event, according to the fifth trial hasn't go to um a mortalities or just the morbidity. So to sum up ve um events in foot and a is very low. Uh It's mainly in the achilles tendon, especially under an O group. What we came to know from this study that we have a defect in the standardized protocol. We don't have a clear protocol for VT E assessment and prophylaxis. Every trust and every hospital has its own, its own way to do that. Uh Number two, we don't have formal assessment for most of these patients. Number 3 30% about a third of the patients didn't have a proper chemical prolex is based on the car and consultant decision, which is not right, which needed standardization if we come to the scientific point of it. So that the events already happened in a patient who will have a event for patients who have a high risk of event. And as you can see patients with high ac grading and patient who are medically uh prepared to have an, an, an, an V event. But on the other side, they were not fatal. So all of them were just causing some morbidity, not mortality. Uh explaining why uh the achilles tendon cases has a higher uh VTA is the problem. As I told you of the muscle contraction, that's why the people who had the surgery to repair the achilles have the option to do an isometric contraction. VT reflex is a risk reduced by half the half the patient who had uh no operation. So, but V TVT E even uh VTE risk with the AET is already well known. The study hasn't, hasn't, hasn't shown anything new. It's already well known that the A kid is an injury in itself is a VTE risk. So it's a maybe observation. The study, the good thing, it was very multicentric at nearly all the hospitals the UK has shared in it is a huge number of patients and uh uh it, it doesn't, it doesn't give any explanation, it just give observation and this is one of the limitation in it and we're working in the fa and the bridge or very for society at the moment to standardize a protocol for VTA assessment and VT prophylaxis and it should be out very, very soon. Um And uh definitely more robust evidence, more proper studies, randomized prospective is needed to explain and to show AAA lot of variation, including the one you, you, you mentioned about the patient who was on, on VTE, on uh sorry, on a conservative treatment for achilles injected to, to operative and how this will increase the risk of VTE. But at the moment, we don't have that or what we have with this multicenter prospective observational study, the V trial. So the f trial is a very good trial. And from my, my perspective, it gives it we now uh individually before we have a protocol, all of us do a VT assessment. Uh The main problem of VTA assessment when we went through the BFA to understand the problem. Uh and our patients are a day case surgery. Uh I'm sorry, day case um patients and the problem with the day case, there is no ro there is no uh genes because there is no genes, there was no formal VT assessment. So the formal V VTA assessment happens in the wards, either in the elective ward or in the trauma ward. The day case is just run by nurses. That's why the VTA assessment wasn't done properly. And uh it was one of the problems and that's why from now onward, uh I'm not sure of the other hospital but for my hospital, uh you cannot uh uh discharge the patient from day surgery without doing a VT assessment and prescribing the VT apophylaxis. So um, it's, it's, it's, it's a good observation study. It has shown a lot of, uh, positive findings and it has shown us where is the effect and how can we correct it? Uh, one thing, Mister, uh, has, uh, I think most of the, uh elite trust in UK now have a VT E nurses to look after the day case surgery and to, uh, prescribe the medication for all this kind of stuff. And also they uh should uh do the VT E uh risk assessment before giving this uh type of medication. Yeah, so, but it, it needs to be standardized. So all of this is just still individual uh uh uh uh proposals, but we're going to have a standardized protocol for assessment and prophylaxis. Uh There is a question from Mary about um if the increase in VTE uh instance has been observed after COVID or COVID vaccination. Uh uh yes, definitely. So after COVID vaccination, especially the risk of VTE has increased. Uh uh it hasn't been, hasn't been studied frankly. So I uh to on top of my head, there is no, I don't have a clear evidence to answer this question, but definitely from uh based on observation, the patient with VTE, uh I'm sorry, with um COVID vaccination especially has a higher risk of having a VTE event than others. Uh It has, yeah, it hasn't been involved in this study especially. So we haven't commented on the COVID itself. Uh Uh But yeah, it definitely needs some study to uh to answer this question uh with an evidence. Yes, please. Can I have a comment? Sure. Uh ho how are you? I'm fine. Thank you so much. M many thanks to you and to mister for, for this nice presentation uh regarding these questions, I have uh uh two of my colleagues who had a VTE after uh COVID vaccinations by 2 to 3 months And it's reported to, to not to be immediately but even late after COVID vaccination. Yeah. So, yeah, a lot, a lot, a lot of um uh of surprises inside the COVID box. So this, this black box hasn't been open completely yet. But II, I'm aware of a lot of studies which is running um around the COVID and COVID vaccination and their effect on the, on the clinical practice. Um Ahmed cha is asking um about elective foot and anchor surgeries who will need nonweightbearing. Will we be given a chemical uh prophylaxis or not necessarily? Uh Yeah. So, Ahmad this, that is, that's a normal practice. So this is, this is uh uh if the patient will be normal weight bearing, you'll be definitely giving a VP. Well, this study has shown that if you give for electric foot and ankle surgery, if you give the proper vla uh instance of events or VTE events are very low. So, um uh this is one of the good things that um the risk has been increased with the achilles only. But regarding the elective foot and ankle, the patient who is prepared, who is optimized. Um uh if I uh risk of events with proper, with axis is very low. So answering your question and the answer is yes, with elective foot and ankle surgery, you have to give, um, or if they are non weight bearing, you have to give a chemical uh prophylaxis. And I can assure you according to the faith trial, that the risk of having uh events or vte events will be very low if your patient is just elective and well prepared. And also these questions highlight the need for standardized risk assessment before asking uh for uh every case by case, if this patient need uh chemoreflex or not, we need to have evidence based standard uh risk assessment. Uh Not to study case by case just to go for the standard. If this patient for the standard uh need a chemo perplexes, we will give him if this patient probably the standard uh needed. So we uh know that this patient can uh go without any uh VT prolex. So it's very important to highlight the need of standardized uh uh limitation of this study uh to have a standard uh protocol for chemo perplexes. So, uh I think there is uh one last question because we are uh beyond time. So Arafat is asking what type of prophylactic drug can we use? So, um A as you have seen the communist uh drug use is low molecular weight heparin. We are not gi no one will be giving um unfortunate heb anymore. Uh It still there is a big question because we give a, a lot of our patients, especially the achilles patient. It's according to the trust policy. So my trust policy is in trauma patient. We give low molecular weight in elective uh situation. We give uh oral anticoagulant which is anti uh factors 10 um uh some, some trusts I know that they are giving antiplatelet, either one in um 11 drug or, or you antiplatelets and they are doing well. Uh This is one of the questions which the BOFA um protocol will answer. So we'll give you a standardized protocol including what you should give as a chemical prophylaxis in trauma and in uh elective situation. But till the moment that uh according it is different from trust to trust. I think the communist practice is uh trauma gets a low molecular weight and elective, get to work or direct or anticoagulant. Ok. Uh We have to shift to the next uh interesting presentation. So another very common problem was the peripheral surgeries including foot and a sorry. Um It's a very common with the wrist and foot and ankle surgeries is the CRP S or chronic uh region of pains in the room. And Hatton will be taking us through a paper which uh correlating between uh the effect of Vitamin C. If you get Vitamin C POSTOP with uh CRP SA for the active surgeries, please. Hat one. Yeah, we couldn't hear you. Yeah, see on my screen now, but we still can continue. GH Cotton, you know. Um, the so is the sound is a little bit weak? Can you hear me now? II can hear you but if you can raise your voice more. No, no, I don't think we, we can hear you. So the problem with you using um headphones or something, you just use the normal computer uh sound. So um OK. About no, still there's a bombing with the voice so you can change your microphone. Ha it. So it's about the microphone hasn't been muted. Is any better now. Yeah, it's much better. Yeah. OK. Uh I'm using, I'm using my phone. So uh sha will be sharing uh my presentation. Yeah. Currently I have some technical issues with my laptop. Uh Sorry about that. Uh So uh just one second. Can you hear me now? Can you hear me? Yeah, we, we can hear you just one second. I will, I will share the, the visitation. All right. OK. Thank you. Mhm OK. And is now hot. Yeah. Yeah. OK. Uh Sorry for the technical uh difficulties. Uh So um this paper uh I'm going to present today is discussing the role of Vitamin C in uh the prevention of complex pai uh regional pain syndrome. After foot and ankle surgery. Uh Here are the name of the authors and uh myself, Hatam Hussain, um, a senior technical fellow in South End University Hospital. Next slide please. And this paper was published in 2021 in the international uh journal of orthopedics. Next please. Uh complex regional pain syndrome or known as C RPS, is a serious postoperative complication that can develop after foot and ankle surgery and it has significant impacts on the patient, uh mobility and quality of life. There's a lot of studies uh that suggested that Vitamin C supplementation might prevent CRP S. However, all of these studies were studied in context other than foot and ankle surgery. Uh given that uh foot surgery is common, assessing effective preventing measure is crucial. The incidence of CRPS in foot and ankle surgery is reported to be around 13%. However, only one study uh that has been performed uh exploring the role of Vitamin C and foot and ankle uh surgery and prevention of CRP S. It's worth mentioning that the way Vitamin C prevents CRP S is still unknown. However, it might be related to its uh antioxidant effect. Next, please. So the objective and aim of this study was to investigate the efficacy of Vitamin C in preventing CRPS after foot and ankle surgery in a population of surgical patients including trauma and elective surgeries. Next, please. So this was a monocentric uh prospective randomized controlled trial, uh conducted between January 2018 and December 2019. It involved 329 patients who underwent different uh, foot and ankle surgeries. And we had uh these patients randomized into two groups. One receiving 1 g of Vitamin C daily for 40 days postoperatively and the other is a control group not receiving Vitamin C. The incidence of the RPS was then assessed using the Budapest criteria and corroborated uh by the three F three phase bone scintigraphy at the follow up visits. Next, please. Uh patients included uh basically everyone had foot and ankle surgery, uh including ankle fractures, arthrodesis, ligament reconstructions, hallux disorders, as well as uh midfoot and hind foot disorders along with the removal of orthopedic uh implants. And that excluded pin removal, surgeries and toenail surgeries and exclusion. Uh patients who were excluded from the study. Uh uh Anyone who had a history of CRPS or anyone who had an uh pre or postoperative infection or fibromyalgia patients or patients with psychiatric disorders or any patient who were uh well known who was well known to have any uh addiction to any recreational uh drugs. Tourniquet was used in 91% of these surgeries. So that was not considered a discriminant factor for C RPS. Uh postoperative. Next, please. Postoperatively. All patients received the standard uh similar postoperative care uh concerning uh physiotherapy analgesia and vte prophylaxis. And uh the control group. The patients had Vitamin C received daily. Uh 1 g as I mentioned earlier for 40 days after the surgery. Next please. And data was then collected uh uh using uh the medical records including age gender BM I history of diabetes, uh cardiopulmonary conditions, smoking and alcohol consumption. It's worth mentioning that alcohol abuse was defined as consuming more than six units per day uh for for men or more than four units per day for women. Next please. And this table is showing the patient characteristics and the operative data. And you can see here uh that the incidence of C RPS in Vitamin C group was around 6% compared to 11.5% in the control group. And if you look down there, you can see that coughing and alcohol uh both have um uh eminent role uh or a risk factor for developing CRPS next, please. So this has the results, as I mentioned, uh Vitamin C group, uh C RPS occurred in 6% of patients compared to 11.5 in the control group. And accordingly Vitamin C intake is associated with a significantly reduced risk of C RPS. Alcoholism. And the use of C immobilization emerged and risk as risk factors uh for developing uh C RPS. Next, please. Uh Before running to conclusion. Uh Can you show us the next slide, please? And then we'll go back to conclusion. Yeah. So uh the strength points for this uh study uh first, it was a randomized controlled uh study. Uh the size of the sample size was quite good. Uh There was clear clinical endpoints and uh statistical analysis as well. However, some limitations as it's a single center study and also due to the nature of Vitamin C supplements. Uh so we had a lack of blinding and also the potential confounding factors related to lifestyle needs to be uh studied furthermore uh like alcohol abuse or cost uh immobilization. Next please. So I believe that further research could focus on exploring uh the optimal dosages and the treatment uh timelines for Vitamin C in various contexts. Like for example, patients with alcoholism are not well known to be malnourished. And I think uh increasing the dose of Vitamin C might be quite sensible. However, there is no robust evidence uh regarding the dosage. Can you go back to the conclusion slide, please? So, um the conclusion of that paper that administering 1 g of Vitamin C for a duration of 40 days following foot and ankle surgery is effective in significantly lowering the incidence of C RPS. And I believe that uh we can use this paper as a strong evidence for routine use of Vitamin C as a preventive treatment or prophylactic treatment in the surgical population. Uh Thank you for listening and I'm open for any questions. Thank you. Has uh has is very, very uh informative one, very nice appraisal and to be honest, it's a very nice paper. Uh it hasn't given a clear, uh, new message, but it has confirmed with the message that the normal practice we're doing. Uh, C rps is a very obscure point of practice for us and for hand surgeons, um, we don't understand the, the, the mechanism, we don't understand the BSI. We don't understand um, how we prevent. Uh, I believe, um, all the people on the floor are using, uh, Vitamin C regularly to, um, reduce the risk of CD. And I agree with you, we don't understand uh the, the, the, the, the, the basics behind that and how it doesn't stop it. Uh The even the theories explaining how the CRP is happening for neurogenic theory, inflammatory theory. Uh They are all just theoretical. There is no evidence on uh clear about the PC RPS to happen. So we don't have a clear answer for the question why C RB is happening? And that's why we don't have a clear answer to the question. How can we prevent it uh from practice? We all agree that pragmatically Vitamin C for six weeks, 1 g 500 mg twice daily for six weeks. Uh does the job for uh preventing CRPS or at least reducing um reducing the incidence. Uh We don't have an explanation behind that. So I think um the study has emphasized on effect which is happening without clear evidence to make clear evidence behind the normal drug doing um the point of alcohol um use and increased incidence with uh the C RBA alcoholic vision uh is totally understandable and uh expected. So basically, if it's neurogenic, either or inflammatory, both uh theories will be supported in alcoholic uh patient because we at least alcoholic patient, they already neuropathic and they have some, some, some sort of, of, of, of neuritis and this definitely make them more susceptible for CRPS. Uh it needs more um uh research, more, better, better quality research to run on it. But I think the message from the paper is very, very clear. Uh It is not, it's not a new one, but it's definitely a very important message. And C RP is one of the devastating problem. All of us facing the practice speaking with brief surgeries, like foot and ankle and hand surgery and uh yeah, we need more and more evidence coming to support the practice we are doing. Uh So thank you so much, Haim. Um And uh we're open for any question. I think we already have two questions. Yeah. The first one, from rad, he asking if we can use uh Vitamin C as a part of treatment of uh chronic uh renal pain syndrome that was not addressed in the paper. The paper was made about the prophylaxis in foot and anchor surgery. Uh So that was not addressed uh as part of the paper. So a lot of for, for, yeah, we, we, we, as I told you, we don't, we don't understand the most physiology behind CRPS. So speaking about the treatment, to be honest, is one of the most painful situation you face in the clinic if a patient come to you back with the CRP S. But um yeah, Vitamin C definitely do have prophylaxis. So we nearly um in patient which you you think that he's going through C RP, especially with this injuries. Uh uh and definitely for the ankle surgeries. Uh we start Vitamin C um uh twice as I told you 500 mg twice a day for six weeks. Um at the end of the day, it's, it's harmless. So Vitamin C is, is, is, is just a natural vitamin. It's um and the patient definitely get some benefit treatment. There is, there is a lot of options of treatment. Uh I can, I can promise you from now, all of them uh has no consistent results. Uh They do sympathectomy, they do a lot. The, the patient get a lot of neuroleptics. Uh But II, so I promise you especially with the wrist injury, this patient would be never happy. So, um uh de definitely the paper speaks about prophylaxis and, and just showing uh evidence on the relation between Vitamin C and prevention of C RPS. Uh uh answering the question about the treatment is a very difficult uh question to answer. We have another question for you. Yeah. Yes. Uh What, what's the other question? Sorry. Yeah. Uh from Mohammed Khari. He's asking if uh Vitamin C is sufficient alone in preventing CRB S. No, it's not, it's not sufficient alone and it's not preventing, again, it's decreasing the risk, but it's not preventing. Again, uh, around 6% of the patients, uh receiving Vitamin C, uh developed CRPF in that study. So, apparently so it's not, it's not sufficient to prevent it. It's not like a magic solution. No. Yeah. So again, hammed is, is, um, as I tell you, we know that the patient on Vitamin C is at lower risk of having C RPS. We don't know why and we don't know. Uh And this percentage is a huge percentage from 4 to 11% is not a, not a simple one. So it's more than double the patient who was protected from CC RPS by a regular Vitamin D intake, uh C intake. I'm sorry. Uh but sufficient alone or not, we don't, we don't know how the CRP happen and that's why we don't have an answer for. Is it sufficient or not or what we can assure you from the paper is from the practice that Vitamin C prevention or regular Vitamin C intake definitely lowers the risk of having a CRPS in your patient at least by 2 to 2.5 per uh uh uh uh times than without Vitamin C. Uh I, I'm sure all of you deal with dysteria fractures, especially in non operative treated patients. And it's a very frustrating complication to have a patient with C RBS. Uh, you have to have a very good, uh, and like symptom suspicions. And once you feel that this patient going to C RBS, Vitamin C has to be started immediately, I know a lot of surgeons who do it as a normal practice. But, um, at least in my trust and, and the trust that have worked it in, uh, it's not a normal practice, but we definitely, once we feel that the patient is going to see RBS or at high risk, we start Vitamin C for six weeks. I think it was the last question. Ok. All right, perfect. Thank you. Thank you. Thank you. Thank you. Thanks Mohammed. Uh She thanks uh for, for the two nice people and a very good appraisal process for both of them. Uh They definitely both of them carries a message. Thanks Mohammad Chalan for uh moderating and organizing this and uh sorry guys for the technical error. But this, yeah, II think it went and the message has been delivered and received uh were received. Um Feel free to comment if you have any comment. Um If you know you receive a feedback from amid all, please uh bought all what you need in the feedback. What's, what's good, what's bad. We're aiming to make this um as a regular monthly uh join a club between uh Egyptian Orthopedic Association and the uh Ortho Bema. Um I'm in the process of getting uh Royal College Accreditation for this. Uh So we needed to make it every time better than the, the one before and this will not happen without you. It's aim aiming to you to give you an up to date knowledge with a very good uh robust evidence and novel papers. So please, your feedback is the guide to us to how to improve this. Um So feel free to both what, what what you feel in the feedback, all your comments will be taken on board and all of them uh are are valuable for us and very appreciated. Uh Once you submit your feedback, you will receive a certificate and uh I promise you by next Journal Club, this certificate will be uh having some CBD from the College of Sur uh Professor Ham. Thank you so much. Thank you so much. My dear brother, uh Professor Mohammed has for, for the uh scientific uh knowledge and uh ch uh exchange of uh thoughts and knowledge uh between our dear colleagues from UK. And uh I wish you all the best and I promise you the whole support of the Ejection Orthopedic Association. Thank you so much. Thanks, Professor Ash and uh for everyone uh have a, a good New Year and a Merry Christmas. If you will not be uh seeing you before that uh in, in an hour, we will have our uh third literature for in the Foot and Anchor course. All of you are more than welcome to attend. And I promise you of a, a very good fruitful literature in, uh, in one of the, one of 33 of the interesting topics in Foot and Anchor. Uh, see you all and have a good evening.