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Hello, everyone. Can anyone just in the chat? Let me know whether you can see the slides and whether you can hear us. Um, sorry, if anyone in the chat could just let us know whether you can hear us or see the slides that are being presented. That'll be great. Ok, thanks Adn. So I think you can just, I just, I think we can just start right now if you're happy to Miss Roslin. Yeah, for sure. Yeah. So I'll just, I'll have an introduction first. So welcome everyone to the first talk of our sub specialty series titled The Deep Dive series. So, any in collaboration with the Aberdeen Trauma Orthopedics and Rheumato Society as well as the University of Glasgow Trauma Orthopedics and Sports Medicine Society. So our first talk, um, we're delighted to have Mr Joe ESL who is ASD seven in trauma orthopedic surgery at the role of Edinburgh. He has a particular interest in orthoped oncology and today he'll be talking to us about soft tissue circum resection as well as the use of endoprosthetic in the field of orthoped oncology. So, Miss Roslin whenever you're ready. Yeah. Brilliant. Thanks for the introduction. And, and welcome to everybody on a Friday Friday evening. That's an un unbelievable commitment to come down on a Friday. So it's so well done to all of you that are here. Um When there are a few things to say just off the bat, actually, when I was told about this series, I was asked to talk mainly about some of the in theater things. Maybe it's the things that you see happening if you don't really know why or I don't know, maybe it's just the, the next things along from undergraduate training. I'm not gonna be talking to you today or to teach you really about orthopedic oncology and undergraduate level. I'll definitely go through it. OK, as a reminder to make the rest of it, make sense. But what I'm hoping today will allow you to do is think more clearly about orthopedic surgery broadly and to a less recent orthopedic oncology. Specifically, the second thing just to let you know about is, yeah, when we were corresponding with OS, we said about soft tissue sarcoma and feel the bits and Bobs. I'm actually not covering soft tissue sarcomas today. So we're gonna be talking really about bone, primary bone tumors and metastases around the soft tissue sarcomas. So I hope that doesn't disappoint anybody. Um Lovely. Right. Let's get going. So, um we're gonna go through a and a very quick overview of orthopedic oncology. It's something which as an undergraduate, I don't expect it changed a huge amount. Not that I trained up here, but it was covered in a few lectures and that was really it, there wasn't much, much else on it. So most people have a very misunderstanding of, of what is actually an enormous subspecialty and that's fine. Everyone's that way. So let me go through some of those things just to, you know, wet your appetite and then I'm gonna be speaking about doing a surgery on these patients and what we do and how we do it and what we're thinking about. And I hope that in so doing and I hope with the rest of this season series more broadly, you'll start to get more of a nice thing of actually how surgery happens. And if you do when you're in theater with us and you say some of the things that we'll be talking about today, it really makes you stand out, ok. It's simple things, but it goes a long way. So I hope you hear some of the things I discussed with you today and I hope it makes being in theater more enjoyable. We'll go through lots of ca we'll go through three cases, but in, in a fair amount of detail as we're going, if you have questions, type them in the chat, please, I can't see it. Um, but um, someone will shout it out. Lovely. All right. So orthopedic oncology as a actual term, it can be divided broadly into these three subsection, soft tissue tumors, primary bone tumors and metastatic bone disease. So soft tissue tumors, soft tissue sarcomas, which are the movement variant thereof. They make up a fairly big proportion of the UK burden of orthopedic oncology. It's dealt with both by orthopods but also by plastic surgeons. Both have the skill set to manage these conditions and they're just tumors of any of the sort of embryological mes and carnal tissue. And you, you sort of work through that if you ignore skin and then just directly be below that. Anything that going down to bone is a soft tissue can become a soft tissue tumor. I'd say the fascia, the nerves, the sheaths, the muscle, smooth muscle, cardiac muscle, skeletal muscle, all of these things can be just a soft tissue sarcomas. There are lots and lots of those. They're a huge burden of benign. And the most common you will know is lipoma. You'll have heard of that before. Ok. There's lots of lipomas, but there are malignant variants of that and there are lots of other malignant, although rarer uh soft tissue tumors, I'm not really gonna speak about that in much detail. As I've already said, primary bone tumors, you'll know a few of these. Ok. There's also an enormous amount of primary non malignant bone tumors. Sorry, my kids are in the background. It's a bit annoying. So I'll, sorry if they're distracting from time to time. Sort of bedtime. So, apologies for that if you can hear them. So, primary bone tumors, malignant, benign, benign is a big problem. So, benign bone tumors are a problem. They don't kill you, but they can cause pretty castor problems that we have to deal with. And the malignant ones are the nasty ones. And you'd have heard of some of those osteosarcoma, chondrosarcoma, ewing sarcoma. But there are lots and then metastatic bone disease and this is a really important one first because people are living longer now with a high burden of tumor. Ok. Of, of something else. So, usually a carcinoma, usually a breast cancer, prostate, something like that. And there are a lot of the people are living longer now with a longer burden of disease, high burden of disease. And so you're gonna see in your careers and it's already changed in mind as more people presenting with metastatic bone disease that need treatment. Ok. And that's in and of itself another big part of being an orthopedic oncologist. It's very rare though in general, right? Primary bone tumors, there's probably about 350 per year in the UK. And that means that you don't really have to have many centers that can do it in the UK. There aren't many at all. In fact, there's London Oxford, there's a hospital outside Birmingham, one on street and then there's Edinburgh and, and there's a little bit shared between Aberdeen and Glasgow as well. Ok. Um, So there isn't a high burden, soft tissue sarcomas, a lot of sense to look after those. But primary bone tumors, not many at all. And there has bone disease everywhere. And it's a big problem. Now, if you look at primary bone tumors, I'm mainly talking about now about primary bone tumors and sometimes I'll speak about MBD. But I'll tell you if I am, they're very rare and they have a bimodal distribution here. So, a big glut of patients with primary bone tumors are in their teenage years or early twenties and some in late childhood, right? So that's a really important group of people that we look after and they are growing. So the fact that they are growing is important. Ok. So they're growing and that's important. You don't get a steady rise as you do with essentially all cancers, with the advancement of age. And there are two groups, there are those that have primary bone tumors, but there are those that have malignant transformation of a benign problem or um and that they account for this group as well. Ok. So for example, someone pagetoid bone who then goes on to develop osteosarcoma. All right. So they're rare. That's the, the headline here and of the primary bone tumors. The three big ones are osteosarcoma, chondrosarcoma. And then small blue round cell tumors are bone, that's a get a bigger group, but it includes Ewing's sarcoma. Ok. Um So that's what's in there. No, there are loads of others. Some of these are soft tissue, by the way. Ok. So what happens when you get a sarcoma? Well, a few things and I'm talking now about bone cancer just to remind you primary bone cancer is what I'm talking about at the moment. Right? So, the first thing is you get, you get sort of centrifugal growth from within the bone. Ok. So what, what will happen is as the tumor enlarges, depending on how quickly it's going, it will do things to the bone. It will either distort the bone, the bone will grow around it, remodel as the tumor expands slowly. Or if it's very rapid growing, it'll just erode through and then go into the soft tissues also within the bone. It can move OK. So you can have multiple foci without anything between them, they're called skip lesions. You will have heard of that in relation to Crohn's disease probably by now in your OK. But you basically noncontiguous bits of tumor, but within the same bone. All right. So you can have multiple foci within the same area and they are, they, they are essentially metastases. It then comes extra osseous and it stays within the compartment, the usual the muscular compartment that it then it expands into OK. And lastly, it will metastasize. And the thing about sarcoma is not all, there are a few exceptions to what I'm about to say, but most metastasize hematogenously, OK. Carcinomas, breast cancer, bladder prostate, they all, they tend to spread through the lymphatics. Sarcomas spread through the blood and because they spread hematogenously, they tend to go to places that have very high cardiac output. And some of that gets your whole cardiac output is your lungs and the lungs are the primary site for metastases. But there are lots of other sites including skeletal and you can go to other bones. All right. And there's just a classification here which reflects how that changes. Ok. So these are, so these are called the eine grading 2312 and three. It presents radiographically anyway, as a hole in bone, that's the term you will hear people talking about. There's a hole in bone, hole in bone. Holes in bone are very common. They can be benign, they can be, you see a lot of them and the, and, and what you're trying to do is tease out which of those have been more sinister and we can talk about that in the next few slides. Ok. So when you first, when you see a whole limb, the things you need to think about are in, in order, in my opinion, as follows the location within the bone. So most primary bone tumors are metaphyseal, the metaphysis. And there's a, there's a reason for that. The aba bone has three sources of blood supply. It has an endosteal blood supply through a nutrient vessel. It has a periosteal blood supply through the periosteum and it has a periarticular blood supply through the fine vessels that, that traverse the joints that at each end of the bone. And most of the blood in the endosteal blood supply through the nutrient vessel goes all the way up to metastasis to the physeal scar, which is where you were growing, which then fused 14 or 16 if you're a male or female or a male respectively. And at that juncture, the vessels ta take a sort of 100 and 80 degree turn back on themselves. They're called hairpin sinusoids. For that reason, tumors tend to seed or sit in this area. And the same is true for osteomyelitis tends to be in this area. The other reason you get metaphasis or tumors is because tumors as you will know, tend to be associated with very high turnover areas of tissue and the growth plate, the pisis is a very high turn area that's turning over as you grow. And therefore, in adolescence and childhood, it makes sense that tumors would be predominantly focused around the growth plate. And indeed, they are diaphysis is not common. There are some, there are about five, probably brain tumors that affect the diaphysis. There aren't many and the epiphysis is also quite unusual, but there are a few and I'll show you some a bit later. So first think where is it cos it influences what you think's gonna, it might be then the size and shape as a, as a like if you just sort of like squint and have a look what sort of size and shape it is. And then look, is it broadly li white, uh black sclerotic white or something in between? These are the things you need to ask yourself and then go really go for a great. So I've got, I know roughly where it is, it's rough size and shape and it's mainly lytic. It's mainly a black hole. Let's say that for example. So this will be a lytic one on, on, on the left of your screen here. OK. So clearly just a rowing bone and this one here will be sclerotic or mixed. Um um Sorry about that. That's just my, I'm on call. Um Nothing, nothing important. And then uh and, and then there's sort of a mixed one on, on the right there. OK? Where it's sort of sort of black and white, whereas the one in the middle is quite white and on the foot on the left is mainly black. OK. Lovely. So when you, when you've then got a sense of it, start in the middle and work out, OK. So first, the first question is, is it making matrix? So if it, if it's, if it's lytic and it's just a black hole and it's not, but if it's floss or makes it, it's trying to deposit something in it, an osteoid. So that would be a bone forming primary bone tumor. There go osteosarcoma or similar things that gives you these sort of things that are described as cloud like or like blobs of cotton w and then some of it's trying to form cartilage. These are the two diff, the two are different ones. Ok. Bone forming or cartilage forming chondroid. They, they just described as rings and arks. The other term for that is walls, wh or LS walls, sort of like crescent type bits of white bone, but isn't what it is and it's like a blogger or, or popcorn stippling is the other term. OK. So these are these, you'll see. So, so this one here, you'll see here if, if you on the right screen, this is the right proximal femur. It shows a very poorly defined lesion, doesn't it? It's probably mixed, right? You know, it's in the metaphysis up here in the proximal femur, it's mixed, it's got one obviously white bit, but there's also some black areas, right? Some lytic areas. And this here is a is kind of if you again, if you squint, that's, that's popcorn stiffness. This is a chondroid tumor, it's deposit in Chondroit. The next, the last two things are really important, the zon transition and the periosteosis. So, as I've already described a few minutes ago, if something's growing very slowly, the bone will remodel around it, so it'll stretch the bone out. And if you look at that tumor there on the left and you see that the cores although thinned, have changed around that slow growing tumor, ok? Whereas in the other two here that patently is not the case and you get this very wide zone of transition, you can't draw a line around there and that would be more sinister. And the last thing is the periosteal ration. This is extremely important. All the bones are invested in periosteum, ok? And in an adult, they're very, very slender for the most part. And in a, in a child and adolescent, they're actually very thick, much thicker than you probably imagin to be. But ordinarily because they are closely adherent to the bone, you can't see them. But if there's a tumor growing and it pushes the periosteum off of the bone push because the tumor comes out of the cortices, pushes the, pushes the periosteum off of the bone. Well, then you can start to see different types of periosteal reaction. If you stretch periosteum, it tries to grow essentially. So here are some good examples of that. So benign, very slow growing things. They, they, they, they will stretch the bone, they may, they may come out and they'll continue to slowly. And if you, if you stretch periosteum, it tries to form new bones. If you do it very slowly, you get like a solid smooth area of bone. Ok. So often benign and the next ray are very important. Ok? So lamellated lamin is, is sometimes called an onion peel, spiculated, something's called a sunburst appearance. And lastly, there's something called a Codman and a Codman is very important. This is similar to spiculated. But what you actually see are the two triangles at each end. And if I take you back to, to this one here on, on the right, you can see a Codman triangle. So that this is, there is tumor coming out of bone here. Can you see there's a triangle here, then nothing, there's a small triangle here, then nothing, there's a small triangle here, then nothing. These are Codman triangles. These are highly aggressive tumors. They're growing very quickly. OK? In the middle, there is a sunburst as you can see. All right. So these are, these are the things you're looking for and I've just taken you through this. All right. So a patient, how do they present in primary bone tumors? Mastotic bone disease is similar symptoms, but a totally different patient, right? So primary bone tumors, they can be found as incidental findings. So very common that you'll see benign primary bone tumors completely incidentally, they sprain their ankle. They had an X ray of the stomach in the distal tibia. It's an irrelevance, OK? Or you can actually fracture through them. So you, so you have a, you did have a traumatic injury and you say you've broken your proximal humerus. But when we look, there's actually a benign bone tumor there and you've broken through it. Ok. Fine. You've got a primary bone tumor. You might have broken it anyway. It doesn't really change too much. Ignoring that patients have a few symptoms. The most common is pain. So pa this is pain and, and, and the key thing is it's pain which continues when you take the weight off of the skeleton. So this is sometimes referred to as night pain. It's not pain that only comes on at night. That's obviously not impossible. Ok? It's pain that doesn't resolve when you lie down and you take the weight off of the skeleton, which is unstable by virtue of the fact that it's got a tumor in there. Ok. So you, you have pain which is present a and, and, and at, at night, it's not worse at night, it just doesn't go away when you lie down. And can you, I, you know, I know all of you are probably in sort of early twenties, you probably still remember having growing pains and, and, and for that reason, lots of adolescents are diagnosed with growing pains, cos these are such rare tumors that can make sense that that would happen to begin with. And the average delay from a patient presents to their general practitioner with say an osteosarcoma or urine sarcoma, say they're 14 or something like that somewhere between four and nine months is the most common time frame to be then referred in as then having actually a primary bone cancer because they're often misdiagnosed as, as growing pains. The next thing is if there is extra osseous expansion, if it's come out of the bone, then you may feel a AAA massive tumor and very aggressive tumors that is not uncommon at all. So they might come in with say asymmetry of their calves has come out of the tibia and they've got an asymmetric calf now, for example, and then one, just to always remember is Ewing's sarcoma, that's more of blue round cell tumors. Ewing's sarcoma is sometimes called the Great mimic. And that's because it can mimic other things that are more common and it also can respond to that treatment of that problem. And the most common thing is osteomyelitis. So it can have very similar radiographic appearances, clinical features, osteomyelitis. And if you don't get a biopsy and you treat it empirically, which cos IZED in Children is extremely common then compared compared to an adults anyway. And as an orthotic, you might not see it ever if you do something else, right? Which is very common for us. Um Is the patient will come in with a fever and a sore leg, da, da, da, da, da. You give him some antibiotics and they actually get a bit better, but then they, they don't already transiently respond to that. Ok. The other thing. So the other, that's the thing about you just, just to remember, they're a great mimic. The other thing it can, it can mimic is acute uh lymphoblastic leukemia A L they can have very similar presentations and that's cos it in, uh you can get the head of the, um, an ARB sort of b symptoms of leukemia lymphoma. You get fevers, you get itchy in the bath. There's a few weird things like that anyhow, signs, a sign is usually impressively nothing. Ok. So if it's intraosseous, they, they may still, they may have nothing to find at, at all. If it has, if it, if it's come out of the bone, then you may feel a mass and that mass would be tethered to the bone and the tissues would move over it. And the lymph nodes are actually pretty unusual because I've already told you hematology spread, it doesn't spread through lymphatics. Some of them do. Ok. So a few of them do but not many. And so for that reason, lymphadenopathy is, is not a common thing to find. Ok. How are you gonna work them out? Well, if you think someone's got primary bone tumor, they get something called a triple assessment. There's a history and examination and some investigations, the investigations are blood. It depends on their age, what they're gonna get. But you're gonna get essentially things that look at the metabolic turnover of bones, things like lactate, dehydrogenase alks calcium or phosphate. These are, these are all helpful. They're not really diagnostic. They may have an anemia of chronic disease. All right, depending on how offers any bone marrow involvement, Ewings, which can go to the bone marrow. Um So these are things that you would look for on, but it's not diagnostic per se imaging though is very helpful. So, imaging depends where you're looking at. We always start with a plain radiograph. An ultrasound scan will be the will be the investigation of choice in soft tissue tumors. But for those of the skeleton, an MRI is better. Now, you may have been, you, you will know, I'm sure that CT scans are better at looking at the skeleton than MRI S MRI S. Look at soft tissue. Thing to remember here is that tumors are soft, they're not made of bone. They may try and make some bone like matrix, but they are themselves soft. They're like a jelly type consistency. These tumors. So an MRI because they are soft tissue masses, although arising within the bone, they're still primary bone tumors. Even if they're bone forming, they still soft. Ok? An MRI is what you need to do, ok. And then everyone will get a CT chest to have a look for any metastases. And the last thing is to do a biopsy. Ok. The biopsy is the only diagnostic test now, a bit of sort of medical philosophy here in a way we don't really make diagnoses very often as doctors. You, you, you make you, you make a best guess based on the history physical examination and investigations, but to actually get a diagnosis of something, there aren't many ways to do that. Right. You have to get a microbiological or histological diagnosis. So that, that's basically any way you can diagnose anything. But how often do you do that? You can't, you, you, you don't, you look at the, you say on the ba balance of probabilities, everything is correct. It's probably this, right? But in tumors you do have to biopsy them. OK? And, and this is something called a Jamshidi needle. Um it's big, OK? And that's because you need to push it in through bone, you need to take a biopsy from the inside bone, right? But and I'm gonna go through biopsy and then one of my sequen my slides here and get you to think about how, how it would be done. So, bone biopsy, all we need to do a bone biopsy. And bo box has a few principles. The key thing is in this, this green box here is that if you put a needle into a tumor or a knife and you put it out, all the tract that you created has been exposed to the to the tumor cells on its way out and it is therefore contaminated. So what that means is if you biopsy something, it's not just a, a benign thing, I'll just stick a needle in and take a sample. You have, you have to think if it's malignant tumor what is the next definitive step? Because you have to then biopsy it in such a way that when we do that step, we can take out that tract that's very important. OK. And the other thing is you mustn't be close to things which you can see it onto, it could then grow up along. And so the new aas structure is very important. Ok. So what you don't want to do is do exactly as I've just described great. It's some definitive skin incision goes through one compartment, pull it out actually. And then you, you see some onto a nerve sheath or onto a vein and it just rapidly grows up that, that plane. OK. Then that's a big problem. If you could tell it in a roster structures, the patient will need an amputation. So um this is not a benign thing. You have to think about it. OK? If we do it open, that's slightly different because bone is hard. Sometimes we really have to, we have to do an open biopsy to drill into the bone, to take a sort of a, a trap door off and then to take stuff out of the bone for the biopsy. There are lots of things that you add in, but we're just gonna talk about the percutaneous one really for the purposes of today. OK. And then how are they gonna be treated? This is the sort of the last one and then the rest is all gonna be like the in theater stuff and hopefully a bit more interesting and less TG. So the great thing about orthopedic oncology is it is a truly interdisciplinary specialty. Ok. So you as the surgeon are, are just one cog of a really big team that look after these patients and you will, you will see that reflected in other specialties. There are still students here. So you will have gone through upper gi lower gi and, and these teams all, you know, they all work as M VT S but orthopedic is not really. We're in a silo a lot of the time, right? We just work as orthopods. That's why you can have orthopedic hospitals just on their own. So, just go to orthopedics there. This is one of the few subspecialties where we genuinely work, isn't it? And it's a strange and it's such a great way of working. I love it. So, surgery, our thing is, what's the diagnosis? How do you treat it? That's alongside the oncologist and as a surgeon, I have two options, which I'll show you the next slide. I can either chop my leg off or arm off, you know, pelvis off or shoulder off, whatever, or we can try to salvage the limb. And I'll come to that in a second. You work with the oncologist. It's a very niche area. There aren't that many oncologists that go into sarcoma. Um, they're excellent, in my opinion. Right. And then you'll have those that are sort of the medical and then you'll have the, the oncologists who deliver radiotherapy and they're a slightly separate group of um, of oncologists. So, medical oncologist and clinical oncologists are two terms for those. Ok. And then the rehab. So if you, if you do do um, limb salvage, they're gonna need some sort of rehab. If you chop the limb off, they're definitely gonna need rehab. Ok? And so, and you may need to work with medics that specialize in rehab. Physiotherapists, occupational therapists. Really importantly, and you won't see many of these in your training. But prosthetist people that design and then create and fit and monitor prosthetic limbs, either of the upper or lower. And there's specialist nurses and we have a specialist sarcoma nurse who's full time attached to our team who will come into the consultations, um, when we're breaking bad news and, and offer for serial visits for patients who have a sarcoma. Yeah, she's great with Ashley Brown. She's an extremely valuable member of the team. Ok. Right. Then let's, let's talk now about orthopedic surgery. That's why you're here on a Friday evening. So, the, all the, all the next bits are gonna be talking about about surgery and what I hope is that it will illuminate some things and, and be of interest. I hope more than, more than this sort of teach you a bit, which you may wanna have heard before. Ok. So, limb preservation is the gold standard. So what, what you used to do if someone had a tumor? Ok. In, in the extremities of the limbs, you should drop it off. And that's actually a very effective way of treating it. Right. So, like the unquestionably effective, but it's not the most humane thing. Ok. And it's al also not the best tolerated I II go twice a year to Malawi um, er, to a hospital in, in one of the cities in the north though. And this is how they still manage. Uh extremity achieves against because they haven't done anything else but, but we do. All right. So, so we have access and, and really the financing and then, and then the opportunities, training, limb preservation, sometimes called limb reconstruction would be the other term here. All right. So what do we need to fulfill to be able to salvage a limb, to preserve the limb? OK. We're, we're gonna have to put things in, all right. But, but the limb will still look and function like a limb. So a few things, the surgical margin. So this is just a key concept in tumors in general. OK? Is the margin. That is the the cuff of normal tissue around the tumor that you have excised with it. OK? There is no gold like standard on how much normal tissue you should be taking when you excise tumors, both bone and and soft tissue sarcomas, the bigger the better, which is why amputation works. Ok. But on average, you, you want about the only consensus statement that I've ever found ever is the French orthopedic college as I do, who said two centimeters? But papers go between five mil to 50 mil. Right? It can be, it, it, it's really quite discrepant and sometimes you can't take a margin that big. So you might do limb salvage anyway, you know, it might recur and then you'll do an amputation that is also reasonable in say a, an adolescent or a child, for example. Ok. So the margin is important. Can you get a margin? There are different types of margin. I've written that a green box there intralesional. Sometimes it's called debulking. You hear a lot about debulking when you do neurosurgery, debulking tumors in the, in the cranium is important because it takes pressure off from the ma da da, da da da allows the um ventricle to drain and so on. OK? But it's not curative. OK. But intralesional. So that's not a thing you should never see intralesional excision in orthopedics. It, it doesn't make any sense. If you, if you can't get a margin, you amputate, that's it. Unless it might be really, really close. But they young, you think you give some radiotherapy, it might work and then you might try and that that'll be a discussion obviously with the patient, their family. And right, the next thing is if, if, if you get a margin there, there should be no major traverse in your v structures that have to be sacrificed that don't have collateral fallen. Right. So, there's no point in keeping a leg or an arm looking like a leg or an arm, but it doesn't function like a leg or an arm and, or worse, it gets painful in your own. So it's sore. So that isn't a thing. It should never be a thing. So what you can't do is lop it out, put a big slab of metal in and give them essentially a biological prosthetic limb. Ok. That isn't OK. That would be a bad thing to do. Ok? You need to be able to cover the tissue. So we work very closely with plastic surgeons here in Lothian and at some of the very big reconstructive cases, plastic surgery will come and give us a hand with if, if with flaps or local coverage because that's our, with our, our area of expertise, last, a patient should be in good physical condition. So if a, if a patient has a chondrosarcoma in her eighties, if you, you know, you rehabilitating from a massive liver salvage procedure is a lot harder than rehabilitating from a, from a amputation. So you might say on balance here with the function requirements, we be elect to amputate and try to salvage something. Ok? Ok. So, endoprosthetic replacement is a term that I don't think many of you will have come across. The other term for it is, is mega prosthetics. OK. Or mega prostheses. The there is a key distinction which I'll come to you later. But look, if you look, I'll show you some examples and then we can try and work out what they, how they differ to other things. So on here, here is a right, total femoral replacement. This is a left proximal femoral replacement. A right distal femoral replacement and a right proximal tibial replacement. You can do some other things in the upper limb. Ok. I'm just showing you lower limb um because it's far more common. Ok. So, e pr so we'll, we'll sort of come over, there's a little bit more uh in the coming slice. So if you don't get any extremity, primary bone tumor, unfortunately, there is a high burden of primary bone tumors in the pelvis. Pelvis is obviously a much more difficult challenge. Um It's a complex bone in its shape. It has a lot of traversing uveal structures and it has the hollow viscera of the abdomen sitting within it. Ok. And you know, the bladder rectum and so on. So it's a, it's an important area of orthopedic oncology. You tend to get chondrosarcomas here and therefore, the patients tend to be a bit older somewhere between 5070 by much. Ok. This here is the anything classification of pelvic resections and it just shows you that you can have tumors in different regions and they are of different differential importance. So if you look at type three first, which involves the superior and inferior pubic remi. On an X ray of this, actually the iscu tuberosity in the pubis in real life. But on an X ray, you would call it the former that is a non weight bearing area of the pelvis. So you can just chop that out and the patient might have a bit of pain around the groin cos some of the abdominal muscles that insert there have come away. But the patient will be will, will just get up and walk no issues. Similarly, for type one, if it, if it involves mainly the blade here, ok, up towards the eye of the out crest, we can just chop that out. Yes. Again, some abdominal muscle insertions. But from an ambulatory perspective, the patient will be fine. The same isn't true if it involves a bit of bone bag here, it's called the posterior colon and the acetabulum that that is different. But again, type one patients will generally do quite well. Type two is the problem you take out the socket of the hip. Yeah. And that's difficult and you have to be able to reconstruct that in a much more tricky way. And type four here is, is the sacrum. Important thing about the sacrum here. If you look at it's the left, the left hemisacrum that is annotated, it's lateral to the foramina, that's 123 and four. If it was media or two, it would involve all the neurological structures. And so that would be a, that would be a significant problem. You do see them, unfortunately, you have to do a total sacrectomy or total take out the whole pelvis. That's, again, that's a big problem. We do do that. OK. That's called an internal uh sorry, an external heavy pelvic. So we do do that. Um But it's very mutilating. Um but we do do it. OK? Lovely. So some examples of those incisions here on the right is a, is a, it's a type one going back here. It's a type one on the, on the right hand side. But this column of bone at the back, this thing called the the posterior column has been removed. And therefore, in this case, we've had to reconstruct it with a, with a strep graft, femoral strep graft to hold that on to uh L5 on the. Oh, this is here is, is, can you see the the the limb is, has been amputated here in this one on the image on the right of the screen, it's the left uh external hemipelvectomy because the patients had their leg taken off here um alongside the pelvis. Um the top, the top of the screen, this image here shows a, a big excision where we just leave the leg. We haven't had to take the leg off. OK. So this is now called an internal hemipelvectomy. And we just allow that leg to sit in space now that, that actually functions really well. Not, not for you and me. Ok, it wouldn't for you and me. But if you're a 75 year old with a chondrosarcoma and this is a life saving procedure, this gives you a short leg. So you need a, you need a, an orthotist to help make you get, make you a shoe, ok? But this is a painless problem and patients can walk on that. All right, they're not gonna be going up, Ben Nevis, but they can have a, they can have a functional lifestyle with this. OK. Albeit with a short leg. This here is a nice reconstruction. This is, this is imaginatively named the, the Stanmore ice cream cone. So there's like an ice upside ice cream cone that's been pushed up. Yeah. OK. And it goes into the really good bone just left of the sacral joint. Um And so we've got a rebar on the top there and there is a slightly old thing here in, in, in the, in the thing, it's called a resurfacing. So that's what Andy Murray has. Um You don't see many of those in the UK. We do do that from time to time. And then this is sort of like Game of Thrones. It's called a modified Harrington procedure. It was very cool. I only done a few of those uh in my career. All right. And then the last one as a sort of pie in the sky. Um Before we talk about the in theater things for the last 20 minutes, is this cool procedure? I've done two of these and they're amazing, right. So a Van Nes Van N Rotation Plasty. So for patients that have distal femoral or very proximal tibial, usually osteosarcoma, occasionally Ewings, usually osteosarcoma. And so I'm gonna go back to that. It, it's almost always distal femoral. So in these patients, you could in general, this is for a massive tumor that is involving the some of the neuro neurovascular structures. It doesn't have to be what it often is. And in that patient, you would think about doing an above knee amputation. OK? And an above knee amputation is, is not a good amputation. So when you're walking with an above knee amputation, it takes per step about it. It it varies a little bit, but it's around between 70 100 and 20% of the extra effort of walking with two normal limbs. Ok. So per step for your energy expenditure, let's say 70 has the lower estimate. But different papers say a bit higher. So that's a big problem. Someone with a bologna amputation done on an elective basis and not for a vascular condition is a 10% energy expenditure differential. So the aim of this procedure is to give someone who would otherwise have had an above knee amputation a below the amputation because that is functionally better. They have a knee, they have more options for the limbs, ok? For the prosthetics. And in terms of the energy exposure, it's much less and that preserves some of the joints, particularly the hip and the lower lumbar spine. So that's valuable. So in a, in a Van Nes, you, you essentially take out a distal female, proximal tibia, you turn the tibia and the foot back to front, ok. So you leave enough tibia as you excise the femur. So that then your ankle sits at the same height as the contralateral knee and then that foot is pointing backwards clearly. OK? You reattach the vascular supply, we reattach the ner well, the nerves actually are usually OK. We, but sometimes they're not, we do tendon transfers and that gives you this, we do this for plastic surgery. It takes, it's an all day procedure as I'm sure you can well imagine. And this is the famous case. This isn't that our patient? It's the famous case, someone in the US who went on to do ballet to a high level with rotation plasty. So really cool stuff, you see your patients a lot for 10 years as a minimum follow up with the orthopedic team. OK? Very frequently for the first three years because that's when most recurrences tend to happen six monthly for the f the volunteers up to year five and annually thereafter, each time they get a chest X ray and an X ray at the site you have, you have managed and then they will get CT chest depending on what that their primary tumor was. And, and also whether they had any pulmonary metastases at the time. Ok. So, um you see them for a long time and what's brilliant about the specialty is you really just know your patients, um, and you see them for years and years and years and those that, that the history have never come back, you'll keep seeing them because they've got mega prostheses in and you will need to do more surgery in their lifetime to them. Ok? And they'll, and you'll be the surgeon who will need to do that. So, a really privileged area of practice. Ok. That's orthopedic oncology in a nutshell. It's a great area in a great team, doing great operations and ultimately saving lives, which you don't do much of in orthopedics. Ok. And that's fine actually because we do lots of other great things. But saving lives is what we do often. This is one area where you're saving lives and it's, it's a really great area. So let's now think about the whole, the remit, forget you can forget as much as I assume that you'll know. Right. Remember what you wanna remember, whatever this is, the, this is the stuff which I hope you'll find more interesting is thinking about. Now being a surgeon, a deep dive into orthoped, thinking about being a surgeon and I think you're gonna have o there's others in this series as I understand that I haven't seen them yet. But what I hope is that we'll start to talk to you more about the things that the surgeons are thinking about. Ok, cos if you want to be a surgeon and that's ultimately what you're gonna be trying to get to. The earlier you get there and the earlier you think about these things, the better you'll do, you'll ask more interesting questions. People will think you're better than, right? And you'll get more opportunities. That's just the way the world works. So let me tell you about what we're thinking about when we're, when we're gonna do an operation on to, to Mr or Miss or whatever. OK? So every time we go to the theater for a case and we're gonna apply this and tumor cases in a bit the following things. OK? So theater set up patient positioning and draping. I'm gonna show you a paper in a few slides that talks about the former two theater, set up patient positioning. And so in theater set up, the set up is just unbelievably important, you know, I and, and actually not. So I'm right at the end of training now, I've done all my exams, right. I'm just sitting about doing my last little bits now. OK. Going off to fellowship soon, right? To go and do two years of orthopedic college in London and Sydney. So I have lots now of, of more junior surgical trainees coming through in my reg list and so on. And they're always like, I wanna be able to do this operation, da da, da, da da. And you say, like, slow down, right? You'll get there and what uh but, but to be able to execute the procedure or steps that you're to try you, what is, which you're trying to describe to me, all of this is an important prerequisite. You cannot start the rest without getting this right. And if you don't get it right, and you don't think about it carefully for every case issue, it can, it can cause just, just things to be more difficult than they need be. And trust me, that's not what you want as a surgeon. You want them to be just be nice, chilled, doing your business. Ok? Cos cos things are happening, drops to leave and you don't want the other things to be there. What, what if and when they do so see, set up, I'll show you a slide. Very important thing about or patient positioning, similar thing, you know, in orthopedics, there are loads of positions. If we do general surgery, patients just always lying on their back or their belly sticking up to the ceiling. Ok? But with orthopedics, there we go in. Look, we go in all different areas, all different sites from different ways depending on the problem. And therefore positioning is extremely important and positioning is not benign. Ok. So what you can't do is just slap if I, if I would exercise one of you, well, I could very well. But let's say I tried and I lied. You on my dining table here where wood and I was left you there pretty quickly. Bad things would happen to you. Right? Notwithstanding the fact, like let's say you're ventilated you and you're safe, bad things happen quite quickly. Ok? So pressure sores can happen within hours. Pressure, neuropathies, cos a lot of nerves are subcutaneous and and around bone problems happen quickly. You can have problems with the vertebral arteries from the positioning of the head and chin, which we will sometimes a lot of shoulder surgery will tape the face and the foot in certain positions, ok? And it can cause strokes and other things like that. So it is not a benign thing, patient positioning a patient. And the next thing is you don't want them to move, ok? As it as in when you're doing things, we use mallets, cos bones are hard. So w when you're hitting things, you don't want the patient to move. So they have, you have, they have to be positions stable, da da da and lastly is draping to maintain sterility. Yes, but really importantly is to see the site you're operating on to, to drape out things that are dirty and you don't wanna be in your field but critically it's that if the shit hits the fan and you need to, you need to increase your exposure, you've left yourself the space to do that. OK? This is a very important concept. If it goes wrong, are my drapes gonna stop me? Now, my prep and my drape from them doing what is necessary to them act quickly. Ok? And usually the surgery that's extending things, OK? It's usually making me bigger. The next thing we always think about is antibody prophylaxis. Um that has revolutionized perioperative care of orthopedic patients, right? Putting metalwork into people is a terrible idea, isn't it? Right. Conceptually a terrible idea. You've got a slab of foreign material which has no blood supply. So you can't deliver anything to it. If it gets infected, you can't get any antibodies to it just sat there goes in for a bit, does its job. And then the rest of your life is just sat there doing nothing. It's literally a terrible idea, but you have to do it right. So, so that, so you need, you need to reduce the chance of the patient getting an infection and usually as an ambient something ambient in the, in the air, the theater drops in during the case. That's the most common way of getting a acute infection. Would that work? Anyway. So giving patients antibiotics at induction. Ok. Before the tourniquet is inflated. If you're using one remembers to do that. You don't want to give it be outside the tourniquet. And then if required as a prolonged procedure, high risk patient, high risk implant, you'll give it further doses 1816 hours. OK. To reduce that chance of, if there was an ambient organism in the air of the theater, cos like squames are falling off the face all the time. For example, people are doors are open, they da da you don't want that to cause a deep infection obviously. And th and this changes things we were thinking about. Do they need it again? And if you put metal work in the answer is usually yes and never orthopedist often will get antibiotic. And in VT deterrence again, you know, you, you I'm sure you were all aware of trial. So the patient is gonna be static. It's gonna be sitting still potentially two hours, sometimes four hours. The orthopedic oncology case can take longer than that. It might be considerable number of hours. So you need to have something called an Ts. Yes. And then we use pneumatic compression stockings that inflate and deflate episodically throughout the case to get just to get a muscular calf pump, pushing stuff back up towards the right side of the heart. But we think about this every time. The next is the approach. And this is then when, when I, you ask most of these about surgery, the cutting is what you're thinking about because you don't wanna harm, you don't wanna harm someone quite a small part of surgery. It's an important part of surgery. It's quite a small part. So, the approach and, and I'm gonna show you some common approaches in the, in the following slides. So we think, how are we gonna get there? So this is the problem. How am I gonna get in, what's the best way for this patient? And in orthopedic oncology, you have to use some pretty unusual approaches. You just, you can use all the main ones and then we're gonna need to talk about three common ones in a second. But the tumor will often dictate what you need to do in orthopedic oncology where you need to get to that. So you may have to use some of the less common approaches. We talk about that. Then we're talking about the kit and the implants. So kit is like, mm like a knife and a fork, like scalpel forceps, retractors, all these things, ok? And then kit specific to the procedure you're doing, doing, then the prosthetic replacement, it's gonna be stems and cement and balls and sockets and all these things. Ok? And then you have two, you have sort of two things, right? You have your in plan A, you go, right. Have all that kit ready. This is what I'm gonna use if it all just goes well, da da da no issues. But then you have to think, right? So it doesn't go well or if there's an issue with something I don't, II did anticipate but it happened and I didn't want it to happen. No, da da. What's plan B and C and D and E and, and, and so in the, you wanna say, right? You know, folks can you make sure that this is available? You don't have to open it but just is it nearby? Great um bring it in the room, don't open it. And some say you don't bring it in the room. It can, it can be unopened. But I just want to make sure you know where it is, if I need you to go and get it and they'll be Oh yeah, yeah, it's, it's in this store. Great. But some stuff you say, II don't think I will need it. But if I do, I'll need it quickly. So can you just bring it in to the theater if you don't use it, you can just put it back after the case. So you have to think about these are things we're thinking about a lot and this is a critical one. So with experience, you start to say, well, nine times out of 10, what we're about to do is routine. But if it is a routine, what are some of the challenges based on this patient and their tumor or let's say fracture, whatever, right? What could, what I can I foresee or have I seen happen in the past and how I'm gonna mitigate that. Um, as I go through the case, what things will I change? And all of the bits hitherto 123 and four to much reduce the chance of those things happening. We think about closure and dressings and the last is the postoperative care. So that's what we think about right at home. Let's go through some cases, let's apply those concepts, some orthopedic oncology, um conditions. So thi this is a um a a youngish er sorry, that's not true. This was an Oldish person. I beg your pardon. Patient was sort of in their mid sixties previously been fit and well and presented with an atraumatic fracture of the right hip. Now, if you present anyone presented with an atraumatic fracture of anything, you have to think that's a pathological fracture. The bone must have been abnormal rather than the the energy being transferred to it being abnormal like trauma. And one of the differentials for pathological fractures of bone is a tumor. Ok. There are others. So me metabolic bone disease is a big one. things like pagetoid bone. Um There there are lots, there are lots of others but pages is a big one. Um osteoporosis obviously, but and then the other one is infection, there's a few others, but you think about is it a tumor, if it's a tumor as a primary or is a metastasis? So someone in their sixties, you're thinking and, and in the proximal female, you'd be thinking about metastasis could be primary bone. But, but we weren't sure. Right. We weren't sure. So we, she went through the whole thing. She had a scan, this is her MRI and what this shows is a fracture. But it, but it shows the tumor which has come out of the bone. It must have come out of the bone cos the bone is fractured now. So it might, it will have been in the bone to that point probably. But it's now seeded out into the soft tissues around it. And importantly, I hope, I hope you can see my cursor um cancer is up here and you can see there's tumor coming past the lesser and down into the proximal femur. So, so this isn't just a tumor up in the neck. Actually, it's going down the proximal femur all. So we, we didn't know what it was. So we needed a biopsy. All right. So let's say this is a very simple procedure. So I want you to have, have a look at this and then think about what you would do. So this is a paper. The, the mnemonic is a helpful one to remember. It's called tulips. It's a bit different to an eye. L tulips in this paper, but it's similar. OK. So tea is the table and a tourniquet if you need it. So what table? Not every table's the same. We're, we're gonna need to take an X ray. So it must be a radiolucent table. Not all tables are so it must be radiolucent. That's the first thing to say. OK, and it needs to have the right padding on it such that I can lay a patient anti if they, if they don't move, they don't want no pressure sores, et cetera, et cetera. The next is you and your position. Where are you gonna stand? Where's your assistant gonna stand? And the other for you? That's not here. But what I was taught this as a, as an ST one that was seven or eight years ago. Now, I did an MD along the way. So I've been here for years is use the utilities. So earth wind, fire and water basically. Where do you want your suction and diathermy? Where do you want them around the bed? Ok. L is the lights very important. There aren't only two lights on the ceiling. Ok. It looks like two lights, right? But there are innumerable b like bulbs in there. And that's really important. You don't just have two light bulbs cos that would cast shadows. So you need lots of lights, although there's two big clusters of them. Ok? And you need the lights to be in such a way that you don't generally want it right over the wound. It can, it can be, but you generally would avoid it because you don't want things dropping off, let's say the handle fell off of the, of the light medication. You don't want it to drop into your wound. Ok? For example. Ok. So cos the inside of it was not sterile but the outside was, but so you want, yy, you, you wanna think right? Where can I put them? So, so they illuminate what I need to see how illuminated but they are either gonna drop into the wound or something or importantly, not, you're not in the way of them. So that, that's a common thing you see in more genius surgery. But trainees is, is they'll put the lights and they'll stand in front of it and oh, it's really dark and OK, you think about your lights, you think about your image intensifier. So in orthopedics, you know, we take a lot of x rays in the in theater. So how is that gonna come in and where is its screen gonna be? So I'm not like craning my neck looking around and I can do my operation without looking over my shoulder. Ok, cos you again, you'll see that you might see again that you start doing something and then r over your shoulder, it's really difficult to then manage um the patient and the personnel positioning. So what position does the patient go in? And where do you need your personnel? That's mainly the, the scrub practitioner. That's the new term, by the way for scrub, nurse. Not all scrub practitioners are nurses anymore. Ok. Some of them were, were, were, were not doing, go to nurses school, they were just trained as either O DPS or nothing. And they come up through a, like a, what's called a surgical first assistant pathway. So, um they're called, er, practitioners now and lastly is screen image. So that can either be from the, from the x-rays you're taking, but all x-rays that you need to, to plan the case. So they come to that point you'll display as well, won't you say? Right? We'll definitely do the correct side. Where does that screen need to be? So let's think about it. So we're gonna be doing a right hip percutaneous biopsy of a proximal female. So it's the right proximal female. So this is a schematic. I've put up here with the lamina flow within which everything should be happening. OK? Sterilely is this outer blue ring? The table is the black thing and I've, I've just put like a the blue dot is the head ring, let's just say that's the head of the patient. OK. So head this way, feet that way, right is the bottom of the screen and the left is not doing a right sided procedure. So table, well, we've got a table. It is gonna be radiolucent tourniquet, not required. Where are you in your position? So where would you stand by? I think this is pretty intuitive here, isn't it? You're gonna stand by the right hip So that's uh green scrubs right? In, in loadings. That's that. The next thing is lights. Well, you're using x-rays and this is percutaneous, so you don't need lights. So they're irrelevant here. And that, and you should turn them off if they're on, all they're gonna do is they cause issue with you seeing the image intensifier. Where's the image in terms of about gonna come from? Well, again, it's pretty obvious here just coming over from the left. So it comes over the left and then images through the right. So it's the other side to you. You don't want it on your side here. The screen is that black line image that has the one rectangle. Um The personnel, there'll be a scrub nurse to your, to your right here. You don't have them to the left cos that's where the anesthetic machine is and the anesthetist. So they're always gonna be down by the foot of the bed. And then lastly is the screen image that you're gonna use to confirm you're doing the correct side or that's in the, in the theater in Lothian. It tends to be if you're looking at anesthetists on the left hand side of the room, that, that's just roughly where they are, they some of the, the, the mirror. But that so OK, so nice, nice, easy one to begin with. All right, in a biopsy, we've already spoke about the principle. So I'm gonna skip over them. But you know, you, you're gonna prep the area. You make a tiny incision under II guidance. You put that big jam sheet and needle down onto bone. You push through the cores of the bone and you take several core biopsies which you then send away informa in to the histopathologist and you get a result in about three weeks, a simple stitch at the end and a simple dressing and that's it. Ok. So that's what this patient got. It doesn't take long, it takes about 10 minutes. It's not for the easiest operation, right that we do in orthopedics. Very, very easy. OK? OK. This confirmed it was a solitary renal metastasis. So the patient that you can cure patients who have a solitary renal metastasis, if you treat the renal carcinoma and you excise the solitary metastasis. So that's what we do is we excise solitary metastasis. We've put in here a right proximal femoral replacement. So let me tell you more about that one. So I want to think about the same things that list what we're gonna do here. OK. So let's think about this. So we're doing a right total hip replacement. So we want the patient lying on their left hand side with the right hip uppermost. OK. So it's called the lateral decubitus positioning. The table doesn't matter, you can do it any table you like as long as it's got side supports. So we can attach things to it to hold the patient in that position to all. Ok. No, where are you gonna be? Well, the operating surgeon to get into the hip, there are several ways. In this case, we need to go in from the back that's called a Southern or a more approach. And we're gonna stand behind the patient with our assistant in front of the patient in case you operate from the back here, where would the lights be for this case? Well, in this case, I, you know, as the operative surgeon, you don't want them behind your head, we generally want one coming in over the shoulder and one roughly on top of the patient. Ok. So this is where the lights go for. This particular case, usually have one over your left ear or right ear if you're the other, if it's the other side. Ok? One over your ear and then one pretty much coming straight down on top, not on, as I say, not directly over the wound, but pretty much straight down image intensifier is not required. Oh, utility. Sorry. So this this is supposed to be diathermy which in Lothian is a, it's like a blue and yellow machine. It it's blue with like a yellow stripe on it. That's, that's this rectangle, this is supposed to be suction. Now, key thing about this, if you're thinking about it when you're in theater is we never want these wires coming up and over the patient, we move the legs around a lot. This is all just not moving. So we always have the cables coming in from the head end of the patient. If women who in this case lower limb surgery, never ever have them coming in from the foot of the bed, it's really, really frustrating, very difficult to manage. And importantly, here, I put these two dirty machines outside of our lamina flow. Ok? They should be outside of this sterile area. There's a lot of trays when we're doing this procedure. So the scrub team, the scrub crap will generally be uh just over to your right here and the image, that's it. OK? So just thinking about this is essentially like doing a primary hip replacement, similar idea. But lots of things just to think about before you can even consider cutting a hole in somebody. But if you do cut a hole in, so what are we gonna do? So some of you, II don't know what the spread of years is here. Um But some of you will be preclinical, some of you will be in the clinic here. Nevertheless, this is an important area that will make you look really, really stand out and hopefully it will be interesting for you as well. It's the concept of um an approach. So I I'm very compliant that we're, we're getting low on time. OK? So I won't, I try not to keep you off for too much longer. But um the approach is very important. So the approach is the cut here and this is a Southern or more approach to get into the back of the hip and the proximal femur. So this is called a Southern approach. And whenever you're asked about an approach, so like you know what, what approach we're gonna use? How are you gonna get in similar same question? You have to say a few things beside it's, you say it's common use. So you would say this is a utility approach used to, used to get to the hip and proximal femur, for example. And then you say something which is a bit, it's actually quite a a misnomer here. You say something called an internervous plane. So a lot of surgical approaches are between muscles, lots of them are and the internervous plane is if you're going between the muscles, what nerves supplied those two muscles that you went between. So it's, it's sort of an in it, it's an inter nervous plane, but it's based on the muscles. It's based on the intermuscular plane. So it's slightly, it's slightly funny concept, but that's what it is. OK. So this doesn't have one, this is a muscle splitting approach. It doesn't have an intra nervous plane. OK. But it's based based on the inferior gluteal nerve. So it's a curvilinear incision just off the back of the femur heading down towards the great side notch, which is where piriformis emerges. OK. This is it over those muscles. Piriformis is is here and piriformis is sitting right over the hip. OK? So piriformis is what we're looking for here. So we go through skin, this is the plan. So there isn't one you through skin and fat and that and that reveals the epimedium of gluteus maximus. You come down on to gluteus maximus and that's what you can see here. OK? You open maximus in line with its fibers. So you divide it epimedium and you divide half of its tendinous insertion and then you split blue max approximately. OK. And this gives you the sort of the incision is usually not quite as long as this is a bit longer than you would need for, for, for a lot of things you're doing in the hip. But you know, that's fine and that then shows you down onto a pad of fat. Now, if you ever see a pad of fat sandwiched between muscles, it is almost always perineural fat. So if you're going to your muscle, suddenly, you're saying yellow, you have to say, well, nerve here, you should be anticipating that obviously, right? But if you're not and you're out of pain, we don't know quite where you are. If you see this, you think no, and what nerve is here. Well, the sciatic nerve is here. So this is a, the perineural fat which invests the sciatic nerve which sits around these short external rotators. So what we're looking at here is the shorter piriformis at the top quadra in, at the bottom of them. And then the middle three are indistinct to look at, OK. But they're super inferior with the ter Internus in the middle. And what we do is we reflect those off. So we take those and reflect them back and that covers the sat nerves. So, so that's the nerve that comes into the posterior of the thigh between peri fors and the superior Gellis. And by reflecting those, you pull the satin nerve back and out of the way and you protect it, you leave quadrati on as best as you can. You sometimes have to take a few fibers here. It bleeds like stink. OK? There's a circumflex vessel sitting in there. So it bleeds a lot, but sometimes you have to take a few fibers off and then you can open the joint capsule here, want at shaped capsules for me to reveal the hip. And if we're doing a proximal femur, we then just carry that on down the back here. All right. So that is, that's the posterior approach to the hip. All right. So in that case, we've gone through a few things set up with a simple case instead of a more tricky one. And we've spoken about what an approach is a very common one. You'll see a lot of orthopedic surgery, posterior approach to hip, which was sudden approach. Ok. Lovely. Right. We'll just quickly whistle through the last couple um just for interest. Um So this one here, this is a, a left distal femur, there is a, a scallop lesion here, isn't there. So there's an area sort of punched out. It's a hole in bone on the medial aspect of the left distal femur. This is the MRI of it and it shows actually this is predominant how this whatever this is, it has extra osseous expansion. That's all this nasty tissue here. And it is displacing the muscles in the anterior compartment here. Rectus and so on. So that turned out to be uh that was a chondrosarcoma and the patient required a distal femoral replacement. So let's think about it. A distal femoral replacement. How, how are we gonna do that? So we need to get the distal femur and the knee. If you look at that, the knee's been replaced. Ok. So the knee and the proximal. So we need to see the knee and the proximal thigh and we do that through an anterior approach. So how we can do that. Well, this is how the patients are set up. You know, if anyone's seen a knee replacement being done, it's a similar set up here. So the patient is on their back of supine, they have a side post on their proximal thigh. It has to be as proximal as you can. Cos your incision is gonna be coming up here. I said earlier about don't drape yourself out, giving us enough space. Ya, ya, ya. Ok. And we want this, this, this post under the foot so that we can straighten the knee flex the knee if we need to. And also it's usually raised just slightly off the bed because we can then hyperflex the knee and tuck the toes under the post so that we can bring that up and hold it in the hyperflex position. If we need to table what needs doesn't need to be radiolucent. It just needs to stand table that you can work any patient on. Where are we gonna be? Well, this is a left, isn't it? So the you're gonna be on the, on the left of the patient with your assistant on the right, the er lights here come from the end of the bed and one pretty much from the top your utilities outside uh the lamina flow, the team and the images on the screen always as they are. OK. And then how do you get into the knee? Well, this is another approach type thing. So there is again a, a sort sort of an K, not another inter pain. The last one I can just tell you in the last few years, it does have an inter, this one doesn't. So it's a straight anterior incision. OK. It's called a medial parapatellar approach. So it's a, it's a longitudinal skin incision down through skin and fat and then a medial parapatellar approach. So we take out this is, this is the, the quadriceps tendon, which is a shared tendon between the four quadriceps. We leave a small cuff of it on its medial side here. This is a muscle called vastus medialis. But these fibers that are called the obliquus VMO. So we take off the VMO and we come down just lateral to the patella tendon here. And that gives us our arthrotomy, takes us into the knee and then we flip the patella over and that exposes the knee. And again, there are lots of approaches to the knee, but this is a common one that we use a lot. OK? And I'm gonna skip that just for time. It's the last one then just uh slightly a slightly different case. It's upper limb cos I'm pretty sure it's been lower limb heavy. This here is a, an expander C lesion, isn't it? In the distal radius? Um It looks nasty and this is a s and this is something called a giant cell tumor of bone. There is a giant cell tumor of tendon sheath as well. There's a giant cell tumor of bone. It looks pretty nasty. There's extra osseous expansion so that you can see that you can, the courses are broken here, you can't draw around them. So there must be extraosseous expansion. It's gone into the soft tissues in, in earlier parts of this disease. You don't have to do the operation. I'm about to show you, you can just take out the tumor. This is actually, it's funny, it's called locally aggressive. It's actually a benign tumor. Weirdly. It metastasizes but it is still benign. It's quite hard to die of this. Um But it, it's very aggressive locally and this is a cool case. So this is one we'll do quite often here. You excise the distal radius that's done through the front of the wrist. They go through V here, but you can see the players on the back, on the dorsal side and we're size the distal radia. So what with the tumor in it? So what is this? So this is actually someone's this patient's fibula. So we take the patient's fibula from the ipsilateral side to the left ankle on a, on a pedicle, on its artery and we plumb its artery into the radial artery with the plastic surgeons. And then we fix it all down with this bridging plate. And we give, this is essentially something with a wrist fusion. So the patient can't, can't flex or extend the wrist, but they can still pronate and supinate and they have good power. OK. So this is a, this is a, a case that you need for G CT. So how will we set this one up? Well, this time, we have to turn the table 90 degrees and to present the arm into the, into the theater. So where the, where the legs would have been in the last cases, right? We need three surgeons for this. We need someone to take the frill gra from the left ankle and the surgeons sat in the axilla and their assistance sat up by the head about the arm utilities here coming this time because we're operating on the arm predominantly, we're gonna have them coming in from the bottom of the table from the feet. And so the cables are out of our way, the lights, they have to come in from the distal approximate end of the arm. Otherwise we just illuminate the back of our heads. We take a lot of x rays and it's really hard to squeeze the X ray machine in the image intensifier in the eye is what it's calling it. So the IR has to come in obliquely by the assistant's feet. Ok. It's quite, it's quite awkward, but it's the only way to get it in with the screen just on the, on the surgeon's right shoulder. So here they can see it, scrub team will be done here and then year old. Is that all right? And how do you get into that? Well, there's lots of, there's lots of ways into a risk, but the most common here is the, it's called the F CR approach or the modified Henry's approach. And this one does have a proper internervous plane. So in this particular case, you're going between flexor, carpi radialis and Flexor Pollicis Longus FP LS by the anterior Antero nerve and F cr is the median nerve. So you would say this is a common approach to the ulnar aspect of the distal radius. It's based on an inter nervous plane between the anterior interosseous nerve and the median nerve supplying F PR and F cr respectively. That's how you would start that question. Maybe not as a third year, but as 1/6 year, he wants to do surgery, Maybe you go through uh it's a longitude of incision and, and the incision to the v forearm is a straight line from the lateral aspect of the biceps tendon. OK. So the radial aspect of the biceps tendon all the way to the radial styloid. So you can do one long incision there. So this is the distal third of that incision, you're through skin and fat. There's not really any fascial layer here. It's very thin that you just come down to flex carpi radialis. OK. Which is this tendon here, you open the sheath of flex carpi radial artery, it comes out as brilliant sort of white tendon appears. Now, what you have to notice here is that the radial artery is abutting it. Ok. So, and, and it's non pulsatile cos it's a tourniquet on. So you do, you can, you can feel it but it won't be pulsatile. You attract F cr ulnar would and that pulls F cr and the median nerve out of the way and then you retract F PL which is the tendon here. Flexor pis longus, uh ulnar W as well. Once you've retracted F PL, yeah, which is under the retractors here, under the langer. Back. In this case, you get onto a square muscle pronated quadratus quadratus and his fibers run medial to lateral. So all the other muscles and tendons are running longitudinally and you then come down onto a muscle which is a square firstly and its fibers are running medial slash medial and you divide that and that takes you down onto the radius. I see. All right. So that was a, that was a deep dive um into orthopedic oncology. I'm just gonna stop sharing my screen. Um I'm sorry, we've run over, that's not great on a Friday. Um Is there anything at all that you would like to ask about anything I've said today? Um or anything idiosyncratic? Um very happy to take questions. It's a R mm I think because I guess we're running over time. We could just, if everyone could just, if you have any questions, you can put it on the feedback forms. We appreciate any feedback we could get and then before the mister, if there are any and then we could just let you know and then we'll e email the rep replace back to you. That sounds good. OK. More than folks. Yeah. In which case, enjoy the rest of your Friday. Yeah. Thank you for coming. I won't keep everything too long. But if you guys could fill up the feedback form, that would be great. And do check out our med all as we have a conference happening next Saturday, which the theme being inclusivity and accessibility in orthopedics. So do check that out and other than that, thank you everyone and have a good evening. Thanks all. Bye for now.