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Um the. Ok, I could see. Ok. Uh we're just uh uh we have everything prepared. We just gonna start at six o'clock. So good to see everyone for another talk. Ok. Yeah. Yes. Yeah. Ok. Ok. I, I Mhm. Yes, I, I, I, so far we have three viewers but uh there probably will be more joining. We have had 15 sign ups just sure this morning. But yeah, don't worry, not to worry. It doesn't matter how many it's um by creating the content for the future doctors to have a look. Ok. Uh welcome everyone. Thank you for joining us in another talk of Deep Deep Dive series in this series. We are interested to have a chat about different sort of subspecialties in orthopedics to provide a better insight about uh what to expect, what to prepare for and uh answer some of your questions about this subspeciality. This is our fifth stop with Mr Simon Barker with uh who is a orthopedic pediatric surgeon. Uh Mr Barker has trained in Guy Hospital in London and currently working in Aberdeen. Uh He has kindly allowed us to have a conversation with him so that he could share his experience about orthopedic pediatric surgery. So without further ado I would just leave the floor to Mister Simon, Mister Barker for you to take on. Ok. Well, good, good evening folks. Uh Thanks for spending a bit of time with me this evening. Um, so I've been a children's orthopedic surgeon now for, oh, like 20 years. So, um, I suppose when II was asked to do this, I thought to myself, um, what, what, what II decided to do this when I was a medical student. Funnily enough. Um, II was interested in children's orthopedics back then, but not everybody makes those decisions straight away. And you've got a broader range of opportunities as medical students to choose from. I appreciate that. So, er, I thought I'd try and give you a sort of in a bit of an insight into what makes me want to go up, get up in the morning and go to work because I still enjoy my job. It's greater and there's some really, er, exciting aspects to working with Children that I want to tell you about. So, I'll, I'll, I'll talk first of all just to give you a bit of an intro. So, what's the sort of goal as a children's orthopedic surgeon? If I had to put it down in one sentence? It's a bit of a mouthful of a sentence. But I do think we're about, um, trying to sort of fulfill the potential of Children uh we're trying to support them, fulfilling that potential through aspects of their growth and development, which of course is normal, um, trying to achieve what functional goals that they might have. We don't want to, er, invade their, their body with, er, surgical instruments more than we have to. And we certainly want to limit any negative impact of our actions upon them. So there's quite a bit of uh tension around ii in those goals to trying to make sure that we do the least harm and the most good for each child that we operate on. So the first of those sort of aspects to our goal is to look at sort of growth and development. All Children are going through a period of growth and development. As you know, from infancy through to about sort of 1617, 18, we are changing um at different rates at different moments in that process. But um as we go through that, it's important that we try and anticipate what the needs of that child are gonna be as they go through growth and development. Now, some of those changes are our friend and I'll talk about those, some of the aspects of growth and development help us to um to achieve better results than we would otherwise achieve. We can harness that growth and development for the child's benefit. And sometimes it can be to our disadvantage and make it more tricky and make it more difficult to navigate what we're going to do. So, just to say that that's a very important consideration for probably pediatrics as a whole, but certainly for children's orthopedics as we deal with people growing and developing. And we have to think carefully about the impact that has on the actions we might, we might take as ts orthopedic surgeons. So the next thing is a little bit about functional goals. Um, different people, different families, different Children have different functional goals. Not all of us are gonna be cont pianists, not all of us are gonna be athletes. Some of us have far more limited functional goals but nevertheless, very valid ones. So this child with cerebral palsy wants to be in an erect position so that they can interact with their peer group so that they have a an ability to, to um interact in the classroom or the different settings. I mean, that's a clinic, but you would use this particular piece of equipment out in the community or particularly in school so that you can interact better with the people in the, in the class with you. So um some functional goals are pretty limited compared to the more elaborate ones. Sometimes it's about communication and sometimes it's about simple adaptations to enable people to uh to use instruments and implements that we would take for granted. So we're gonna be really aware about what the goal is for a child. And that's something that drives us as Children, orthopedic surgeons, we want to make sure that what we do is is goal focused. We're not just doing things for nice x-rays and for nice outcomes that we, that we pat ourselves on the back. We want the the child to have an outcome which is gonna be pleasing and helpful to them. And then you've got this interesting kind of balancing act between not diving in with surgery that you don't need to do and having a minimal impact on the on the child. There are huge numbers of appointments out there for Children, come to Children in orthopedic care that they come over and over and over again and it can gobble up an awful lot of their time, particularly if they've got complex needs and they're going to see other pediatricians with their diabetes or their heart problems or whatever they can end up spending aid portion of their life in hospital settings. So we don't really want frequent interventions. That's, that's an un um deir thing for Children. And we've got to think a little bit about whether the cost to the patient versus the benefits that patient is, is worth doing. So, one of the obvious examples for that would be in cerebral palsy. So there's something that's been dubbed shark attack surgery. That's the sort of picture on the, the left there, obviously. Um And what that um sort of rather um gruesomely summarizes is that sometimes we go in and we do, um, what is more politely called single multilevel surgery. So, we're doing a lot of surgical dose at one moment in time to try and, um, address the deformity and problems that the child might have versus what's called birthday surgery. The picture on the right where traditionally people used to come back once a year ie birthdays and, and have, uh, yet another procedure at once every year down the, down through their whole childhood, which of course puts them an awful lot of time in hospital. So there's a trend towards doing as much as we possibly can at one moment, which we can do safely that we know will benefit a child rather than sort of eking it out bit by bit over the over time. So that's an important consideration we have to factor in and then I think what I wanted to do next, er, having talked about that, that goal direction that we have is talk a little bit about what makes it challenging to me. Interesting to me as I, as I, as I practice my, uh, my um specialty, my subspecialty. So four titles I kind of came up with that I thought would be in, that might be interesting, maybe not. But uh first of all, something about physiology, uh that's to do with the growth and development of, of bone and we'll talk about that in a minute. Then a little bit about when things go wrong. When, when when formation doesn't go well. Um And then a bit about skills and adaptation and then finally, a bit about the process of how we cognitively go from being dependent to autonomous. Um I'm not spending a long time on the last one, but it is an important part of what we do in terms of how we um process the decision making for a child. Um You know, when they're young, they have um an awful lot decided for them, but over time that changes. So we've got to factor that into our thinking as well. So these four things are sort of headlines that I think make my life more interesting than it would be if I was just doing something else. So growing bone, that's the one I want to talk to you about a bit first. So you'll have heard about all of this stuff, I'm sure already. But uh physiology of pediatric bone bone structure, um You've got periostal ligaments that support the, the joints and the bones themselves and the fiss, of course, which is the growing plate of bone, enabling longitudinal growth of the appendicular skeleton. So that, that's pretty basic stuff you'll have heard of all of that. Um But here's the kind of more interesting thing that I don't think gets emphasized very much that when we think about the structure of a child's bone inside it, there's more collagen than there is in an adult bone. There's more porosity, more holes running through it. There's more cellularity and there is more plasticity. In other words, more bendability of that bone.