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Welcome everybody and thank you so much for turning into this live case discussion on complex lower extremity trauma. It's really a pleasure to be here today. Uh This conference is presented by the faculty and staff of the Harvard Global Orthopedics Collaborative alongside Sona Global. So, the Harvard or Global orthopedic collaborative is a group of Harvard affiliated orthopedic faculty and trainees who are dedicated to improving access to musculoskeletal health care globally. Sona Global is a nonprofit organization which aims to improve essential trauma care by providing free virtual education like this one alongside affordable devices. So Sona Global is actually developed a low cost negative pressure wound therapy device and affordable external fixator. Uh You can learn more about that at Sona Global dot org. Um So all of us at H G O C and Sona believe that high quality education and training should be available to all regardless of where you work. So when we collaborate, share ing knowledge, ideas and also our challenges only then can we work together to improve orthopedic surgical capacity worldwide? So it is our pleasure to uh to organize educational webinars such as this one, fostering dialogue between colleagues all around the world. So, next slide, please, we are very proud to be running this conference in collaboration with the South Sudan Orthopedic and Trauma Society as well as world orthopedic concern. And you'll get to know a lot of the faculty associated with these two organizations today. Next slide. My name is Karen Augur. Well, Harding, I'm the director of the Harvard Global Orthopedics Collaborative and I'm joined by my co chair, Doctor Brian Madison from South Sudan. Brian. I'll let you say a few words. Yes, hello everyone. Uh uh Sorry, I think I'm having a lot of echo here. Uh But my name is Doctor Brian Morrison and thank you very much for joining us in this course. Um I'd like to take this opportunity to, you know, thank everyone who uh is contributing uh for the success of this conference. And we're really, really thrilled to launch this uh conference in collaboration with Harvard Global orthopedic uh collaborative as well as on a global and sorts. A lot of heroes have been doing a lot of work on the background and I would like to thank everyone, especially Doctor uh Yak Kieran and in the, in the, in the team, the faculty behind uh my, also, my prediction also goes to the to the team from sorts for, you know, taking some time and uh prepare these presentations. I would like to take a moment to express our sympathy with the Sudanese people. Uh You know, they've been in, in a bad conflict. And uh you know, these, these are two nations which bound historically. And uh we have a very big South Sudanese community up in Sudan. We're caught up in the war. So we would like to appreciate by sympathy with them and we hope that everything goes well. Uh apart from that, uh welcome to the, to the conference and I hope you guys have a full, full discussion. Thanks. Thank you Brian and thank you for those words in solidarity with the Sudanese people. We uh you know any, any war is horrible. And so uh you know, our thoughts and prayers are with all those who are affected. Um Next slide, please. So today, we have some really remarkable cases for presentation. Many cases will be presented from our colleagues in South Sudan who are very proud to be running this conference in collaboration with. We'll be hearing from Dr my poor doctor, oh Majak, Doctor Brian Madison, of course. And Doctor Emmanuel Obor, next slide, we'll also be hearing cases from all around the world. We've got Doctor Abraham from Addis Ababa, Ethiopia, Doctor Merriam Jufer from Gambia, Doctor Wahidullah Mohammadi from Afghanistan, Doctor Marcella Ryan Coker from Kenya, Doctor Daniel Issue Toe from Kenya, um and Doctor Walid shut off from Yemen. So I really hope that you'll enjoy these cases next slide. And of course, we have really remarkable faculty who are here to provide discussion and flavor to the conversation as well and their commentary on the cases. So from world orthopedic concern, uh international as well as the UK, we've got doctor in them Banerjee and then Doctor Deportivo's uh from University of Missouri. We've got Doctor James Cook and Doctor Gregory Della Rocca next slide uh from W O C Doctor Mohamed Fadel. Um and then from Yale, Doctor David Fromberg from Ethiopia, Dr Ephraim Ghabra Hama and from Brown University Dr Roman, I'd up next slide uh from University Missouri, Doctor Mauricio Kuri from Gambia, Doctor Kevin Marina from University Missouri, Doctor Kyle Schwitzer and uh my partner from Harvard, Doctor Jack Winstead. Next slide and of course, uh you know, to echo Brian's lovely comment earlier, I really, uh you know, have to give, give my thanks um uh to this amazing team at H G O C and so on a global for having organized this all of the educational videos that you guys found online, all of the course content that was curated and put together, you know, really big thanks to everybody who was involved. And I have to give a special shout out to Yak Mac who was running the slides right now and uh was the person who really established this connection between uh between South Sudan and H G O C. So thanks so much for the entire HBOC and SONA team. Next slide. So today's agenda, we'll have a brief introduction which is almost over now and then we'll move straight into uh session one where we'll talk about traditional bone setter related complications to presenters from South Sudan will be getting, taking us through those cases. Then we'll have a brief break and then come back for session to one complex polytrauma. We have some great cases for that one as well including mainly firearm related injuries, which is something that we're all thinking a lot about given the situation on the ground um uh in Sudan and in several other countries. And then session three, we'll move on to post traumatic reconstruction. We've got some great cases related to bone transport. Uh And then we'll conclude and there's a little bit of a breakout room for networking and conversation afterwards. Next slide. So of course objectives, we're gonna improve participants knowledge of complex lower extremity, trauma management principles. Um We're going to foster international discussion regarding orthopedic trauma care delivery and motivate and support the younger generation of orthopedic surgeons practicing in low and middle income countries. That's really the focus of these conferences. Next slide. So as you guys all know our course structure on Sunday, uh Last weekend we launched are self directed learning guide. And I really hope that you guys all had the opportunity to go through those lectures and articles in preparation for today's live session. Next slide, the self directed learning guide has recorded lectures by international faculty, many of whom are here today. Uh And we really thank them for taking the time to record those lectures for us. And then of course, we have some relevant articles. These are curated by the staff specifically related to the topic today. Next slide and here are all the fantastic lectures that are available for free. They're all all on youtube. Anybody who got the PDF copy or uh learning guide should be able to access those, but they're also freely available on youtube for anybody who's interested in listening to them. Next line. So without further a do, I'll hand the mic over to our first speaker for our session. One managing traditional bone setter related complications. Next slide, we have two speakers. The first will be Brian Madison and then the next doctor um oh joke about James from South Sudan. So without further a do Brian, please take it away for your first case. Thank you. Uh I'm going to present on uh T V O Calcaneocuboid uh TB Talocalcaneal nail, uh retrograde fixation of neglected ankle practice you in sinus. Um Next late I declared a conflict of interest. Next light. So I'll just give you a brief about myself. My name is Doctor Brian Madison, uh graduated from the University of Juba uh when was still in Khartoum Sudan in 2009. And then uh did my M met uh orthopedics and trauma from uh Tanzania and the beautiful uh city of Moshi. Uh And there for some reason I did the diploma, tropical medicine again from London School of Tropical Medicine and hygiene, the East African problem. Uh Then I did uh went for a 11 year fellowship program in uh orthopedic trauma inhabited Ontario. Uh currently practice as an orthopedic surgeon, uh Juba teaching Hospital as well as a lecturer, uh the University of Juba Department of uh Surgery. Uh I mean the um the inaugural presidente for South Sudan topics and trauma society Next flight. Uh So I would just like to give you a brief on on the society which is collaborating with Harvard Global uh global Political Operatives. So our, our society is called the South Sudan orthopedics and Trauma Society sort. Uh In short, uh it's actually a professional society that brings together orthopedic surgeons, uh surgery, trainees and diverse medical professions, uh professionals with interest in the field of orthopedics. Uh We are not not for profit organization that focuses on unifying these roles towards the common goal of enhanced patient care, healthcare professionals, welfare as well as transformed lives. Uh We think that these other allied professions very, very important uh because we really, really value teamwork. Next. Yeah, next slide please. Next light. So the society was established in June. Uh Can you go back a little bit sorry. So the society was established in June 2021. So it's only two years old, maybe the news of a big trauma society in the world. Uh It was actually established a small, very small group of seconds uh as a brief 1000 it's a country emerged from a protracted uh conflict that lasted for about half a century. Uh As a result of that conflict, there was actually lack of basic, basic infrastructure uh starting from road, electricity, water and healthcare is actually one of the biggest uh the ones with the biggest impact. We don't have a lot, we don't have proper healthcare infrastructure. So on gaining independence in 2011, there were two uh foreign panel for pedic surgeons uh who decided to go back to South Sudan and establish the profession there. Next. Uh Yeah. Uh So the number increased from two in 2011 to 11 in 2021. And this is actually the group that established the society. Currently, we stand at 13 orthopedic surgeons. Uh So we do have the common understanding that uh you know, with that orthopedic is a big problem in the country. We need to find ways to solve this problem. So based on that, we registered ourselves as an N G O because we wanted to be in the thick of the Axion, not to be as a professional body, but actually an NGO that can go out there in the field and do the work next, right? So these are objectives and you can see involved that uh one of the one of our main objective is to enhance an equitable and quality access to a diabetic care among South Sudanese. And this is all focused on, on the concept of global surgery that everyone has the right uh to have access to a fabric care. So these are core objectives that we're actually working on at the moment next. Okay. So without further do, I'll go straight to my case uh case presentation. Um So ankle fractures in general are relatively common and as we know that it has by model distribution uh where uh there is increased incidents in elderly osteoporotic, uh patient's most of the time as a result of low energy uh fractures. And surprisingly, this has a mortality of 12 months mortality of about 11.9 to 27% which is quite high for, for for fracture, which is relatively benign. Um In the young patient's usually results is uh moderate energy twisting force and these are usually easy practice uh to deal with open reduction, internal fixation usually give very good results. Uh The problem is that these fractures are challenging the stop in the osteoporotic. Uh the patient's because of a lot of risk factors including copen quality as well as uh if it presents late. Uh as we'll see in the case that uh we're going to discuss. So, apart from or if we, there is an option of using uh TB a telecyl Kenyan nail, which is actually, which has gained a lot of uh interest uh recently and mainly the focus of TTC nails on um ankle, uh you know, difficult fractures such as ankle fracture, dislocations and bad pylons in settings where they present late. Uh It's also useful in the elderly with poor soft tissue or poor bone quality. Uh These, these nails actually come in handy next. So our case is a 36 years old lady who presented uh to me 15 months after uh left ankle fracture. And uh as as is the case is many parts of uh South Sudan and in many parts of uh maybe Sub Saharan Africa family say uh the fracture was inappropriately managed by traditional bone setter. And the patient presented with an ankle deformity, swelling as well as pain on weight bearing on examination. She had a limited uh ankle dose reflection next. So these are the x rays, I'm sure a lot of you, especially those ones from Africa, uh cities kinds of x rays. Uh This is, this was actually this was a case of a crime fracture dislocation. We can see that there is a posterolateral tele shift and we can see that there is already some degree of union. So it's a, it's a case of malunion, uh also degenerative changes as, as you can see from the osteophytes on the interior ankle. Next. So we talked with the patient and uh she understood that uh we're going to fuse the joint because it's a late presentation and the patient already had osteoarthritis. Uh And for us to get a good function. We, we really needed to fix, uh refused the joint. Uh So we uh we took the patient to the theater and through an anterior approach, we were able to approach the ankle joint. Uh uh you know, take a cheaper bond with cartilage. Uh This enabled us to, to achieve the reduction that we wanted. Uh for some people, you know, you can fix it, you can fix the reduction provisions with some K O s uh before we advance the nail, but that's optional for us, we just decided to um to, to proceed uh to hold the reduction manually and then advance the nail. So in this case, we use sign nail. Many of you could be many of you are familiar with sign nails. Um There are a few important uh technical points, especially using this specific type of implant because we know that sign nail has sort of it was designed for for fractures of the tibia. So it has that typical bent on the nail. Uh that is typical of table practice, but the nail is being used universally for practice of the fema. And in this case for, for, for, for ankle fusions and probably maybe for, for uncle uh you know, fractures. So the entry point as with many TCC nl's is we just drew a line uh along the the medial lateral malleolus towards the plant aspect of the foot. And then on the medial lateral plane, we just go in the middle. Uh you know, some people say that you have to go slightly lateral just to try to avoid injury to the uh medial uh plantar nerve. Uh But in this case, we just went straight on. Uh and then we made our staff incision all the way to the calcaneum. And then using an owl, we we we access uh calcaneum and then the final state has a form a limited rail bit. So in our case, we decided to use that some people may use K wires, but we use it real bit. And then we drill from uh the plantar aspect of the foot going towards the talus and through through the area where we are through the anterior approach where we did the uh the joint preparation. Uh we just ensured that our drillbit exits right in the middle of uh the talus. This is very important uh for, for, you know, for the journal line in, in diffusion. So we are, we have to make sure that we hold the reduction in place and then the drill bit exits at the center of the talus and then goes all the way to the uh to the canal. Uh Some people may use fluoroscopy for this, but we know that uh in most resource limited setting that there's no fluoroscopy and that's actually the utility of sinus that you don't need to use for osteopenia. But if you have to do it then you can use for oscopy to make sure that your reduction is achieved. Next. Yeah. So while we're maintaining the reduction, that is the food will be in plantigrade with about five degrees of hindfoot, valgus. Uh We, we, we inserted a larger uh real uh which is in this case, a step drill in the signal set, it's just a larger grid bit. Uh And then we just followed the same track all the way to the TB tomorrow. And then after that, uh we graduated to a larger diameter, uh you know, 100 m that also uh then uh then sign and set and then we inserted the nail. And this is an important point because uh in the TBA in general, we locked sign a bill from media to lateral. So in this case, when we're inserting the nail, we had to ensure that our locking also goes from media too lateral to try to avoid the soft tissue that, that are in the lateral aspect of the lake. And in this case, uh we had the option of either placing the ball, the bone, the proximal nail, either the ball should be facing apex anterior of apex posterior. We think that it's very important for the ball to be facing as apex anterior just to ensure that we maintain that planting great food. Because sometimes, for example, if the boys apex anterior, then we may have an equine us uh posture for the foot next. Okay. Yeah. Mhm. So this is uh this, these are the post operative X rays and we can see that you were able to maintain good alignment, uh try to reduce gun, maintain good alignment. And uh yeah, so you can see that the locking is from the medial side to the lateral uh side. Next. Yeah. Okay. So post operative recovery, we asked the patient to weight, bear as tolerated. Uh she started walking on a frame, uh you know, a few days after surgery and then graduated two crutches and uh on follow up about three months, post operative, the patient was actually uh weight bearing without, without crisis. So uh she was able to get up early enough next. So these are the one year post fusion X rays, never mind about the screw, which is outside the slot. This happens a lot with uh sometimes it happens with sign nails, especially when the target arm is uh you know, has worked for a long, long time. So sometimes we miss the screw. Uh but it's good that, that this, we had uh most proximal and distal interlocking. And we can see that that one year post fusion, uh we have a very, very, very nice fusion and I would just like you to see to notice on the entry points. One of the schools, the school which was missing at two was going to go through the sub territory and that's the point that we're going to talk about later next. Yeah, that's good. So let's talk about the advantages of TTC in general. We all know that these, these are minimally invasive uh methods and it's very, very useful, especially for the for the elderly patient. Uh you know, who have very poor healing capacity or for fractures that you know, you may think that, you know, uh may delay inhaling. So it increases, it improves the chance of uh the fracture healing or for example, that's what this is for healing. It's also very robust and allows early, sometimes immediate weight bearing. Uh for elderly who undergo a normal or if or regular or if we saw that the more the two months the 12 month mortality was about 12%. And most of this is because of pressure source DVT and also studying the money. So for these elderly patient's who, for example, have acute ankle fractures that want them to get up up and running as soon as possible. TTCL is good if you put on or if, for example, usually the patient stays for six weeks, uh non weight bearing and then maybe after that they start weight bearing. So any period of non weight bearing and elderly is, is really could be detrimental. So that's an advantage for TTC that it allows them to get up and moving uh as soon as possible. And some reports actually, some studies reported superior outcome uh compared to two or if in the elderly and osteoporotic patient's. And in these uh instances, we're talking about a trade off between function and function and healing because uh when we inside a TTC nail, we're going to violate mostly subtle and ankle joints, especially in someone who only has an acute ankle fracture by alerting. These joints may sound uh counterintuitive. But uh for someone who has maybe five years or 10 years to live, you, you may try to balance between the risk of getting osteo uh arthritis and getting the patient up and moving early uh disadvantages, violation of the joints. Uh And we, you know that, you know, the an atomic production would be uh less superior compared to our next. Excuse me. So let's talk specifically about using sign ill as A T T C. The process that signing is readily available and it's donated. So in many countries, it's actually free of charge. So this is a very, very important point because a lot of people do not have, you know, resources to purchase uh orthopedic implants. A lot of facilities do not have fluoroscopy. So sinal does not use the fluoroscopy. And that's a very important advantage uh you know, in resource limited setting, but we have a few disadvantages. We talked about the proximal bend on the, on the nail. And for us who have seen uh conventional law, I mean, dedicated TTC nails, they usually straight, they don't have that. And some of the nails actually have a slight bend to allow a slightly lateral entry point. Uh So, in this, in the case of signal with the proximal bend, I think one of uh technique that we use is that we just, we, we make sure that the bend is a pecks posterior and then uh try to place the food on slide, uh slightly corners because when the nail goes inside all the way it may kick the food a little bit into uh dorsiflexion. Uh sorry. And regarding uh we don't have a lot of options regarding locking. Sinal is usually medial to lateral locking. So uh looking on the on the proximal path, I mean, looking on the TV is not a problem. But now the issue is looking uh at the level of the foot. Uh when you're looking from middle to lateral, we we encounter the neurovascular bundles. So that's very important for us to protect this while we're doing locking. Um The other issue was that on if you could recall the X ray, like one of the screws, which is blocking is actually aimed at, I think at the level of the septal a joint. So you have to understand how, how deep you're missing the nail to be able to lock the nail, uh you know, to get to avoid the subtitle joint while locking the other issues that when looking from media too lateral, we don't have enough bone stock uh at the level of the Calcaneum, for example, uh to hold this cruise where and we know that some, some dedicated TTCL actually, they have looking which is going from uh posterior uh interior. So that's, that's one of the issues next. Yeah. So there's, there's that question of joint preparation uh in T T C. Uh a lot of, there's a lot of controversy in this but many people with fresh ankle fractures who may need T T snail, sometimes they put the nail without preparing the joint. So uh if the aim is to do uh fusion, just like this case, we may prepare the joint. But if the aim is to create an ankle fracture in an elderly osteoporotic patient, when you don't have locking plates or uh you know, when the soft tissue is not good enough, then you can, you can just go ahead and uh fix the fracture without having to prepare the joy. This also applies, for example, for difficult Peillon fractures. But again, there's no robust data on the functional outcome uh when you do joint preparation or not. Next. Mhm Next. Life is so conclusion. TTC nails, viable options for neglected ankle fractures and severely culminated pylon fractures. They're excellent options for Elder law osteoporotic patient's with recurrent soft tissue who want to return back to function early. Why? Because you need to get them up and running as soon as possible. Uh You can prepare to join, you can decide not to prepare to join we don't have long term outcome studies uh that can give us, you know, guide us on this aspect. Uh side milk can be used with a few technical adjustments and this is we're still in the learning process. There are a lot of uh techniques that we need to, you know, you need to adjust our techniques when we're applying, signing fortuitous in uh next. Okay. Next. So these are a few references and uh I want to show the last picture on the slide. Mhm X Yeah. So this, this picture actually um provides a summer of what we do in South Sudan of the Medicine Trauma uh Society. So this was during one of the outreaches and we can see that while we're treating the patient's, we're also making sure that medical students uh get, you know, get to be taught, not only medical students, we do the teaching in the theater. You know, we try to make sure that we combine teaching and treating the patient's at the same time. Thank you very much. That's all for me. Uh Thank you so much, Brian. That was uh fascinating case. Um And I think you highlighted a lot of very interesting topics here, neglected trauma, managing it with limited resources and the work that you do to train and educate the next generations that um you can build capacity locally in South Sudan. Really remarkable. Thank you so much for that case. Um Just uh you know, I want to keep track of time here a little bit, but I do want to pause for a moment and just invite a few folks to make some comments. Um I know that uh you know, we have some foot and ankle surgeons from University Missouri on the line and Doctor Mohamed Fadel is very experienced and limb lower live reconstruction of sure he has some comments. So maybe I'll hand it over first to Doctor Mohamed Fadel. Um Can you just in, in very briefly, just give us a few comments on this case? Oh, it is great. Thank you so much. It is a very nice case and uh confronted with many complications, you solve it. Uh Big problem with a simple maneuver. Uh It is very good for uh what patients', especially if you have the resources, as you mentioned. Uh A nail is a good option. Uh and also difficulty that it is not designed will for fitting this uh retro grid. Uh T T C. Uh So you did a good job. Uh You may be a need for some assessment for the maybe some sort of plantar flexion of the ankle or uh the forefoot. So you may be confronted with some difficulty or some uh complain of the patient. Uh So you uh I hope that you'll be ready for uh some uh maybe uh complain of them and you may safeguard this by doing uh uh some sort of a custom made or uh to some extend high heel to some extent and she's female and I think no problem to have uh such a high heel. Uh So uh also have some sort of rocker bottom and the mid foot uh slightly. It will not be a bad uh but will solve the problem if she asked uh for uh doing something for uh uh prue curve Etem or recurve Etem problems. But as uh globally, it is a very nice and very good and you cut short for many difficulties have been caused by Bon Satyrs. Uh Thank you and congratulations for this outcome. Thanks, Doctor Condo. I also see that we have uh Doctor David Fromberg on the line. David was the one who recorded the excellent presentation on managing pelon fractures. And uh I wonder David, do you have any comments on this? Yeah, I think it's the, to me, it's always the most remarkable thing to be able to get basically anatomical alignment without any fluoroscopy. And I think it's, it's not an easy task. I mean, I was trained doing cases only with fluoroscopy and I really rely on it. And so maybe my anatomy, my surface anatomy and my understanding on how to get good starting points is significantly less than Doctor Madison. I mean, you saw in that case, the corona alignment was perfect. The actual alignment was perfect in the sagittal plane a little bit anteriorly translated, but that just doesn't matter in the end. Um, and you were able to salvage this person's total function and I was just so impressed by it and actually I think that that missed screwed distantly is not as big of a problem as you may think because it'll, it'll give you a little bit more stability regardless. And we know that there's a lot of evidence that prepping the, that preparing the subtalar joint. A lot of people don't even do it. Um Just crossing the Subtalar joint with the nails. Some, some believe causes enough stiffness that you don't even have to open it and prep it when you're doing a true TTC fusion. So I think you are going to get some stability regardless of whether that screw is interlocked and whether you can press that joint at all. But I think that if you can Masturah TTC for a case like this where the soft tissues are sometimes a little bit contracted and it's hard to get yourself medialized and even anterior. Um Then you can use this technique to salvage a lot of legs. Um Yeah, thanks for inviting me. I, I really enjoy the case presentation. Doctor Madison. Yeah, it was fantastic much, I guess. Uh doctor uh Kaforey, um and Doctor Stressor from University Missouri. I wonder if either of you have any comments about this case as well. Yeah, I, I mean, again, I'm gonna echo what was said earlier like that was your reduction was great. For not having fluoroscopy. You know, we rely heavily on fluoroscopy here to get our starting points in our reduction. So, you know, great job on that, especially when you have a bend on the nail, there are some nails out there that have a bend, there's a nail that's posterior, you know, it's post daily base and another one that's laterally based where you modify your start site. But that was a great job. You know, some other things that you could consider for from an approach standpoint. Um a lot I've gotten away from the direct anterior approach. There was some um there's been some papers out of Candida on and other centers um on Angie's Soames and that an anti remedial, uh there's a modified anti media approach that is a little more soft tissue friendly if you're ever worried about, you know, an elderly or diabetic. And you really want to do an approach, oftentimes I'll do a direct lateral and just do a fibula osteotomy because if they have a wound break, I think the, I mean, that is a little easier from a soft tissue coverage standpoint. Um And then you were talking about um prepping the joint versus not. And I think that that's got to be patient specific. So a lot of times in diabetics, uh poorly controlled diabetics or an elderly, I will not prep the joint. Um I will just place the nail, reduce the fracture and place the nail and then at 4 to 6 months, once their fracture is healed, I discussed with them if they want the nail out and some do uh because they have a little bit of pain or they want uh Kyle, are you there with us? I think we may have lost you. Are you guys hearing me? Uh You know, if, if it's in for, if it's a low demand patient where the nails only going to be in for like, you know, 5 to 10 years, it's probably not a big deal, but in a 20 year old who's gonna be really active. Um And you get 20 or 30 years out and you have prep the joint, um They're going to probably have a little bit, they're gonna have some discomfort and some problems. So that's kind of the, that's my thoughts and, and you know, and if anybody else wants to comment on when they, when they decide to prep the joint or not, that, that's kind of my algorithm. Great. Seriously. That was great. Great. Great points, Kyle. Yeah, I agree. Um So typically when I've done my T T C fusions, I will do a direct lateral approach and you do a fibular osteotomy and use that as a bone graft. Um I guess the one question I had for Brian is, is you notice in your case, you know, the subtalar joint is obviously not fused, you know, despite maybe prepping it with the reverse that sort of thing and hoping that poster for some baby is fused. But, um, you know, you don't have that locking screw there. Do you talk a little bit about removing this nail for this patient? If she words ever become symptomatic? Yeah. I think last time I saw the patient, she was, uh, she was already, you know, completing of some pain, which I thought was not going to what's look coming from the ankle joint because already fused. So I think we discussed uh removing uh actually, I thought maybe the pain was the level of sub sub tele joint because uh there was a little bit of discomfort, um uh food inversion, inversion. So I think uh we're planning to get the nail out. Yeah. Okay. That makes sense. Yeah. In some of these neglected ankle fractures I've taken care of in Malawi. We typically do a tibia tailored fusion just with like large screws. But of course, the bone quality is so poor. We often have to cast the patient's and we can't let them wait there. So I think your solution is, is a really nice one and I'll keep that in mind next time I have to deal with this. Um Okay. So for the purposes of time, unfortunately, let's move on the next case. Uh Next slide please. Jack, next case will be by doctor uh no joke from South Sudan. So doctor um oh joke, please take it away. Hello, everyone. Again, uh from you go military hospital here in South Sudan, I'm just going to take you through a few cases that we encountered here in our facility. Uh Next, next slash piece. Uh This is my biography. I think you can read it because of time. Next, next slide, uh nothing to disclose and no conflict of interest. Okay. Uh For us here in South Sudan is sometimes in your clinic, do my face a case like this and then they disappear next and then they came later on with something like this. So you imagine this is a kid, 13 or 14 years old and the degree of disability that he's going to get in his life because of uh most of them they used to come and then they disappear going to traditional bonesetter's uh because of so many reasons. Some, some, some of them believe in traditional bonesetter's and some of them they cannot afford uh orthopedic uh diabetic uh surgical procedures. And for others, the idea of having a metal inside their body is a bit. Uh They don't like it. That is why most of the people that used to go to traditional born set us next. So we used to ask ourselves, why do our people go there next. Next. Yeah, next. So South Sudan is, has been downgraded from uh a middle income country to a very, very, very low income country without estimated population of a bit more than 12 million people that 12 million is only served by the thing, orthopedic surgeon out of 15 South Sudanese or seven stations, some of them are still abroad outside the country are practicing somewhere else. These Latinos we decisions are walking in a very, very, very limited resources and they are all inside the capitol of South Sudan. And imagine these 12 million people are divided among many states. So many people are very, very far away from the Capitol. It's very hard for them to reach a proper, to get a proper orthopedic care in the periphery. So they have to come to the to the capital here. So that is very expensive. They cannot afford it most of the time. So they go for the those traditional born set up. The country went through a tragic worth communal place and cattle reading. So we have so many, many cases of uh firearm injuries. And recently with modernization after cessation of from the north, there are a lot of uh road traffic accidents because of this four roads were having here. All that led to many cases. We we treated by these traditional bonesetter's and the letter they present to our facilities with much complications. Most of the complications that we encounter are your next slide, please. The most common presenting lower extremity fractures complications for us here are malunion, uh union chronic osteomyelitis sometimes and ischemia due to very tight bandage that they used to put there. So I'm going to take you through three cases that we encountered here and how do we manage it? Next. This is a 50 years old male who was involved in road traffic accident. Two years prior to that mission, presenting with limping, an abnormal movement on the right leg. He's not diabetic or hypertensive uh initial assessment. The patient is in good condition with abnormal movement at the distant end of the fema and a slightly stiff knee joint, uh flexion extension degrees from 41 20 degrees. Next X ray short and not in the united fractured distal femur with a shared fracture line and overlap of ends. This is the X ray you see here, it's a bit hard to tell whether it is a mole union or an onion. But there is a clear gap between the 22 fractures ends and there is a big overlap of the the two ends. So we decided to take him for operations after consulting the pain. Uh We did the necessary investigation because some of this sometimes they used to lose a lot of blood during the time of operation. Next, enter operatively, we approach the distal femur interiorly because we are planning to set a retro great nail and we deprived between the two fragments, we remove all the soft tissue and that's who do join. Then uh we reduced the two Ns open the canal and set it the red throat. Great. I am Nell uh This is the immediate post operative X ray. Uh We assess the patient post operatively. He was able to ambulate with eczema frame. It was a bit of pain but the leg wings was a bit restricted. Next. Uh I would go immediately into the second case. 45 years old male presented with severe deformity and shortening of the left leg for more than 20 years. Uh This is uh an athlete, a goalkeeper who used to play football and he got injured during one of the marches and they throw him in the hospital and he didn't, he couldn't afford for surgery. So he left for traditional bonesetter's. But uh you'll see the X ray. Uh Even I don't think they follow the instruction of the traditional bonesetter's because this traditional bone setter sometimes though for us, they're doing a bad money, bad management, but sometimes end up with a good outcome. But this is a totally different case. The patient was evaluated and uh local examination of of the late show some valgus deformity of the left distal 30 via and fibula with postural medial ambulation. And there is some degree of shortening next, next light. So this is the image and the X ray of the patient. This is what I meant when I said that traditional bonesetter's, they used to apply some materials that will keep the limb align. Uh fear most of the times is the limp ischemia or nonunion. But this is a gross uh too much deformity. I think this case was neglected and he didn't get any attention at all. That's a slight. So we planned him for corrective osteotomy. And I, as I said, there was a bit shortening but was due to angulations for osteotomy. If you use a close closing, which osteotomy it will shorten the limb open, which is the osteotomy fines used to uh Lincoln the limb. Uh After evaluating this patient intra operatively, we found that closing which astronomy will will give a few centimeters because we want to correct the ambulation and the leg links will be will be restored intraoperatively. The TV was approached anteriorly and close watch of start um was done then an interlocking nail, I am Nell Sinal was inserted. This is the postoperative X ray of what we did. Uh Mr Here we inserted only one is crew because uh the other screw was loose. We have to remove it. Leg wings, discrepancy was not there in the post operative evaluation and the patient was able to ambulate and he's still on follow up. Next sleight. The third case is a 50 56 years old male. It's a stealth fractured distal femur after a fall one week prior to the admission. When we evaluated the channel, there is, there was swelling at the proximate aspect of the high from the history. He told us that he had a fracture before which was also mismanaged by traditional bone setter. Uh general examination of the question. It was stable and no, nothing to comment about. Okay. Yeah, leg length discrepancy was about four centimeters at slight. Next. Okay. When we need an X ray, there was a fresh new fracture at the distance aspect of the femur and also there was an old man united fracture at the proximal aspect. Can you show next? Next, next. Yeah, this is the X ray you can see here this is the fracture, the fresh fracture of the distal female and this is the more united all fracture. This is a case which is how William innate. This is the first question up into our mind. You have, do we have to correct the old the old fracture or just with uh deal only deal with with with the current fracture. We took him in and we decided to do osteotomy for the old fracture and put the whole limb in alignment and accept and I am nail and this is next. Uh this, this, this was the final outcome after uh the surgery, the distant fracture has been reduced and there is a good alignment in the proximal all mile United fracture. Next. So force operative Lee, the patient was mobilized on Zimmer frame, on non nonweightbearing. Uh There was some some sort of leg length discrepancy about two centimeters but he can tolerate. But I think we managed to relieve him from the disability he was having before next, next slide, please. So this is a few of so many cases that we are facing every day here in South Sudan because of the war. So many people have been injured a long time ago. And now they hear that there is some possibility surgeon who are doing the job in the country. So the shop for a proper management and proper care because uh most of these people are manual workers or soldiers who has become disabled because of this uh Malunion Orman Union. The last slide, I just put it. Uh this case who came to me like two weeks ago. And uh you can see that there is a mall united fracture of the distal femur. But I think it was a segmental fracture. You can see the condyles here are fractured also and more united. His main problem was the movement of the knee. You can see the patella is blocking extension and reflection of the joint. So I just put that slide. So can we can brainstorm ourselves what to do for us such a case? Uh Thank you doctor. Um oh doc. Thank you so much. Those were all fascinating cases. All four including this last one. Um I wanted to give a shout out to uh doctor Malik Diallo from Burkina Faso who has published a case series of neglected at the facial fractures of the distal femur and Children um in Burkina faso from what I understand from Dr Malik. Uh They see a lot of uh traditional bones that are related complications. And he published a wonderful case series of cases that he managed there where he does open reductions pinning and casting for those kids and they end up doing quite well. Um Some of them are neglected for a long time. So I encourage everybody to take a look at his article. Um I would also like to give a shout out to Dr Kevin Morena who is a principle investigator, part of a study called Beau's sad. It's the bone setter associated disability study. Doctor Frm Give Rihanna is also part of that study, but I don't think he's on the line yet. It's a study that's between Gambia and Ethiopia looking at traditional bone setter associated complications. So, Keppra, I don't, if you're on the line, I just want to maybe if you could share you um words your perspective um from, from West Africa, from how you managed similar sort of situations. And what do you think of the cases that doctor um a joke just presented? Hi, Karen. Uh Thanks for having me on the line. Uh Great presentations. I mean, if, if one of us from the Gambia was to give similar, we'd see very similar cases. It's a very similar situation that we have with a huge number of our patient's going to bone setters either before coming to see or so, even after being proposed treatment and we almost do as many nonunion malunion type surgeries as we do fresh fractures with the long bones, especially to be in uh fema. So it's a very similar situation. Um I notice in the comments, some people talking about the lack of surgeons maybe being the issue or lack of awareness. Uh certainly in Gambia, we find that it, it sort of cross uh cuts across the board with regards to educational status, financial status, etcetera. It's just a deep seated belief and it's not really necessary. It's not because of lack of services. Although we do, we are finding a bit of an improvement now that we are doing more surgeries that a few people are turning towards us. But I think it's always going to be, there's always going to be rid of a battle and it's just trying to see how we can salvage some of these before they turn into issues uh helping the bones that doesn't know what their limitations are. But certainly, I mean, the case is always very challenging. Um There are some what fun to do uh in a way because you get to, I guess, bring someone back to their level of function after years of disability and that does raise the profile of the orthopedic surgeon in the country uh to some degree uh and helps prevent some of them going to bonesetter's. But it definitely very challenging. And the sign nail again with us in the Gambia is our friend. We use it for almost all of our nonunion cases. Uh It tends to work very well, either thin or the sign and it's just trying to pick your battles with how you approach these. Uh I mean, all those cases, you know that they were presented a very, very big challenges for most of us and yeah, there's no right or wrong answers to how you go about it. Really, it's the outcome at the end of the day that tends to matter. Thanks, Kemba and Daniel is few to who practices in Ruhr Ulcus Enya. I'm sure that you see cases similar to this. Would you like to comment at all? Hi, Karen. Hello everybody. Yes, I I would say that Samburu County is very much is a lot of similar point to South Sudan. Both are pastoralists. Lots of gun, lot of issue. I have to say I really like that slide that he put when he said the question mark, why, why do people go to the traditional bone setter? That's a very good question. And uh if I have to share my experience uh is uh mostly most of the time is just like uh there is no other option because uh Samburu like South Sudan, the issue of transport and road, the roads are so tough, so difficult. The transport also the cost of transport to reach maybe a facility is also extremely high to reach these places. Uh security also wise is uh sometimes say, well, if I have to go to the hospital and get a bullet on the way. Is it really worth it for me to go to the hospital? So sometimes that's actually the only option. So one of the answer to why is because that's the only option for these people and also the payment, sometimes traditional bone cetera, they can be paid. Uh they're not cheaper. It's not that they do for free. Actually, they're quite expensive but they can be paid in anymore. So in Samburu, you you get almost one full goat for being traditional, attended by them. And another thing and it's traditional sector, not everything that the traditional bone setter does is bad. It has to be honest. Sometimes they do good stuff. I've seen it. They are quite good in alignment of the limbs. They are very good in uh stability. They're very ingenious, they're very uh fantastic and found a way to, to, to stabilize the bone. So they have some good skill in actually treating trauma. They're not so good in compression. Sometimes they tie too much. So actually we get a lot of issue becoming with ischemia. So someone in the back of my mind have this kind of dream of idea that the traditional beset, er can one day be part of the workforce of a trauma team of hardship area like Samburu or like I think South Sudan, you know, with somehow a way of a training or somehow a combining forces between uh medical healthcare and traditional, I think they could be uh if well director support, especially area like we saw the map that he showed where actually the health forces so little compared to the big and huge population and the burden of trauma. Thanks Daniel. Yeah, good points. So our colleagues in Nigeria have written quite extensively about traditional bone setters and there are essentially two schools of thought, one that these practitioners should be completely eradicated from practice because they cause so many horrible complications. Granted, we as orthopedic surgeons are probably biased because we see the complications much more so than the success stories. Um And then the other school of thought is that we should be training traditional bone setters to be part of the workforce to extend the reach of orthopedic care, especially to rel people. But as Kevin mentioned, many people go to see traditional bonesetter's who aren't just from neural areas, they are educated and it's part of the community, it's part of their culture. That's the reason that they see traditional bonesetter's, the payment may be easier. Uh There are many, many reasons why traditional bone setters are sort of here to stay. So I think we need to recognize that um the team in Ethiopia and the team in Gambia are doing a fantastic job understanding the perspectives of patient's and trying to find ways that we can intervene to reduce the traditional bone setter associate complications. There are also others, there's a team of surgeons led by a group in Kumasi by dominate Konadu Yeboah. That's doing a fantastic study, trying to train traditional bone setters and decrease complications that way. Now, there's also a team in Tanzania, uh working with the global uh surgery foundation that has started working on training traditional bone centers. So, you know, it's a controversial topic, but I think it's very fascinating. Um just before we go to break, I wanted to give a chance for Doctor Deep A Bose if she's on the line to maybe comment, you know, given her experience is a uh you know, um limb reconstructive surgeon. I wonder what your comments maybe, especially about case too in case three deep are you there? I'm, I'm here, Kieran. Can you hear me? I can. Yeah. Thank you so much. No, not at all. I was fascinated by the cases. They're absolutely brilliant and the outcome that has been achieved is really amazing. I think, uh you know, it just shows how following basic principles you can achieve really good results without any high tech equipment. So, you know, it's really very impressive, but I'm also fascinated by the talk on traditional bone setters. And I think that if they can be somehow brought into the community of orthopedics, that that would be the best possible thing. Yeah, agreed. Uh Thanks Deepa, appreciate that. Um And then we also have Jack Wixted on the line. Jack, I don't know if you've seen any traditional bone setter associated complications before, but you certainly have dealt with a lot of complex limb reconstruction. I wonder from your perspective at Harvard. What, what do you think of these cases? Mm Jackie there. All right. Well, that's fine. Um Any anybody else have any comments before we go to the break? I would like to make a comment. So first, thank you for inviting me to attend this in credible meeting today. It's, it's fascinating as has been said, um I would like to say, the kids are amazing in the solutions outstanding. And as has been said, using principles is really the way to deal with those problems. Just to give you a little bit of background about myself. I was trained and worked for 20 years in Brazil and Latin America and I got to travel all around, not only Brazil but Latin America and I got to operate so many times without fluoroscopy. So I kind of understand the pain of getting alignment and getting things restored without having infrastructure. And what I could identify in those places was basically either um patient's don't have access to healthcare as has been said because it's too far away or because they cannot afford or even surgeons don't have access to hardware. So then, and then you have a combination of both and uh and it makes it really hard. So this is why you need to like those are so important. So we can align the ideas and we can include people that need more education in order to provide them support and help them to be part of the community. As has been said, my understanding is that including the bone setters in the in the uh context of orthopedic trauma would be something beneficial in order to improve communication, improve patient care, improve outcomes. Um regards the outcomes that have been presented, they're outstanding also in the setting where you don't have a lot of infrastructure available. Um And also it teaches us that sometimes um the goals are a little different when you're seeking for just preserving the limp, just preserving the ability of the individual to walk and to be functional and to provide the family. So sometimes the goals when you go to some areas where people come with significant shortening, significant significant deformities is just to provide them the ability to come back to life. And this is such an amazing work that has been done and I'm I'm very impressed. Thank you for the opportunity to be part of this conference. Thank you. Thank you doctor for you for joining us and bringing that perspective. That's really great. And um just correct use information. We are planning on doing some more teaching specifically to improve capacity for frontline health workers and potentially people who are not orthopedic surgeons to help refer these complex cases earlier. So I'll be in touch about that. Uh Sorry any more comments before we go to the break. I just have one quick comment. I posted a link in the, in the chat on just a technique on how to do a clamshell osteotomy. I don't know how many people are familiar with how to do that there. But, um, for shaft mail unions, it works really well and I think it's pretty straightforward and it allows for great correction without, um, without shortening. Um And then the other thing that, you know, you always want to consider is the soft tissue, right? How contract is a soft tissue? Do you need to do any releases there? Especially around neurovascular bundles. But clamshell astronomy is a great option for those shaft mail union. So if you want to look at that link, I posted a free article in there on how to, how to do it both in the femur and the tibia with different fixation techniques. Thanks Kyle. Appreciate that. Um All right. Well, for the purposes of time, uh let's take a five minute break before we launch into our second section. Um Just so that everybody can take a break and uh and get some water or whatever and then we'll come back at 15 minutes past the hour to launch into session too. Thank you, everybody. Thank you. Oh, goodness. Okay, Pease Bqool. Uh Thank you everybody for joining us. Really, really awesome cases. Uh five or 15 just five minutes, please. If that's okay because we're running a little behind schedule. Okay. Okay, thank you, Mohammad. Welcome. Uh huh. Okay, Roman. Have you ever seen any cases like this before? In your practice? I was just gonna comment. Uh just uh Thursday, I had a patient that was in a motorcycle crash in Nigeria four years ago and he has a 25 degree various mail union of his distal femur with about 10 degrees of motion and about 10 centimeters of shortening. Uh So, uh we're going to do him in steps. Uh We first did uh a manipulation and uh quadriceps, plasty got to 90 degrees um and sampled his bone for, you know, possible latent infection. And then second step will be to correct his various, I think that uh two things I'd like to maybe in the next session, we should emphasize more. Uh This is a common area of problem, you know, those cases are really nice and it's emphasizing the bone, right. Um And we like, it's easy to understand. It's, you know, you show an X ray, it's, you know, you can, you can hone in on it. But um as it was just commented, you know, it's the soft tissues that are often the hardest things to deal with and the most complicated and if they're handled poorly, can lead to the biggest disaster and balancing, you know, the need for the bone to be straight and the soft tissue to be healthy is really, really important that's a really great point, Roman. Um, actually, Doctor Mohamed Fadel, who's on the line, he works in Egypt and does a lot of complex lower limb reconstruction. Um, and I'm sure you and he would have a great conversation about that because his case really does focus a lot on the soft tissue and I think we have one of his cases coming up in the next session. So that should be really good. Um uh It's a whole bunch of firearm related cases as well, which is even more complicated with the soft tissues, right? And it'll really emphasize because it's in the acute phase, but also in the in the delayed phase, really understanding what's going on with the soft tissue. How pliable is it gonna be, you know, and is the patient a smoker and a diabetic or is he healthy? 45 year old, former soccer player, you know, those are very different scenarios and what that tissue will tolerate. And do you need to like do a gradual correction for the soft tissues as well, you know, not just for the bone, right? Yeah. And when do you, well, I think the debate is, you know, number one, the approach, number two is acute versus a gradual correction. Yeah, when to apply those situations. And I decided on a case by case basis, but that's what you have available to you. Like. A lot of these guys, Roman that it's either acute or nothing you know. Yeah, I, I agree. And then when you do acute, what kind of accommodation make, you know? Yeah, I'm going to do a cute, I'm more likely to tolerate a lot more shortening. Right. Yeah. But I also think like that, that concept of, like, you can't do any corrective osteotomy until you get your infection taken care of. You know, it's like, you know, worth, like they're dealing with bone setters who haven't been opened up and there, you know, they're not, they're clearly not infected malunion is, but the infected nonunion malunion is you got to get murder on first, you know. Yeah. And that, that's a big challenge and a lot of settings I know, at least in, uh, in Malawi we don't really have access to bone cement or antibiotics, that sort of stuff. Right. Right. So, even just get rid of Cossio is impossible. Yeah, it's a real challenge. These are, these are just almost insurmountable problems and you, you can make these things worse as bad as the draining malunion is. You can make it worse. Yeah. What's worse than an infected malunion is an infected nonunion or effect amputation, you know, like. Yeah. Yeah. True. Yeah, I thought, uh, case number to that doctor, um, usually presented was really interesting, you know, where he, uh, you know, had quite a lot of, uh, quite a lot of angulations there and did it in a single stage, you know, uh, to bring it out to length, obviously had to do a closing osteotomy in order to, uh, you know, deal with the soft tissues. I'm sure that was part of it was one question I was going to ask but, uh you know, just wear a long break down, uh you know, imply that there was any issues here, but it's always hard to know what happens to these if you have no follow up. You know, that's a big challenge. Yeah. And I think using frames and doing gradual correction is really hard when people live inr oral areas. I'm sure Daniella and doctor, oh Majak and Doctor Kevin Marina from Gambia. Uh We're, we're getting close to the 15 minute mark. So if anybody's hearing me just everybody can use come back to the stage will give everybody a minute. We'll get started with the next section. Uh Thanks for the lively discussion even during the break, Roman and I appreciate it. Yeah. Hey, Karen just want to let you know, I'm just gonna switch um sliding um controlling the slides with Phil for because we have an updated slide. Okay, Marcella. Great. Now is the perfect moment. Go for it. Okay. So it was there. I think we might be sharing now. Mm Yeah. And then we'll switch back to the big presentation. Um athletes. Okay. Wonderful. Uh Well, for everybody who's back already. Thank you so much for joining us again for the second session. We're running a little bit behind schedule. So I appreciate everybody's uh patient's. I mean, the cases are so good. It's hard not to pause and, and really take them in. So uh from Kenya, we have Marcella Ryan Coke who's originally from Sierra Leone, but is doing her training in Kenya and has also been trained in the UK. She's going to present a case of an isolated femur shaft fracture. Don't let the title fool you. It is actually quite a complicated case. So Marcella, thank you so much for joining us today. Please take it away. Yeah, thank you, Doctor Karen. Hi, everyone. Um So I am a second year of the resident in Kenya. As Dr Karen has said, I am originally from Sierra Leone, but currently I'm in, we will be where I'm doing my chaining. So I will take you through a case of an isolated formal shocked fracture. Um It's not the typical complex double trouble case, but these are cases that we see all the time. Uh So um we will quickly go through one of them next slide, please. So I have no financial disclosures or conflict of interest next slide, please. Um Our patient is a 31 year old and that presented to us about 12 hours post uh accident. He was a pedestrian that was hit by a speeding vehicle. He had been initially seen at a peripheral facility and then was referred to us after they made a diagnosis of a right femoral fracture. Clinically, he had no signs of a compartment syndrome. He had no obvious Focalin your vascular deficit, the skin was intact. The other systemic review were unremarkable. Next life, please. So in any we got um a PN lateral X ray, sorry, the images are not super clear but we can see the fracture. So he had a reverse public subject fracture with midshaft um female fracture. Next slide please. So we made a diagnosis of A A 03 to see to fracture is a reverse public component and uh spiral mix shaft. Excellent, please. So the initial management, we follow the A TLS at float should be employed. The adjunct. We started him on analogies, Ethiopian control, the audit for some labs and he got skeletal traction and and we continued with inside care. So at this point, considering the components of the fracture that he's a young active patient, the options that we had really, we're just deciding between two types of nails. So either a corneal or uh to follow legendary nail depending on the availability of uh the implant. Next lightly. So in the end, we we went with a recon Neil. So uh day 14, day 14 was his admission. Um he was taken to theater. So, on the right side, I've put a approach um we did a surprising positioning of the patient, the trochanteric entry point, we had uh image intensifier pre. Uh We, we planned to open just the proximal fragment because we knew that reduction of that would be quite challenging. But intra up, we ended up in both the proximal and distal um fragments and we fix the fracture with attend by 4 20 long um recon Neil. So on the, on the left of the slide, you could see the the POSTOP um image. Next slide please. These are just some more images um who stop. Uh So the distal fragment, the distal fracture was quite well um reduced the proximal fragment. Not so much because uh intra up, it was very um difficult to to reduce it. So um we got a better reduction for the pistol. Hope that the proximal um fracture next life, please. So most of the plan was to continue him on an algae sticks and antibiotics for him to start um partial with, with bearing, with crutches on post of day one and uh wound dressing plan. He was discharged on POSTOP day five. He was tolerating in partial weight bearing well with crutches and he was scheduled for a follow up in four weeks next slide, please. So um some of the challenges we had with managing this case was it had to do mostly with the availability of the implants and theater space, which then meant that we had a delayed time to surgery. He got the surgery about two weeks um post admission and there's this risk of lost to follow up because it has been more than four weeks post his dishes and we haven't seen him in the clinic. So now we're wondering whether he's full weightbearing, what's going on with a fracture, whether he'd present with some more complications at a later date where we, we don't know that. Um, but yeah, these are some of the challenges that we had next slide, please. Some of the things that we could learn about this case has to do with the availability of resources. Okay, I understand that in Lewis's settings, like uh this is a very complex problem. It's not very black and white, but I would, I'd love to hear from other surgeons about their experiences with how we can reduce the time to surgery or how we can improve our follow up rates for some of these patient's next slide, please. Thank you. I'd like to acknowledge Doctor John Kenya, who's 1/5 year author resident and he helped me put this case together. Thanks uh tough case, you know, and, and thank you so much for presenting. I think, uh you know, encouraging registrars uh to, to present their tough cases and share and, and get feedback from the faculty is really uh what we're all about. So, thank you so much for giving that case. It was a really good one for discussion. I think I'll start with Jack Jack Quick Stead. Um Just do you have any tips and tricks for dealing with these segmental fractures, especially these sub truck ones. I think Marcela comments very nicely that unfortunately the sub truck fracture was a little bit embarrassed the placement of your screws. Uh, they're a little bit um approximal. So I do worry a little bit about cut out with the position of those screws there, but, but Jack, go ahead, take it away. Do you have any other comments? Yeah. You know, I'm sort of have a question for Marcela as well. You know what, what she thinks are the systemic challenges for getting a patient like this into the oh, are, you know, rapidly, you know, the one comment I would make is that the reduction is easy in the first, you know, few days and, and you know, if you've got a delay of a couple of weeks, you're, you're making your own life so difficult because the reduction becomes that much more difficult. The other sort of comment I would make is there's no reason to try and do this in a percutaneous fashion. Uh You know, the proximal soft tissues around the hip are very tolerant to a big incision. You know, we do this for a total hip replacement or for whatever reason. And my comment would be if you have a sub stroke like this, the, you know, the best determinant for how it's going to turn out in the long run is how accurate your reduction is and you will make your life a lot easier if you just make a big incision. Um and then you're not doing a percutaneous nailing, you're doing an open nailing, make an incision as if you were doing a total hip replacement. You can see the entire trochanter, you can see the sub stroke area. You can split the vast test and you can get a clamp around the fracture to get that thing reduced because you're, you're staring right at it and then you're gonna do your nail right through that same incision without, you know, compromising on your reduction. This way, you'll get good control over that, that proximal segment, which is hard to control and you'll be able to see the fracture and put a clamp across it. Um But I'm curious as to what you think the systemic, you know, barriers that you're facing and trying to get this patient to the O R in the first, you know, three or four days. That's a very complex question. I'll let Marcela answer and then I'd like to have kept a Marina also comment on that same thing and how you would approach this if you don't. Uh Thank you, Doctor Jen. Um So in my experience here in, in Nairobi, say for this patient, for example, one of the biggest challenges was with, does he have insurance? Will his insurance cover the procurement of the implant or do they have to pay out of pocket? And how soon can they get the funds to pay um out of pocket. So it mostly revolved around um the cost of, of the implant who's going to get it, how soon they can get it and then how soon we can find a theater space for him? Yeah, those uh those systemic challenges vary between countries but some of the same themes are always there. Um Cable, what, what do you think about this case? You do a lot of uh a lot of proximal femur non unions, mall unions, you know, delayed presentations. What are your thoughts on this? Mm Great points, Kevin. Yeah, I mean, Marcella, you had the opportunity here to use cephalomedullary nail, which is fantastic. But a lot of our colleagues including in South Sudan don't have that and they would use a sign nail with that lateral kind of tension band plate for these sub trucks. Perhaps you've seen that before? Marcela? Um Doctor Brian Madison, Doctor oh Majak, from the South Sudanese perspective. Would you like to add a few comments here? Yeah, thank you. I think um thank you. That was a good case. And uh it highlights the challenge that we usually have. Sometimes we actually get these cases a couple of months after uh after the fracture. So, uh you know, in our case, I think uh we'll do a sign nail. Uh Of course, with sinal, we'll have to open the fracture site most proximate in history. So it's gonna depend on whether we're going to split the whole whole in open or we do separate decisions. But one technique point when using a signage is that we can try to access it. Um uh you know, piriformis, piriformis entry while making sure that we keep the fracture reduced. Uh Well, well, uh you know, um uh getting the entry point with an all and, and rimming, we have to make sure that the fracture is reduced were rooming because one big challenge is that uh we get the entry point and then rim the fracture while it's reduced, while it's un reduced, that it will end up in virus. So I think the most important point is just to get a piriformis entry point with the signal. And you know, it's not that bad. That was a really good point that Dr Brian Madison just made. You can't rely on your hardware to get your reduction. You need to reduce it, remit in the right position and then place the hardware that was a really good point. And a pure form a sentry can kind of help you prevent yourself from falling into that various position. Um But, but nothing better than as Jack and Kevin said, just clamping it once you get the reduction, right? So for the interest of time, I think we'll move on to the next case. Thank you, Marcella. That was really fascinating. More questions in the comments. If you guys want to put them in the chat, that's totally fine. Um Let's go to our next slide. Okay. Yeah, while we wait for the slide breaker. This like everybody wants to, you can wait, but it's great just working on getting to the next slide here. Okay. Dr Juice should be on the phone now. All right. Uh From the Gambia. Uh So Miriam, if you're there, please uh please feel free to take the uh take the microphone. I think her mic might be needed here. Okay. Are we having technical difficulties with this one? I'm working with her to unm mute right now. I think she's just having a little difficulty uh muting okay for the time being apologies. Just making our way here to the next slide to the next case. While we work with Doctor Drew, we're getting a preview of the case now. It's a tough one. Hopefully doctor you can give us, give us some presentation so we can discuss it. All right. I think the next presentation that we have is uh is gonna be on firearm injuries. Um So once we get to that slide. All right, here we go. So Dr Gabor from South Sudan, please take it away if you're able to um go ahead. So I believe it's a Doctor Uber doctor over. Are you there? Uh Yeah, Tuna and there but person a bit of a bad connection from your end. Doctor Majella come a great uh uh mhm uh He's asking for the slide to be progressed. Uh We, we can't really hear him at all. The signal is really bad. Uh Hello. Yes. Can you hear us uh and present home related for limits through committee? Uh So next is straight. All right. That's coming through a little bit better. Go ahead. Next slide. Yuck. Just here we go. Did you see that doctor at Uber? Next, next. Uh Yes. Uh I'm using uh Brian. Uh uh I hope you guys can listen to you right now. Uh For, for the sake of time they just jump to the slide of uh the case. Okay. Yes, next, please. All right, thank you. Uh I'm I'm presenting uh this 51 years old male presented to the with a gunshot. Uh If I am to his uh thigh and was a technology that's open grade three a left mid shaft female fractures. And so patient's as family was resuscitated as uh less protocol as, as we know in this uh this type of uh injuries, usually patient dies because of bleeding. So we usually uh proceed with the sea and then uh see a B CS protocol next place. Uh Yeah. Yes. Next. Okay. As you can see here, this uh this is X ray patient had any shaft, female fractures, communities in tribe for sure. The X ray is not adequate, but we can see some return of bullet fragments within the soft tissue. Uh Please. Mhm. Uh huh. Okay. Next, please. Okay. Next slide. OK. Thank you uh the team and I, we brought the patient on and we have, we agreed to go for a surgical department and inter medullary uh fixation. So, uh basically for surgical department, there is a two type of a philosophy. The, the old philosophy they use, uh they used to do a radical like a uh uh the treatment whereby they go for extensive extension of the edge of the wound, they take the necrotic tissues. But the new philosophy now they already uh goes into more like a conservative management. So, so uh they're saying that it's better to go for minimal surgical department. Given that the, the idea of the information that a gunshot wound usually has a low risk infection uh like uh less than 2% and that's a little bit acceptable. So, next slide, next, please. Okay. So uh our patient was brought to the theater room and we uh for sure he was given a span anesthesia and uh 30 degree flexion of the knees or we did just a minimal extension, minimal department of the soft tissue. And then we go at the end, we just uh uh irrigated with a reasonable amount of, of Selena. And then we go for our normal route or the regular route for a retrograde name femur like two centimeter decision was made at the Infrapatellar pool. And then next place we, we uh inside the patella tendon. Next. Okay. So we are we choose the entry point to be at the middle of the intercom that or not for sure, we're not using a uh fluoroscopy. So if you are using fluoroscopy, we're going to see the lateral view should be uh with the extension of the elements that line. But since we're not using that, uh we are in the canal and uh we just uh sorry, we have to make sure that our entry should be in line with the access of the majority canal for the fee of the virus valgus deformity later on. So we're in in the canal until plus two from the desired uh nail size. Next, please. Yeah. Yeah. Okay. So we introduced the IML uh proximal and distal school where places soft tissue, we were able to close it primarily so postoperatively uh yes, won't, won't care. Antibiotic, pain control. Then we advise the patient for an N weight viewing and for serial X ray. But uh unfortunately, the the the same problem that we already uh we're facing here is that the loss of the follow up. So those special usually came from the village. So once they have been uh surgery was done, so they travel back and then we lose the connection and we lose the follow up with them. So I totally lost the follow up with this patient. They couldn't able to have a cereal of X rays or any other pictures X place. Uh mhm. Next please. Next slide. Okay. So, uh for the discussion part, when treating female fractures usually caused by gun shop, there, there is some other mechanical factors that should be really taken into account like side of the fractures along between the differences or other different sides of fractures that usually happen because of the firearms. So sharp fractures may be treated as a very troubling or integrate nail. Uh It has a equal uh equal union rate of 85 up to 95% and all complete community fractures should be treated with. I am Nell uh Next please. Next. So the researchers have have showed that there is not any difference or these things between treating with I am near and external fixator. And so the Israelis choose a intramedullary nail because it has better healing and better mobilizations on top of the external fixators next place. Sorry about the delay, changing. The slides were having some kind of technical difficulty. So sorry. Thank you for your patience while the slides change very slowly. So the uh really the the design nail system is available and in this resort limited settings and we don't need fluoroscopy. I said by my seniors and for the back draws of the using the signing that usually found it hard for me because I've training in Alexandria, Egypt, we don't have signal system. But when we came, when I came 2000 and I have to be trained by uh surgeon dedicated that using sign it and I was lucky enough to have seniors that trained me well in using sign mail. Uh Thank you. Uh next by next place. Okay, next slide. So in conclusion, a lower extremity uh yes. Ok. In conclusion, there is a lower extremity gunshot treatment complex. They are involved to take into account number of factors based on the an atomic locations, the mechanical factors and the infection concern. So in uh it's the the treatment range from non operative prophylactics fixation to uh to intramedullary nail. So we have those type like for example, complete unicortical fractures. So based on this inside forces, we have to treat it prevented fixations, then all complete and community fractures should be treated with. I am nearly next, please. Pocket it's yeah, next place. Thank you for. Yes. Uh Thank you. And I would like to do to give my thanks for this opportunity to, to share my case. Uh And uh thanks over only again for the summer are stability associate again for this. Uh Okay, thank you, Doctor Webber. Now that was a, that was a tough case. Um I'd like to hand it over first to doctor Roman Haida who gave our lecture on on firearm injuries. Uh Roman, what do you think? Uh Well, first Brian, that uh that was a very nice presentation of a difficult case and I think there's, we need a little bit of nuance. Um I agree that the debate on how much to to breed. Uh, in gunshot injury is not, uh, hard science but is one that really needs, um, careful consideration. Um, we don't necessarily know what weapon at what distance wasn't fired, but we certainly know that, uh, in general, yeah, low velocity, you know, handgun injuries, the degree of soft tissue injury, although the combination may be great is not so significant as opposed to a military style style weapon. AK 47 are 15, something like that. High velocity, high energetics, uh close proximity or a shotgun is going to cause a much worse soft tissue injury and a much higher risk of infection. And so you really have, you never since you never know the weapon, you have to treat the wound and assessing that wound very carefully to determine how much debridement of the muscle and possibly the bone needs to be rick is required. Um And so I can't say that universe, you certainly would be dangerous if you just said, well, it's a gunshot, it's going to be fine and we'll just do a minimally invasive technique. Some of them, you have to open up very widely and you'll have a massive muscle injury with necrosis that needs to be debris. Did that said the second step is a good stabilization and I can show you a number of cases that I've been consulted with on from Ukraine that they've been treating with an external fixator and those are very problematic. They don't have the stability, they almost they rarely healed. They're always go onto malunion. And so you magnify the problem. So if you can, you can temporarily expects if that's your setting. But an early conversion to an internal fixation technique, particularly a nail is very, very beneficial. Uh And I think you've demonstrated that with this case, obviously, it'll be important to watch that down the road, one kind of thing to consider. And I'm not criticizing uh the your reduction and fixation, but the more metaphysis eel you are and there the, the nail doesn't control that segment very well. And it's very possible that you, although you'll get bony union that you have not insignificant, various deformity. And so consideration of a blocking screw that will narrow the canal effectively around that nail in the distal segment can avoid that problem. Uh So it's just a consideration, not a criticism, but I think it can fine tune the and expand the abilities of a nail to treat these uh Mata facil femur fractures. Good point, Roman. I mean, yeah, if you look at the reduction, there was maybe a little bit of various, but you have to keep in mind that this is often done without a C arm. And so performing blocking screws is extremely difficult if you don't have C arm again, I'm not a criticism. No, no, no, no, of course. No, this is constructive and, and, and great conversation. So doctor um uh I think your, you had a comment. Uh So thank you for sharing the case again. Very challenging case. One thing I'd like to share, I don't know. Uh your thoughts about is just for discussion um probably 30 years ago or maybe close to that. In my hospital. We didn't have, I am Neos uh in, in South America because we didn't have locking is we had Conquer nails, but conquer nails are not ideal for those uh fractures because you need to lock them. My mentor design before sign my mentor design an au that could be locked without C arm. It was a very ingenious development for South America. And with those nails, we were able to fix many of those fractures without cr we would open a window on the lateral metaphyseal distal femur. So we could see the nail inside of the canal and we could see multiple holes inside of the nail. And we could guess where to lock the nail and get X rays to know if we lock the nay or not. It's an interesting thing I can share with you. But one of the things we've done before, just for the sake of information and maybe to get feedback from the panel, we have used a lot of bridge plates. So in the setting, when you don't have nails or when you don't have C arm or when you don't have many resources, we have used long broad, 45 T C P plates too to fix those or to bridge those fractures in a way that would be working like a kind of internal fix it. Er And yes, it's not going to be as effective as an intramedullary in a oh, it's not going to be biomechanically superior to an intramedullary NAO. But it was a very decent way to do internal stabilization of the fracture, controlling length, controlling rotation in getting screws above and below the fracture zone in making sure that we could give the ability for the patient to move the knee and to mobilize the joints. Even if you would have to have them getting like partial weight bearing and being aware that this is a construct that's not going to compare biomechanically to an inter medullary nail. So I I would like to hear the thoughts of the panel about um if you don't have the infrastructure, if you don't have the implants, if you don't have the C arm, but you have the patient. So if a breach plate would be an acceptable option in cases like those according to your perspectives, Mauricio, I can say absolutely that that stability that will be improved as opposed to traction or uh an external fixator is remarkable. You'll have to be a little more careful in your soft tissue technique uh and care more careful about progression of weight bearing. But I think it's a very effective way. And the other thing I'd add is in particular cases, you may really even consider allowing for a certain amount of shortening uh to enhance the stability and promote the earlier weight bearing because then you have less implant fairly. Yeah, if you had to go in the spectrum, ideally, you know, a, a rod is better than a plate and that's better than our next fix and that's better than traction. And what you, I appreciate your comments and what you said about the technique is the critical thing, the way we did it, we never opened the fracture site. We open above and below the fracture site to slide the plate under the muscle. We could see where the plate would see it on the lateral cortex. So this is why the C arm would not be absolutely necessary. So we would have a retractor to allow us to see where the plate was sitting proximal and distal to the fracture. And we would go with a very long plate as long as we could. And, and the tricky portion was if you'd like to get very proximal, you have to bend your plates to accommodate for the truck and carrick area. If you go to the distal portion of the femur, you have also to bend some to accommodate for the curvature of the lateral condyle of the femur. But it was possible to do this way. And I remember having kind of small templates, aluminum aluminum templates that would allow me to see how much curvature I would need for the plate. So I could bend the plate outside of the uh surgical view and that could slide my plate later on. So I remember doing those things um in the early nineties uh when no Neo was available and yes, um everything you said is absolutely correct. We don't have the same stability as and they, you have to have a patient who has to understand or be compliant, which could be an issue sometimes. And as we've seen failures with early weight bearing in patient's falling into various or deformities because they ended up bearing way too early and because the defect was too long and they ended up not healing. And the alternative then was just to revise the plate to another plate because then you have a kind of soft colors. Now it's a, it's a more stable situation and you can get it healed again. So just some ideas also, you don't have the issue with the pin tracks of the femur that can get infected or you don't have the issue of the stiffness of the need because you can allow the patient's to move earlier. So just some comments about what we have experienced in the past and I appreciate, you know, I mean, I'm really amazed by this conference. Thank you very much. Those are great comments. Um I wanted to ask Dr my poor if he's on the line, if he has any uh any comments, uh, based on what Doctor Kaforey, a doctor who have said, uh, I don't know if these long, I assume doctor, before you're talking about using locking plates, uh, like a long locking plate. Uh, as a matter of fact, when I use those, I use DCP plates, only, uh, standard cortical screws were available in the nineties. But yes, if you have locking plates, it's an option too. But when I used those plates, I used four fives and they were broad plates with alternated screws. So they would not be in the same line. Yeah. Uh I'd like to re emphasize that point right now, particularly here in the, in the States. We all think we'll bridge plating automatically means that you have to use a locking construct. That's not true. You have to have a stable construct and you can do that. If you have good technique with even standard screws with a long enough plate, it does not rely on a block, a locking screw, the smaller, shorter than competes you have, then you'll, then it's going to be harder to control that piece. But if you have a, you know, meta diaphyseal segment with four or 56 screws, uh you're gonna screw holes, not necessarily screws, you're gonna be okay. Yeah. No, I think the point I was trying to make his locking technology is not always available. Um, uh Brian, you're on the line. Anybody from South Sudan want to make any comments here before we move on to the next case by Doctor Fadul. I, I keep my comments until I will start because you are thinking as if all the far arm injuries are striler and soft tissue is not uh traumatized and we have a very nice, not commuted, not as closed. So, uh you usually would like to go through by internal fixation. Think we ignore uh too much the, the fact of many cases. I think all our area uh and darling in, in these cases nowadays while know internal fixation is possible at all. Yeah. Well, Doctor Fondle, I think your case is great. We'll get to that in just a minute. Uh Yeah, please go ahead from South Sudan comments. Yes. Uh okay, we'll get that. Just uh yes. Can I come in? Yeah. Uh Yes, this is the uh yes, we have experience with uh awesome. So we, we have so many cases uh presented with gunshot uh to our hospital, hospital, uh both military and give a petition hospitals. Uh One thing we need to put in mind when you are, when you want to shoot late basis uh interim a drill nail. Uh is that that issue of infect actions? Because when you feel the plate, when you open the practice side, you have to do the driving, of course. So you will, you the Parral did Bryggman and then if you play it, uh there will be that high chance of uh infection compared to nail. Uh So we have been trying to do some pure plate uh when we are run when we run out of uh intradural nails. But uh I infection can, compared to interest Maturin, only that we have uh published a paper on it. Uh Commonly, we have tend to use intravaginal compared to wait. You talk of uh uh maybe a technique here in an open fracture which is commuted as a gunshot. Uh It's very challenging. You will not be able to uh that's your all the practice side, put a plate, reduce and close the wound again. So, uh I mean a agreement with uh allowed a little bit of shortening inside that you have the stability because all those when you're Fragmin around uh in the soft tissue when you allowed a little bit. Yeah. Uh I shortening, you'll bring all this piece of uh uh doctor my poor. I think we were having a little bit of an unstable connection from your side with the internet. So I think we lost the last bit of your comment, but I think your comments were very well received except for the last sentence there. Um just for the interest of time since we're already at the top of the hour and we have a few more cases to go. Uh Doctor Fadel, can you please take it away? Thank you. Thank you. Can we get his slides up, please guys? Oh, thank you. It's very good. Um Our talk today is about firearm major. Please. Slide slide, please. I'm honored and pleased to be here with you in uh one of the fantastic uh Harvard, the global uh orthopedic uh collaborative projects. And it is an honor for me to present this uh this meeting of sorts uh orthopedic trauma surgery uh society. It is a very nice for me to be in touch with you. Although we meet many times in Egyptian Political Decision uh conferences and in secret and all over the world in many conferences. But it is a very nice to be here in your land. Also to thank uh Sona Global. Also. Difficulty is a fantastic faculty which enriched the meeting by many of ideas. Thank you for Brian and for his uh work and also for um uh and many thanks for Kieran, the mainstay of the main corner of this activity and for our friend, Doctor Yak who did a lot for this meeting also for the attendee who I found that very and very good and the tremendous uh fellas from all over the country and also from all over Africa or from over the world. It is very nice for us to be in touch with a fantastic faculty from international group. Uh Another slide please. This is my uh greeting for you from Elmina University and the South uh Cairo 200 kilometers south. This is on uh lie or side is there ever nice slide slide. Yes, looking for this. Uh I think this is uh bypass. Many introduction. I did it uh may solve the problem of the types of uh injury that had been confronted in the cases of uh injury. I'm sorry that this happened that uh uh has extended the one of my lecture is not, but because of the short of time, I think it suits our condition. Uh Now this is a case of far an injury or should or gunshot injury, 24 years old, uh grade uh three be open fracture, middle third, commuted with bonus of tissue loss as we see her horrible condition. Slight, please slide please. Hello. Hello. Yeah, we we hear you doctor Fadel. Can we go? Did you move on or uh I'm not, I'm not sure if we're why we're not moving on. Can we move to the? There we go. Yeah. Next, next. Yes, that's what had been happened in cases that are friends uh ratio ghafoori uh and also our friend, Roman, you and Karen talk is uh to go in a hurry to the bride and even to approximate and do uh conservative debridement, not fully debridement, which is the questionable condition of these cases which depend upon the condition or the type of the measle if it is low energy or high energy or high velocity. All this is depend upon the any tree, the penetration and uh the what is have been missed by some of our colleagues is the cavity ation, the cavity which is cavity penetrating or going through the wound from one side to the other side. Or this need to be excavated and should be the bride it and should be closed. If it is a measure enough to do this, uh If it is a case of low velocity, we may not in need for maybe in the bride mint or something like this. But if it is a mild uh or moderate velocity uh firearm, we can do assessment because it is serious. It is questionable and we should look for the penetration and from the entry and from the exit, which usually the exit is more than the entry. And also there is associate soft tissue and uh and also necrotic bone commune utian inside the uh the area of the bone and also the soft tissue outside. This is for my colleagues and for trainee, we should be in mind these questions that have been elaborated by you and uh previous discussion slide please. This had been approximated by few suture. So is it right to approximate? Absolutely in this condition, it is not right to approximate by enemies. We should the bright, generous the bride and believe it open, we have five or seven days to do what we would like but should not be closed at all. Slide please. This is what happened slight again please. It was prepared to do an extra exeter. So this has resulted in failure and the aim of infection at the aim of infection subsidence and everything had been gone away. Slight please. So we should do aggressive, the vibrant again for the bone and soft and it worsens not be enough by conservative debridement slide, please. And so we are a need for usually to, to go for a temporary extent of theater and look and think for the infection and the necrotic commuted bone and soft tissue. And also if there is Cavite Asian, if there is in and compartment and doing what we would like to do slightly. These slight start, please. So the problem is the infection, not only is the open fracture, the infection as soft tissue defects slight please. So we did very uh hard thinking of ourselves is to do a mono lateral giving the chance for doing the flab for covering of the brightest soft tissue. And also after this slide, please. Following the brightman of the bone, we apply a flap. So this is rotation flap, help us to keep the soft tissue and with uh the bone itself inside, we just do the bribe but uh in a hurry and do a mono lateral fixture slide, please. After a publishing of all signs of infection laboratory and the clinical is like this, we are that everything is well. So we define this area as you see here in the middle third slight please. This is will be resected slide, please. Yes, after this slide, please, the section slide please underneath the cover of the flab. So we did here high in the Metaphyseal area, Acorda Khatemi to make a very nice transportation along this area which is long around 17 centimeters slide, please. Slide, please. There is this is the journey of 17 centimeters from up from the metaphyseal to go down to the docking side there. Slide, please. Slightly years slide, please. This is about to be reaching the the docking side slide, please. Along there the slide, please take around nine months to have this but all these area as we find the patient can go here and there go for uh the past room for going outside his door, going to do any activity. And this seven centimeter regenerate is it is so weak to have a stand on it. Uh If there is a nail or if there is a plate, whatever it would be. But under the control of Lazaro from all over this circling maneuver of a Listserv and the trembling effect and the elasticity uh the uh the stability which is resilient for doing uh regeneration to be enforced and uh and improving in callus formation. It is very nice to go here and there to move. Slight. Please slide. Please. Uh driving to the tissue of the regenerate area of the docking site, we do a bone graft to be sure that everything is well and do dynamism, Asian dismantling of the Hyzaar of gradually until we feel that we have three cortices in a pa and lateral view. And at that time, we can say we may take over the Hyzaar of slight, please. Thank you. Thank you very much. Thanks, Doctor Fadel. As usual, your cases are very complex and you covered a lot of really important learning points for all the junior people on the call. Thank you for that. Um We have a few minutes before the break. I just wanted to leave it open to folks to make some comments um on this one. Um especially Doctor Cook and Doctor Della Rocca. We haven't heard from you yet. I just wanted to maybe ask you guys if you had any comments on this case. Yes. Yeah, this is, this is Della Rocca. Um First of all, thanks so much for having me here. It's a real pleasure and an honor to work with all of you. Um May I ask a question of the first of the first presenter, Dr Madison? Okay. I don't know whether he's on. I was I my, my question may come from uh standpoint of being naive about uh about sign nailing, but the quit. But one of the drawbacks that he mentioned was the uh what I perceived from what it was being said was the difficulty in achieving training to use the sign nail. And I was curious as to what the barriers were to receiving this training, whether it's a lack of instructors or a lack of time or a lack of funding or a combination of all of that? Um Are there any perspectives that any of the panel can provide us for that? I'm sorry. Were you all able to hear me? I hear you. But uh hey, me, I hate you. Uh Greg, I think um if I'm hearing your question correctly, it's what are the limitations for, for teaching people sign nails? I think some of this is just a resource issue. You know, the, you know, these guys have to train in a, in a setting where they can actually learn how to use the sign nail if, if I'm understanding your question correctly. Yeah, I mean that's, that was we can. Yeah. Hmm You know Karen. Um Yeah, I'm really soda guys. No worries, Brian. Yeah. Go ahead, Jack. Sorry. No, I just wanted to uh you know, to make a comment on the bone transport case. That's a, that's a beautiful case and a nice say that's a very, you know, technical and time intensive resource intensive effort. And you know, I I do those myself and I look back on them and I think, you know, every time I do one of these, I think I missed the opportunity to avoid that problem by, by making sure the patient didn't get infected at the beginning. And that's usually about flap coverage and it's usually flat coverage within 48 hours. So when I see those injuries, you know, my main concern, you know, particularly for our trainees is not how badly the bone is or, you know, you know, doing anything with the bone. I don't, I don't care about the put that in the next fix. My number one concern on those in the 1st 48 hours is coverage because if we can get that thing covered within 48 hours, we're gonna win. And if we don't get it covered within 48 hours, we're going to be spending 22 years doing bone training, right? I think, yeah, Dr Kandel made that point very well that, you know, the, the initial attempt to try to reconstruct the soft tissues and not do a third agreement was I think what put this guy in a little bit of a whole? Um I guess my question and also for Roman is, you know, go ahead, sorry, sorry, Karen. I, I completely agree to, I, I would say the other comment is that they tried a rotational flap on that and clearly, you know, rotational flaps are going to be quite limited for, for the trainees who need to learn how to do flaps. I would suggest the A L T flap, the lateral thigh flap is really fairly forgiving, um and technically less challenging than some of the other, you know, free muscle flaps. And we've had quite good success with it in the tibia and you can get huge amounts of coverage. So if you're gonna learn one flap, you know, learn how to harvest an A L T but that requires micro, doesn't it? Yeah, I mean it requires a lot of technical experience and that just may not be available. Yeah. So the availability of microscopes is severely limited in most of these places. So it's really, really hard, really, really a challenge. Yeah. Yeah. Really hard. Um The other thing I wanted to comment on was the management of dead space. You know, if you go in and you do a big reception of all this necrotic bone and necrotic tissue and then you have this big dead space. Doctor Fadel. This question is for you mainly, you know what, what are you using to manage the dead space and manage the soft tissues until you can do a flap to cover it, you know, and say the patient presents late and you already have an infection or signs that infection is brewing. What what are you doing to manage the dead space? Uh Actually, I try to show what has happened from some colleagues is to be happy by having what is looks like a good appearance of uh far injury wound. They feel that they succeeded and the thinking of how can they will do internal fixation. This isn't, this has happened in my trainee, but it's the problem is that there is a hidden problem inside if they didn't, as you mentioned in the very nice discussion is they did, they didn't understand the pathophysiology as a pastor anatomy that the penetrating wound is, it's not inside, it is not a fracture, treating carry with it uh higher energy for damaging and also a thermal effect. And what is hidden also is the cavity Asian or the cavity effect? This cavity depend upon the if it is simple or not simple, you can say that uh low energy or low velocity uh in this case, you can do even you can use even uh plan internal fixation whatever be. But in the mid mild high energy uh velocity firearms, you should look either to use internal fixation or external fixation. If it is not, uh if it is a stable, it is a way is it uh if it is a way of complication of the soft tissue, if there is no uh vascular or neuro vascular problems, if no need for uh extensive or multiple debridement, if it is not questionable around infection to be hidden. In this case, you can't go through the internal fixation. No problem. It is guided one by one. You may have the third type, which is absolutely in many instances in need for external fixation, which is the high energy trauma in this condition. You are confronted. Actually by the pathophysiology of this trauma, you are confronted with damaged thermal effect and the bone combination and the commuted bone, it is not amenable to believe it uh to be as a calm, she'll uh or even a chipping technique for as a bone graft or something on auto bone graft. It is a necrotic bone. So you are from the start know that you have one third of the link damage it. In this case, know thinking at all of internal fixation by any mean, either if you have a clean area and cover the area of soft tissue, you can use what is mentioned by Doctor Kaforey or Dr Heidi, you. But if the soft tissue also is uh an insult and the problem and this is a condition start from the first by assessing if you have one third or 1/4 even to do monologue, Toral XX Asian leaving a room for plastic surgery, consult them. If they can do something is okay. If they couldn't help us, we can behave by ourselves within limits. If we have two centimeters, three centimeter of bone debrided and softer ship, we can do gradual compression and doing shortening, which is gradual shorting maybe do it accurately if we are monitoring the vascularity. Well, we can do it accurately for the for the tibia and the leg bone, we can do it for three centimeter or four. But with questionable, we we we should take care of the pulse, the proximity, the approximate the pulse of the pedal pulse. But in case of we are afraid we can do it gradually with no need for plastic surgery. After approximation of both ends of bone, we can do corticosterone or the metaphysical area and everything now is clear. We have a docking site, we have a short tibia and this shortage, we can do lengthening clearly from the metaphyseal area. This is all this had been done accepted by using external setter and especially Salazar of. In this case, is wiring technique. The wires carry less and fiction uh consult for the bonus of tissue more than the chance. So we have a short limb. We have a closed soft tissue, no need for micro vascular surgery or also plastic surgery we can do later on by orthopedic surgery, a lengthening a procedure and no harm of infection. This get rid of many days and the many a lot of money for uh having antibiotics in these conditions. I hope that I'll cover the uh to some extent of the condition. Know that that's great. And actually, you know, we have a fantastic lecture by Jack Wixted on acute shortening, which, which is available online for free. He gave that last year. So definitely that's an option. So I just want to move to the break now just before we moved to the break since Dr Haider gave the final lecture on this, I want to give a moment for Roman to say a few words before we moved to the break just to summarize some thoughts. Uh and then uh and then we'll move to the third section. Roman take it away. Uh Thank you, Karen. I, I think that uh the case of uh Doctor Fidel is highly illustrative and very important for us to recognize. And uh I think as, as Jack also pointed out, the hard thing is not necessarily the bone, it's the soft tissue and recognizing that as part of the trauma spectrum um is really important and it, unfortunately, though, it is the hardest thing to teach because it's not as objective and it requires a lot of judgment. But I think that if a good debridement can be done at the first or second, go to the operating room without regard for what way I'm going to fix the bone. Um Then you, you have avoided the biggest problem, which is infection. Once it gets infected, you have a much more difficult problem. And based on that debridement, you can figure out how am I gonna cover it and how am I going to fix the bone? And there's various options. And as we're seeing with all of today's cases, we have to set up the conditions for healing of the soft tissue and the bone and, and we need lots of tools and whether it's an external fixator or a rod or a plate, each 1 may be appropriate for that particular situation. And we just have to apply it per the principles per the principles that that device is designed for. And then you can have the solutions you need to deal with these complex problems. You can't, you need more than a hammer. You need more than just a drill. You need lots of tools and know how each one works optimally and optimize it for its situation. And that's how we're going to avoid problems, doctor before you go ahead. So thank you for your comments. Just a very important thing I would like to share. It was mentioned about the importance of knowing how to handle soft tissues and how to know a flap uh as a tool that you should know how to manage. I would say they're very uh interesting flaps that everybody should be able to pick up without microsurgery. Some of those are the gastrocnemius flaps that are very, very powerful for the coverage of the proximal tibia and the solos or heh my soleus flaps that are very important for the mid shaft. Those flaps don't require micro surgical training. They only require understanding of anatomy, especially gastrocnemius. They are very forgiving because the blood supply comes from proximal and it's very rare that you're going to compromise blood supply unless you go too far. Approximal without understanding where the Pedigo is. Uh the soldiers requires a little bit more of understanding of the anatomy. Um But it's still a very good tool to manage midshaft soft tissues problems. Thank you really excellent discussion in amazing cases. Um So let's uh let's take a pause for five minutes. We'll come back at 30 minutes past the hour. Of course, for those of you who just want to sit around and continue talking, please feel free to chime in. But, um, we'll move on to the next case presentation by Doctor Duf at 30 minutes past the hour. Brian. Did you, did you raise your hand and you want to say something? Yeah. Yeah. Yeah, I would just, I would just like to add two to Mauritius uh comment uh you know, for, for, for TB uh lake clubs, I mean, proximal uh gastrocnemius flap, middle shaft, uh the C V, we can use uh solo semi shoulders and we've been using uh reversal of labs very, very uh you know, uh effectively uh for, for distal third tibial uh practice and we do have very good success rate. So I think uh as an orthopedic surgeon, this rotation flaps are really relationship for, you know, for managing uh TB a practice which exposed bones. Thanks, Brian. Uh Brian, are you seeing a lot of these uh these firearm cases in South Sudan? That's uh that's it. Yes, we, we do see a lot of them and uh sometimes we actually get uh apart from the firearm practice, we do see a lot of them and we try to manage them as uh as much as possible. Uh you know, firearms are everywhere in South Sudan. It's just a country we can make from conflict So, uh, we see this a lot and usually these, uh, you know, rifles AK 47 this sort of uh uh firearms. But quite interestingly, we do get, uh, cases of, uh osteomyelitis, not necessarily post traumatic. For example, in Children, you, you find a child coming to you with an exposed, you know, tibia, more or less 50% of the TB exposed and you have to do something about that. Um We, the reason we've been, we've started to do uh born transport. So we're, we're learning to, we're trying to gain experience in this uh this aspect. But yeah, we do, we do get this kind of challenging cases and what, what do you guys have in terms of soft tissue management? Do you have a dream, uh depression? Uh Sorry. Can you repeat? Can you repeat? Yeah, sorry. Um Do you have negative pressure wound therapy available? Do you have uh you know, plastic surgery available? What, what are you doing to manage the soft tissues? Well, we do it, we get it all on our own. We don't, we do not have uh we do not have a plastic surgeon at the moment. There is one who just finished his training recently from Sudan, but he did not join us fully. So we do all the flaps on our own. Um What was the second question? Yeah. Yeah. So what was the other question? Uh Do you have negative pressure wound therapy? Is that something that you, that you guys use? Oh, yeah, we, we do not have, we do not have access to negative pressure wound treatment. And that's actually where we picked interest, uh, from, from your pumps that, uh, you know, I just saw it on Twitter and I picked interest on that. We do not have negative pressure wound therapy, but we're, we're actually trying something interesting. Um, uh, that is honey dressing for, for, for uh you know, open fractures with terrible uh infection. We find that honey dressing would actually does a lot in improving uh graduation tissue at the fracture site. Some, you know, sometimes you get graduation uh tissues gripping to cover the bone. Uh even though it's not as effective as negative pressure wound therapy, but it's uh something that we're using. Yeah, I think honey dressings are very powerful. I first was introduced to that by colleagues in Tanzania. Um I think the mechanism of action is it's basically like a hyperosmotic um you know, compound. So it basically is bacteria static or even bacteria seidel in that sense. Um Roman, just before we moved to the next case, I was just curious, you know, in the situation in Ukraine. Um what what are they like? How are they typically managing these complex injuries that happen on the battlefield all the way up to reconstruction? Can you give us some insight into what the situation is on the ground there? Yeah. So as you may know, the fighting is happening mostly in the eastern parts. And so there is a uh mentor evacuation from the battlefront, uh two parts further west. And this includes not only the military casualties but the civilian casualties and at the early stages, having talked to colleagues, they hardly have enough time to even take in the intake history before they're moving onward. And so they have a very brief debridement and stabilization with external fixator and then they move on and that's, that's the hard part that it's hard to track to know where these folks are going and what's happened to them and what's the plan to go forward. But a lot of these are in external fixators. Uh then they get to a definitive facility. The degree uh and expertise of the surgeons, there is variable and like in a lot of Africa, plastic surgery support is very limited. And so a lot of surge orthopedic surgeons have learned how to do gastroplasty and cyril flaps and other rotational flaps uh which is really useful. Um And so wound vax early stabilization to breed mont uh is really important. And I think that what I have seen and experiences uh and this is common uh the because of the uncertain coverage and fixation plan is not really established, then the early phases of debridement and stabilisation are delayed, leading to the complications of stiffness and atrophy and non union. And so getting these principles established earlier and having a more um robust way of addressing all of these is would be more ideal, but given the volume, it's very, very difficult to do. Yeah. No, thank you Roman for that insight. Um All right. Well, without further a do, let's move on to our last and final section. I'm sorry, we're running a little bit behind schedule, but the conversation has been great. Uh So Doctor Ju from the Gambia, uh please marry him. If you can go ahead and take it away, Mariam, can you can Ewan mute your microphone? We can't hear you. Hello, good day, everyone. I am doctor you from Edwards, Francis Small teaching hospital and I have two cases to present in this conference. Let's the first case is a 34 years old man who stood by his vehicle when he was uh knocked by a fast moving vehicle. He presented with cross injury of the leg as well as trauma of the same uh of the home, a lateral hip. So in his, he presented very early between the first hour of the trauma, then all the vitals were okay. Then this patient was admitted at the any next next slide. Hello, Mariam. You're muted again. For some reason, we can't hear you. There we go. Now it's okay. Please continue. So within the first one hour, the BP went down to 80 and 50 patient was tachycardia drowsy, unpeeled eight D was also low. It was about eight. Then this patient was started on normal slammed. 1.5 liter of normal slammed was given and one point of blood was also given. So we request that three point. But as you know, blood is not always readily available, one point was what was available and this was what was given to the patient next slide. So an initial X fix was planned for the patient and anaesthetic review was brand but the possibility of immediate external fixation. So based on this review, addition was made to continue resource it ease in the patient and ex fix was blunt the flying the next. So the patient was optimized at it's uh on day two, patient was fully conscious tabled. However, on the local examination, the industrial speedy's was palpable. What was faint posterior tibial is was not palpable and the clothes were appealed. So there was lots of sensations. So with little optimistic, we decided to go ahead and then do the deprive mint and expects was done as immediate amputation was something that you cannot take of in the Gambia. You always try to give them the opportunity to have a limb. So in theater, only the posterior TV values, I mean the political actually was palpable. The rest were not palpable, go ahead next. So the tide, the post uh post X fix, we noticed that the toe was already becoming black. However, the patient believe that he was getting better. He was saying that he was feeling everything and he was getting better. We proposed amputation with the patient refused almost uh seven days after the first operation. Then finally, he accepted and then uh the operation, uh an amputation above knee was done uh next. So this is how the patient came. This is one of the lacerations that the patient come. This was immediately on the lateral side. There was also a bigger one go to the X ray good. So this where the fractures, the fracture goes to the as long as to the TV, a plateau, we are involved and then uh down to the proximal part of the TV. And also if you look at the X ray, the hip X ray, the sub truck was also affected. Mhm And this is the X fix that we met. So this was uh the four date post operatively. So finally, this patient was amputated today. The patient is at uh the 36 still uh the hip is not yet fixed, but the patient want to go for oversee treatment for to have uh prostheses go next. Next, that is the end of the case. So that is the end of the first case. So uh this patient is still around the hip is not as thick. I was waiting for the for the storm to get uh heal properly and then it will be maybe A D H S A difficult let us will be fixed because the storm is very, very short. It's about uh 15 centimeters from the joint. So, but now now the patient is asking for medical reportable for oversee treatment. So I don't know what are the possibilities, whether I should do uh dynamic hip screw and then allow for healing before he go for the hip. I mean for his prosthetic or not because in the Gambia, we don't have the Gammon you. The only thing that we have for this kind of fracture is the dynamic hip screw. So the second, the second case, should I go to the second case or should we discuss this one? First, Mariam. Is this not your second case? This is the one that happened. This is your second. Yeah, go, go up, can you go back to start? Just go back. So this one case is also a young man, 35 years old, a nonpsychotic patient who was involved in our t a vehicle of uh he was working on the road when he was not down by a car. He came with decreased level of consciousness, the deformity of the tried and then was not able to wait. However, his vitals were normal good. So a right close segmental fracture with non with malunion was diagnosed. So energy skin tractions were given for this patient. We had a problem because uh we don't have D H S that we are readily available. There was no, no, no family member. So we had we, we luckily we, when we took him to, to, to there was one details that was available, which was only four hold, but we realized that this couldn't fix it. And then I am uh female was uh used, however, it was very, very difficult and then the cortex was perforated. And that is the X ray. We have go to the next next next slide, please. So this is the patient fracture. You can see that there is a malunion of the chemo. So on top of this my union, he has a new new fracture which is just above the malunion making it impossible for Neil to pass. Initially when it was discussed in the morning meeting because of the malunion, we say that it was not possible to put a nail. So we are going to try to use a long DHS or at least a blood plate. We have few blade plate that are available for patient who do not have a monitor by the implant available in the country assignment. Sunday is not also uh gamma nail. So we went into the charter. The only uh DHS that was available for filling was four hold it was too soft participation. And the next last option we have was to use the female. And then at the end of the day, we couldn't, it was very difficult to uh repeat uh open the canal. And because of that, the cortex was open and then see em was not used at the end of the day, we have X ray that was out, go to the next select next slide. So that is the X ray that is the nail that we have for this patient. So all these things are difficult cases. That is why I brought them. It was very, very difficult for us to take any single decision on these two patient's. Thank you. Thank you, Doctor Duf. Wow. Very tough case. Reminds me a little bit of the case that was presented by Dr um a joke at the very beginning where there was a malunion and then a new fracture on top of that. Um So just before we moved to the bone transport cases, I'll just leave the floor open for any of our faculty to comment on these two cases of uh Doctor Duf. So, so doctors oof um thank you for presenting those cases. Those are rather difficult and I I understand that you have, it sounds like there are difficulties with obtaining uh certain implants, one comment and then one question for you. Um My comment is that early on during the, during the discussion's this morning? Um Dr Sue's er mentioned the clam shell osteotomy, which is uh something that can be very powerful to treat this deformity. Now, this increases the complexity of the case. But the clamshell osteotomy technique involves cutting the bone above and below the old deformity and then splitting this in the intermediate peace. In this case, you may not need to do that because you already have a fracture up above. And so then you can um and then you can theoretically put the nail down so that it goes all the way down to the distal femur if you have that available. Um But that's, but that, that increases the complexity and the number of places where the bone would have to heal. And so that may also be somewhat difficult. So my question for you is, do you have uh we've talked about sign nails uh previously, do you have those available for use at your hospital? Yes, that is what we have. Those are the only nails that we have readily available. Yeah. Okay. Thank you. The uh the nail that uh that Miriam was describing that thin nail, that's actually a variety of the sign nail. Uh It's typically sorry, Miriam, you can probably explain it better than I can. But from what I understand, it's originally designed for retrograde mail because the thin component allows for basically uh uh it to wedge into the isthmus and prevents you from needing to do pro the proximal interlocks when you do the retrograde nail. Now, I think it was actually quite a brilliant idea for you guys to use it here. And two great knowing that if you perforated that healed kind of cortex of the malunion site, you'd be able to wedge it in there and be able to get enough of a fixation to stabilize the proximal fracture. I think it was very creatively use of the technologies that you had available area and I congratulate you on that one. Um I wonder if you've considered putting one of those tension band lateral plates on. Did you, did you guys consider doing that because this is a subtrochanteric fracture? No, we didn't consider that because of the malunion. It's very difficult. Like, unless we break that entire malunion, it was going to be very difficult to put any plate on that Mariam. That's a, that's a beautiful case, really nice, you know, way to handle a difficult problem with the creative implant. I would second, you know, Greg's comment about the clam shell osteotomy being extremely useful in this case because it would allow you to use a standard sign nail, which diameter wise is gonna give you, you know, an implant that's gonna last long enough to get the sub troche area to heal. The problem with using a small implant in the sub stroke area is, you know, there's very high forces across that area. And I think there's probably a good chance your nails either going to bend or break before you achieve union. And a clamshell osteotomy, you know, moving down, you know, 8, 10, 12 centimeters below, you know, right to the apex of that deformity and then making a transverse cut at that level and splitting that whole deformity in half in the, in the uh in the corona plane allows you to, to put a long nail all the way down to the distal segment where it's intact. I'm not so concerned with correcting that deformity. It just allows you to put a bigger implant in. Yeah, Brian, you, you'd raise your hand. Did you have a comment? Yeah, I was more and more in the line of uh, Doctor John, uh using a clamshell uh that would allow you to use a standard uh interlocking sign nail rather than uh and what we have done uh in a few cases of subtrochanteric practice that we use, we use sign it and then we can augment it with the side plate just to add more stability. Um you know, to the subtrochanteric fracture because obviously the HSC is going to fail because uh it's sort of uh subtrochanteric with the latter of world law. So it's going to be a sharing force that's going to fail. Uh the implant, another uh tool that that actually I think it's very, very uh robust is uh angle angle blood plate. Uh I know it's absolutely the west, but over here, it's still a very, very useful tool. So a 90 degree angle black black can do wonders for this case. Thank you. Thanks, Brian. Yeah, that, that lateral plate is what I was describing uh for the sub stroke fractures. I know it's recommended to the sign nails but, but anyway, let's uh let's move on to our next case because we still have two fantastic cases to present. Um I did also want to say that we've been talking a lot about soft tissues. There's a fantastic lecture on the youtube page for H G O C by Doctor Same Doleta. He on um you know, he's a plastic surgeon like Ortho plastic surgeon, fantastic surgeon and he goes through the reconstructive bladder and all the different techniques for lower limb, soft tissue reconstruction. So highly recommend that. Uh So doctor my poor, if you're available, please take it away for this next case. Okay. Yes. Yes. Hello everyone. Can you hear me? Good. So my name is Doctor Mark for, I'm an orthopedic sergeant uh working at Juba Teaching Hospital. Uh uh It's a great privilege to present complex limb deformity uh organized by habit Global orthopedics in collaboration with South Sudan North African Trauma Society, which I'm part of next inside. So these are my disclosure. Uh Most of the implant we are using here are donation from Science Fracture Care International. Uh There's no financial or any other interests involved. Thank you. Next slide. So these are my credential. Uh I graduated in 2010 in University of Barrel Gazelle by then, it was based in uh Northern Sudan in Khartoum. I did my M Edin Darussalam. I finished in 2017. Uh Then I went with Sophia for fellowship in Pelvic and Acetabulum Trauma surgery in 2018. And I also happen to be, to sit for a local or original exams, which is, uh, fellowship of, uh, college of Surgeons of South East and Central Africa in 2021. So I work here at Gibbet Hill Hospital as a head department of, uh, African Trauma. And I also teach in tube in University of Yuba. Uh, and I happen to be, uh, General secretary of the society which is collecting today in this webinar. Next. Mhm Yes, it's all mail uh present to the clinic with limb deformity. He was working with crash, he doesn't have pain. It reported a childhood of chronical soma litis at age of five years on our clinical assessment, the limb was shot by six centimeters compared to the opposite limb. He has no one. He has no sinus discharge. So that means he has no active infection at that uh time of presentation, but he has an hypertrophic scar and tra media to the uh of the lake. Uh He also has deformity at the anchor joint, but he has a normal range of motions uh at the knee joint. Next slide. So these are the X ray we took on presentation and uh everybody asks himself or herself, what is the diagnosis at this uh stage at this presentation? For example. So if you can see shared uh the fibula here is maintaining the length of the limb and you can see a sclerotic fencing like a parent as at both fragment, uh proximal and distal and there's a gap, they are not touching each other. That means there's a gap in between. So when you look at this, you we came up with a trophic nonunion at the mid shop of the right tibia. So that's our working diagnosis. So now having this diagnosis in mind, what should you do? What will you do next slide? So here because of a trophic nonunion. So uh we are faced here with a gap in between two fragments. So what we decide, we, we decide to treat this patient uh by using data. So we plan to do osteotomy before osteotomy. We open the non union side, we clear out the fibrous tissue. So in between the two fragments and we remove the sclerotic part of the bone until we find the bleeding area of the bones. So we were left with about 5 to 6 centimeter length uh bone gap. So we put the ring quick set on and we did our thea to me at the metaphyseal die official junction next slide. So uh doing uh destructive osteogenesis at this patient. So you have to ask yourself after doing osteotomy at the metaphyseal die official junction, when will you start uh distracting or transporting that segment? So, it depends on the type of patient you are dealing with. For example, in young age, the body is still active and uh in all age, the bone cells are not that much active because of element of osteoporosis and other things. So because of this was a young uh male or a young person. So we start our distraction at day five from the day of osteotomy. So we spent five days and then we start doing destruction uh that, that osteotomy side. So, next slide. So this is the process of destruction of destructive osteogenesis at day three, uh sorry at week, at the third week, next slide. So up to here, we achieved docking at week seven. And you can see there is a visible colors that is being formed at the bone transport area. So achieving this achieving docking uh side, the question is what is next after achieving docking side. So uh putting in mind uh after achieving dog inside, you still have an issue with the length because the limb was shot by six centimeter. Number two, there is deformity at the ankle joint. So these are the things you have to incorporate side that you come out with a full length that you uh will restore later on next slide. So these are the question here. After achieving docking side, you have to think of the lens and you have to think of corrected uh correcting the deformity at the ankle joint. Next slide. So here we took the patient to the oh are we opened the docking side? We refresh the bone ends and we played it with uh the DCP plate. Then we thought of correcting the deformity at the ankle joint. So we did an osteotomy just above the centrum osis, uh ligament because the angle, the ankle joint was, was, was, was, was not rigid, it was flexible, there was a range of motion at the ankle joint. So we thought the deformity is at the bone level is not because of the sub tissue. So that's why we did osteotomy at the digital people like just above the cinemas is uh pigment. Then we, we adjust our friends like that. We realigned uh the digital aspect uh of the frames. So one of you may ask me, why do you, why don't you put uh why don't you cooperate? The ankle join into the ring fixator is because we are lacking, we don't have enough ring fixator. We don't have enough wire and we don't have enough roads. So that's why we did that. So we later on adjust the distal pin align it with the dest a roadside that we realigned uh the anchor joint after putting, after doing osteotomy at the fibula side. So here uh after doing osteotomy and after plating the docking side, we are now transitioning from the bone transport to the bone lengthening side that we give a length that was not there before after achieving uh the docking side, next, next slide. So, so after transitioning from bone transport to bone lengthenings, this what we achieved. So the next question is when do you remove an extended fixate, an extended fixator or the ring fixator after achieving uh the bone transport. So here you have to think of the bone healing because you were transporting the bone. So you were creating a newborn information at that level. So you have to wait until the bone is consolidated enough to take the weight of the body said that you remove the extent of etcetera. So at this level, we were patient enough to wait for at least six weeks. So we wait for six weeks. And then after six weeks, we thought the bonus already consolidated, putting mind the edge of the patient. Also, you can wait longer up to three months if uh the bone healing is uh low or delayed, particularly in elderly patient next slide. So this is the follow up. Uh The patient now has uh standing in both limbaugh's limb are equal of equal length. You can see at uh let assume desires and ap and the right one is uh the lateral view when you are observing the patient next slide. So at 16 week, uh sorry, 16 months, you have come all the way from the fixture on, on the X ray fixture on the left side to the fixture on the right side. So uh that's the end of our case. And uh the rest of the fact that we are left, we will discuss it in a discussion that is coming up next type. Thank you. Thank you, Doctor Mountain for a while. Fantastic case, an excellent outcome, really remarkable. Um I just want to pause maybe a few minutes for a few comments. Uh I'd like uh she's available to maybe comment on this because she gave a fantastic lecture on, on bone transport and uh deformity corrections. So, uh are you available? Hi. Yes, I am. Yes. Uh I thought it was a really great case actually. Uh It's, it's a very nice solution to what was a really challenging problem. Um It's one of the great things about bone transport is I think someone said earlier that you don't have to be afraid to remove as much bone as you need to because you have the technology to recreate it. Um and then uh plating, it's to gain stability at the end is also great because it allows the patient to regain movement in their joints and they can rehab faster. So I thought it was a really great case. Thanks Deepa and, and doctor my poor, you answered my question. I was going to ask why not cross the ankle joint? Because I think that would have been easier to maintain the alignment of that distal fragment. But you answered that question already was the limited resources. But I think given what you had available, you did a really remarkable job. Um So we have one last reconstructive case before we can open it up to conversation. Thank you all for being patient. We're at the top of the hour, but we'll certainly have time. I hope for doctor Daniels Kyoto's case from Kenya Daniel. Are you available? Yes. You know what I'm here. Uh Thank you so much. Very happy to be with all you guys. Not so happy to be the very last one. So try to give it light and interesting. We were saving for last because it's so interesting. Thanks for everyone to holding on. Uh Okay, are you seeing my screen? Because I have to share my screen. Good. Can you see me? I can see you but I can't see your screen yet any other? Okay, now we can. Okay. Can I go? Yes, please. Okay. So this is the case I'm sharing with all of you. It's uh 19 years old boy who fall from a three. So it's more than we see the day. This was December 2021. Okay. Supposed to be a eight hours before arrival in our hospital and then uh the brain mint after six hours from arrival. So now I'm sure some of you are probably everybody of you is asking, hey, what? This is a complex drama, uh webinar, what are you throwing it as such a simple, a simple fracture? And this gave me the opportunities actually jumped to one of the conclusion. That was one of the home message also of doctor Heda. Very nice video which he was saying, I don't have enough to stress about the importance of the brine and the brine and the brine and the brine. Uh And uh and so also I like how they put, they say why. So sometimes we have a lot of challenge. So this debridement doesn't happen immediately in our hospital. Uh But it's also true that some time because this patient came to us, come to us in a very delayed. So sometimes they come six hours, eight hours, 12 hours, even 24 hours. Uh I have to say that in the back of our mind, we kind of tend to relax a bit in the sense that we say okay. I mean, this guy has already stayed there 12 hours, a couple of hours more doesn't make a difference. This brings one of my points said, okay, we cannot control what happens before the hospital. So we cannot act on that, but we definitely can act when the patient arrives to our hospital. And I think this is one of the home message I want to deliver at the beginning. So anyway, we took uh many challenge, took six hours to go to the art that the prime it was done. There was apply P O P with the window, maybe we can discuss about that also if you wish. And uh what happens, you know, the report was like patient is doing fine, patient is doing fine. Patient is doing okay. So after five days of patient doing well. That was the situation. Okay. So actually it was a lot of paths infected. And uh so when I saw the wound and say, okay, let's go straight to theater, open the wound. Uh Look at the bone. I think all of us can say this bone doesn't look so well. Uh did the brain meant and uh kind of extensive the prime and because also sometimes we have the tendency to pay a lot of attention to the part of the bone which exposed to the trauma but not so much to the hidden part of the of the trauma. So sometimes there is a lot of dirt, a lot of soy, lot of pocket hidden. So again, the brain has to be no scheider branding, I would say aggressive, the brain and good the Brymer make sure that we remove everything. So at that time, what I did together with the brain, put ring fixed set from the distal part because somehow I was foreseen or I was fearing was going to happen next. And I only used wire because the distal fragment was so little. So I said, let me put something that can minimize the trauma to the bone that there's more, more I mean. So also I cover with the reputational flap. I think some of the colleague before said, also this is a very handful flap. So I tried to cover as much as I could. Also the defect and I mounted, uh let's call it Hybrid X Fix. So it was an eye brid X fix and I would say it's a real hybrid access because if you, for those who are keen, you can see there is at least three types of extend of etcetera combined together. Uh you know, this company, they, they like to do etcetera, they don't match. But if you're a bit creativelive, you can, you can mix them, combine it. And uh so this was the POSTOP. So unfortunately, that was I was fearing was going, it's about was about to happen. So you can see the soft tissue we're not healing. So you said, hey, that bone, they looked very white to me, it's not a healthy bomb. Probably it's that that bone. But you know, maybe sometimes you still you're busy. There's a lot of kids in the world you buy time. Now, this is how I look at five weeks. Now here you have the certainty that that those soft tissues are not going to hear. I mean, that's a dead bone and nothing is going to granulate or grow on top of the dead bone. So there was no other option to go for the plan. So those five weeks also gave me time to get my brain ready for the next step. And this next step, you know, I this was the pre op planning. So make sure that so to transform that uh hybrid fixator. Now using the last ring to a full ring fixator with ready for a TB a transport. So usually I do this with, with the patient. Uh because uh most of our people have never seen a ring fixator and never seen external fixator. So for me, it's very important they understand what they are going to face when we're talking about long bone defect, where we're talking about tibia transport. So this was the the day of the operation. And so I kept the last ring and then I dismantled the rest. I did a radical the primary, remove all the dead tissue. And uh when I mounted, I actually did an acute shortening. The nice presentation also on the video or uh Doctor Wixted said uh I think it's quite handful and I didn't shorten completely because I just shorten enough for me to close comfortable the soft tissue. So this was the POSTOP. So I prepare everything for uh for a TV, a transport proximate osteotomy. And as you can see on the yellow, uh this is how I get the alignment. So with some because having a ring already set has some limitation okay when you try to align. But some with this, you know, simple flag from Eliza Rov, you can get a fairly good enough alignment. So as you can see now, you know, remove the death boom boom, just the soft tissue heal nicely and heals very fast despite the condition sometime of our setup, you know, uh the contamination of the local dressing and you know, the, you know, our situation sometimes stuff, but still the biology of healing of these people is amazing. So despite of that soft tissue heals very well, so this was the follow up of one month transport is going well. It's progressing soft teacher also healing. And this was now we're hitting March 2022 this was the final alignment and the compression. So what happens here? So now when we're almost reaching a good time, I change uh the last part of the external fixator and I'll show you in the next slide what I mean and to achieve a very good alignment. And when I have a very good alignment, I did that full compression. As also Doctor Adele was saying the good thing is this patient uh they walk, you know, they need some assistance but they're not staying bad. So, and they're not all the time in the hospital, they just stay home, you train them, the lengthening was done by him alone. So this is what I meant. You can see the difference uh this was the previous before the alignment. So with just some simple uh Konica converse acttive washer, and then you can build kind of a motor with some simple part of the, of the Eliza of. So basically what you do, you just release a bit uh the bolt and then with the motor, you can mobilize uh in a frontal view and in a sagittal view until you get the good alignment and then you lock it completely, you compress it, lock it. So this is kind of uh basic but very effective way. That is the work that the modern exam podalic stand affects cetera does. And also we had that very nice video from Doctor Fromberg. So the fact that maybe that zap podalic technology is not available, we have other solution to get a good alignment, good compression. Uh Usually I do this uh you can plan for this and I do this in theater under the C arm. So I don't exhaust the radiographer. You can plan it one day. The cr me the operating room is free, you can go there because you need a fresh mind. You need to think you need to be happy with the alignment and also okay can be very useful. Have someone to uh check with, you have a good friend, a good mentor, very expert in the uh this kind of procedure that you know, you connect in theater. You say, hey, how does it look to you direct? You can adjust. It's always good not to be totally alone. And today's technology help us a lot. So this is something you can plan, you cannot do chop, chop. I mean, you cannot do fast, you need to do this part with a fresh mind. So this was after the alignment. So this was, we have reached in May 2022 patient's progressing well, so we can go fast. This was finally the removal day and it was June 2022. So once you reach the, the compression and the good alignment, that's now the point that you know how much you want to continue lengthening the tibia transport because only when you have that compression, that alignment, you know how much you want to continue up to go back to the contralateral length. So now this is June 2022. So that's why I call this presentation cheap is expensive because once again, the home messages, the Breiman, the Breiman good. The Breiman is a key. Sometimes this case gets very complicated. Maybe I say maybe not 100% maybe could be avoided this kind of pattern of TV, a fracture. If everything goes well, maybe the heel and weight bearing in seven weeks, eight weeks, this this one took about seven months. Okay. So this was a follow up August 2022. So patient, you know, our hopefully they show their pastorally long distance is very important and just order making care unhappy. I just recall last week, the patient I said, can you come? So this was a follow up April 2023 patient is working fine and I think uh he's doing factory well, okay. So just to close up, I think the home message from my side once again is uh early, the brain meant let's try not to use our challenges in our set up some time to sit back and relax. So we have to be aggressive and do good debridement. Uh Second one is, you know, we have, there is a way to also handle this complex case without exam podalic. Uh there is a way so it's a possibility already available for everyone. And also the last one is acute shortening sometimes can be a very good tool when you are in this situation for soft tissue. Thank you. Thank you, Daniel. Uh phenomenal presentation. I think you combined a lot of the concepts from some of our lectures, which was really lovely. I think that's why we wanted you to go last and it sort of covered some of those key learning points. Um Since doctor my poor gave such a great presentation of boat transport, well, I'd like to invite him to comment first and then maybe Doctor Mohamed Fadel because your presentation was also in for transport. So I'm sure you have some comments, Doctor Mop or can you, can you comment and then? Mhm. Okay yet. Uh Thank you, Daniel for your nice presentation, Daniel. You know, by the way, Daniel has been my, are we doctors up or can you hear us also been coming? Mm I understand the situation is practicing in it's like us. Mhm. That's, that's a pity. Was about to say nice things. About me example, you uh well, doctor uh for maybe uh in the same room as uh Brian, I could use this computer because I get a good signal from maybe Doctor Fadel. Can you go first? Can you just say? Uh so that's the situation we are facing here in South Sudan uh like our neighbor Daniel. Uh But otherwise the case he has just presented and everything he has just put the energy and the time, very uh wonderful. Uh You can see the success. Uh He has just uh given to that patient. Thank you. Thank you. Yeah. Um uh May I repeat my thanks for Karen and the group of uh Harvard? Actually, you did a lot of uh we can say green hands for those low admitted income countries. Uh Actually, I am in love with Africa and I'm living in Africa, my, my homeland Africa. So I would like to have it a chance that you have Secret uh Cairo uh as uh I am uh board member elected in uh Egyptian Diabetic Association. I am actually inviting you all to share. It is uh cheaper to come with us in Egypt. Even by uh airplane. It is cheaper than other uh secret to be in the Europe, for example, or for uh Kuala Lumpur such as uh last year who Karen uh got three medals. I think. So I promise you if you come Egypt, we give 44 medals for you. So I invite you. You have such good cases. We still have two days for abstract submission for secret. Please uh present your case. Is this fantastic cases and you should put it under sub Saharan complex cases it will be accepted. So please, we have many cases today and the privilege for Karen is to present five or six new abstract submitters from Africa. It is very nice if we got up from this meeting by this outcome of research because either to publish or to share in a presentation, a conference or to perish. So Africa have a treasury of cases. We are doing the future of the world by many cases which is not well known for them. So please try to add this uh facts. Otherwise we are doing bad by our uh basic uh cases. We have a lot of cases and Kieran will help us and me also, I am so near well and close with you and Karen have the organization who can help us all. So again, please chair and we have still two days for secret abstract submission. And I know that many countries from Africa have a good relation with Secret Association. Thank you, Karen. Thank your and Daniel and uh Brian and um Amber and all the team of uh South Sudan os medical situation. Yeah, I just wanted to echo Doctor Fattal's comment. Um We, we at H D OC stand ready to help all of you guys if you guys do need help preparing cases for submission to see quote. That's a wonderful opportunity. But obviously, like you guys probably don't even need help. The complexity of these cases in your sophistication of your approach is just really amazing and was on display today. So, thank you so much. Um Any any other comments from the faculty on these last two bone transport cases deep? Uh Jack Weeks, Ted uh Doctor Fromberg, you guys gave lectures that I think covered some of these concepts. Any any comments? Well, these are beautiful cases that you know, if anything they illustrate that what you need is really good judgment and thoughtful care. You know, the the you don't need a computer controlled system here, right? You need good judgment and patience and, and really these are really excellent cases. There's just nothing to add. Yeah, I I agree with that. I think basic principles proper debridement, proper planning. Uh you know, they, they solve more problems than, than computers. 11 thing to add, technically that we saw on Doctor Scooters case that was just presented is he really took the time to mount his frame, orthogonal e to the limb if you actually it takes a lot of time. And that's I think a lot where the learning curve starts off and why people maybe are shying away from this kind of treatment. But if you have circular frames and even unilateral frames, if you really take some extra time and maybe put a wire through the joints. So you can orient yourself, really palpate the tibula spine. Try to get the limb aligned and mount the frame orthogonal. E even though you can convince a frame to translate or angulated, you saw how easy it was for him to go to the operating room and correct the alignment later. Um So if you, if you really take a couple of extra minutes, even take an extra half hour and really try to get your frame to be perfectly in line with the limb. You don't need fluoroscopy and you certainly don't need to exhaust your radiographer as he said to try to get your final corrections to get your alignment. Perfect. Um Really impressive. Thank you, everybody for allowing me to be here. I learned a lot actually that I will take back and poor doctor Teso in Ethiopia when I send him some rings is going to have to, he's gonna have to present at this next year. Some of the crazy cases that he's going to be doing. So, you'd be more than welcome. And thank you David for joining us. Any other comments from the faculty before we move on to our concluding slides. Thanks for your group for that and thank you. Ok. Well, let's wrap it up since we're a little bit over here. Anyway. Can you hear me? Yes, we can hear you. Go ahead. Yeah. So I'll uh thanks, thanks Karen. And, and the team, it's really uh a wonderful uh conference where we get to share a lot of challenging cases. And uh this is actually the situation in, in most of Saharan Africa. So I can say that uh we speak, we speak for uh for the resource limited uh settings. And uh we, the convention of teaching is that, you know, the conventional teaching in books, let me say is uh those of resourceful settings. But uh I think we need to uh you know, take an approach where we can actually publish more on creating certain types of fractures in resource limited settings. You know, this will give an opportunity for, you know, uh for us to share our experience and for, for the trainees who are coming up and walking and being training, resource limited setting to be able to, you know, uh handle cases that they face on a daily basis. Um I think there was a question on earlier on the use of signal and how, how easy or how difficult is it for, for people to get trained in, in using side nails. Uh I would say most uh sub Saharan Africa, I would say Eastern Africa, Eastern Africa to be specific uh Kenya, Uganda, Tanzania, uh where, where I received my training, where doctor Mobile receive fix training. Uh most countries actually use spinals for, for, for fixation, which it's a very versatile type of nail. Um and uh more or less this is what we use uh in this, in this region. Uh for some of uh you know, from Egypt, for example, Egypt and uh northern part of Africa. They do have access to the other type of more expensive nails because they do have the resources uh but sign nails usually uh not very difficult to, to masters just needs a few cases and then you, you're off and running. So that's, that's my call. Let's just try to do more papers on treating practice and resource limited setting. Thank you. Thank you. Great concluding words, Brian. And I agree with you completely. I think the knowledge and skill and ingenuity of African surgeons to handle the complex challenges they face is just really amazing. And I think anything that any of us can do, I think if I speak for any of the perhaps all of the speakers from uh you know, the United States, we all stand ready to support however we can to elevate your voices. And I hope that this conference has done that in some small way. Um So just his way of conclusion. Next slide, please. I just wanted to say one final thank you to everybody for their participation. The faculty were amazing. The cases were amazing. The conversation was great both the live conversation as well as the conversation in the chat. Uh Really thank you so much and thank you for metal putting this together and for helping me deal with all the technical challenges that inevitably occur when dealing with unstable internet and multiple speakers. Next slide, please. Uh So we do have a certificate of participation that will be available um for uh for folks who attended the live session and can complete the course of valuation. Next line. Hello. Thank you for joining. Oh, yeah. Hello. Yes, I'm waiting for my presentation. Is that Doctor Abraham? I wasn't, we thought that you didn't make it. We uh try to find you. I'm so sorry. Yes, we, we have, we have your presentation as well still, I'm sorry for that. I can't make it in, in 10 minutes. That's great for those of you who are available to stay for Dr Abrahams presentation will be phenomenal. Listen to plastics to be sure. Yes, please. Please go ahead. We'll, we'll end the end the formal part here and we'll just leave anybody who wants to stay to listen to Dr Abrahams presentation. Go ahead. Thank you so much, everybody and please Doctor Abraham, you can go ahead. Uh Yep, we can share your slides. Just give us a moment. Shit, shit cut. Yeah, give us a moment. We're just trying to find them till then I can, I can continue with with, with the introduction. Is that possible? Yes, please go ahead. Yes. Thank you very much. I'm Abraham from Ethiopia. I'm a plus surgeon uh working in uh the University School of Medicine Alert Hospital. Uh Well, I was, I was asked just to put a little bit of meat on what we're, you're, we're discussing them that it has been a lot about all the complications and big cases regarding to the bone. I just want to do something regarding to the challenge is what is the challenges in low income countries, particularly with, with low extremity reconstruction. One of the, the challenges that um that everybody was talking about resource limits in those countries where that uh kids are coming late later, rebel is one of the, one of the reason that there is uh what I see is that there is no sort of um that coordination with plastic surgery and orthopaedic. So the principle of uh or to plastic uh joint venture is not as such a common thing like in uh low income countries like ours. That's another another thing that what what I have seen in a lot of um that registrars in orthopedics is that trial of closures and that everybody because everybody is scared of uh having um that exposed one. So uh I saw residents some that doing them that minimal development and trying to close with the sort of pressure and later on coming with a big defects. So these are some of the, some of the things I I just, I just want to comment and uh to go uh next slide please. Uh my, my, my, my slide serum that uh representative of these cases. This is one of the patient who came late, later rival is one of the difficult part. And uh if you see the reconstruction of particular with the soft tissue, as it can be the upper served with research prolapse search, it has been discussed on that during the previous presentations. One of the major issue is that uh we're a little bit um that uh so conservative regarding too d abridgement, uh because we're afraid that to, to leave the the bone exposed. And at any cost um that at the end of the day, we're going to face a debt issue with exposed bone with let with late comers. That is 11 of the challenges. These one of one of the case which I received recently, a 15 year old male patient who involved in a road traffic accident with sort of crash involving the middle cert and the lower cert including the balconies. If you see, I'm that special, he had uh ex fixed done. Initial development was done somewhere else before uh referral to our hospitals. But the time when the patient arrived on that, there is still a patient needs more department with exposed falconers, lord tibia and all the vital structures are gone, particularly with the medial part, the posterior tibial and all the so on this patient. Uh Well, this is one of the the challenge he's a 15 year old. So the challenge is that there are deep structures are gone. The bone is exposed. Uh So uh maybe I'm that still, there might be a sort of argument, it's better to do an amputation and putting a patient on processes. And there are also one that people might still argue that there is a possibility that to reconstruct this, this. Uh So in my view, I'm that somehow I'm that relatively acceptable, limp might be better than processes rather than I'm that definitely I'm that process might uh be financially, I'm that acceptable because you can, you can leave the patient disturb the patient from the hospital earlier. Anyway, I'm that this is a badly crushed lower deck with extensive soft tissue with neurovascular uh structures are gone. As I mentioned, next slide please. Next slide. Yes, then. Uh well, what, what we, we plan to execute on this patient is that doing extensive abridgement which is left from the first uh procedures? And uh then as I mentioned before, I'm that you have been, I'm just discussing about the soft tissue coverage for the proximal ones. Usually it is easy. There is no any need um that to do a uh sort of micro surgical type of uh interventions. Uh Gastrocnemius is good one and that everybody can, can exercise the gastro gastrocnemius as such. It's not a difficult one unless he in disarray some that somebody's trying to dissect more proximately and uh damage the pedicles. But usually it's unlikely to damage that because it's coming higher up in the conduct. The other issue is that with the gastrocnemius um that you can take full gastrocnemius or even half part of the gastrocnemius in the middle certain of the leg. And that solace is the famous one still solis. And that sometimes we also do what is called the classical solace or sometimes you can't also the reverse type of which is rarely you can do that. But in case of the reverse, the reverse ones solis, it is only you are allowed to take half of the solar so that the reverse is going to get a vascular supply from the the other height from the distal aunts from for the for the reverse solis, you can also use in an area which is junction of the middle certain and the, the Lorcet. That's what but in cases where it is involving the lower cert that was the challenge. And the micro surgical uh technique is that is the vital areas where you are entertaining or the muscle flaps and the fascia Catanese flap like Eliquis. What happens in areas where you don't have the micro surgical facility? Because that is one of the demand in skills demanding sources. So he's 111 example of I'm just challenged where if you don't have the micro surgical uh facilities in a patient where you don't need to do an amputations. If that is a small uh wound, small bone that is exposed, you can use also what's called the peyronie's Brevis muscle covers, which can cover around the ankle one. But like in a patient, this one's the best option is going to be what's called the delayed wrap up type of. Um that cross leg flaps, cross make flaps can be a classical uh oral type, what it can be on that wrap up in the wrap up, um that you can do other medially based or laterally based on a medial based type of wrap up Facebook tennis, you base it on a perforator which is coming from the posterior tibial artery on the lateral ones. You can use that one, a perforator, one of the perforators. What what usually I'm not using either the perforator that's about four centimeters above the lateral malleolus or about eight centimeters or usually about 12 centimeters on this particular areas. There are commonly a persistent perforators that are coming. So based on that one's you do, I'm that uh delay on for this one, I'm that we, we, we use them that both the middle and upper runs. And uh we, we did a delay. The importance of a delay is that um that you can uh glove almost nearly circumferential part of the leg to cover the counter, the counter, counter part of the effect on the other leg. So X fixation was both extreme. It was done. The donor site was covered with uh skin graft and the patient was put on X fix. So that uh patient is not going to rip off the flag. Next next slide, please. ***. This is, this is what, what what was done for this patient times. So almost time that the left lower extremities, uh nearly I'm about 60 70% of them that the skin was already big loved based on the medial perforators from the posterior tibial. That's covering almost the whole, the whole TVR. What was done is that we did decortication, both the balconies and remaining dead tissue on the tvs and the patient was kept these positions for three weeks. Next slide, please. Then on, on the 3rd and 4th week and that we divide the flap covered uh most of them that uh the law and uh the Lorcet of the tibia, but which we we we couldn't make it is that on the, on the classical calcaneus where, where it is as a soft tissue suit. So this is 11 was a challenge in the best setups where you have all the facilities. This is the classical case for a free flaps, particularly with that Mr See or uh also the fascia Butanis flap like reality. So as as previously mentioned them that uh it's not a big issue and that knowing them that all type of uh flaps or all type of microsurgery surgical arms at interventions, if uh one surgeon knows at least 11 flaps like uh entity, then almost 100% you can cover or you can address the one that is 11 classical case least can't case shortly. Next slide please. This is another patient, a 34 years old male patient, particularly this patient is co morbid. This is a patient with literal viral uh infection on treatments and he involved on a road traffic accident at the same time because I just wanted to to present times at the most difficult area because on the middle cert and the proximal cert, usually it's not difficult time that the lower cert depending all the extent of the wound one, the structure that's involved. Second and the third is a term that the tissue involved, that's another issue. So in this patient time, that is a patient with uh type three B where there is um that big defect, big soft tissue uh defect. So still, I just want to emphasize debridement and debridement and extensive debridement. That is the issue on that. If you are going to be a little bit conservative, then all the cases that were involved in that present with, even with the nearly um that uh letting they want a little bit late. It's sometimes I'm that we're, we're going to face a dead ball which are going to remove it. And then all the procedures that that were mentioned uh the sequel of um that being relatively conservative Gregory to uh aggressive, aggressive uh development. So I'm in favor of I'm doing as much as possible big and um, that aggressive abridgement. And that is the main issue. And the second issue is the time that we have to do that as much as possible. After doing the abridgement within a maximum 48 to 72 hours, we are, we should be able to, to cover the that area with the soft tissue, whatever soft tissue is a local or regional or cross legged ones. That's one. So for this patient time that because this patient came from far away from the east part of Ethiopia, that's about 430 kilometers out of addis. He had a primary um that conservative treatment with ex fix in one of the orthopedics units. I wish I'm that there was a sort of auto plastic type of uh joint ventures want to do, I'm that aggressive development and uh to do some, some uh soft tissue coverage. So uh for this patient, uh the only thing I'm that the dorsalis pedis was not palpable uh arterial TV or alter is okay. Definitely the patient had uh drop but extensive analysis is in fact, next, next slide please that the X ray showed um that a big defect on the lower type of the. So for this patient times that what what I did is that I'm that based in one of the perforator I mentioned that is from the perennial artery, particularly on the middle, about above about four centimeters and eight centimeters per. Fighters are usually they are persistent. You can't find them constantly. So based on that one, um that we raised fascia Tetanus good fashion Tetanus flab covered that one's and uh there was uh one thing that was mentioned about how are you going to fill a gap? That's also, that's what, what I, I heard this discussion in that case, if you have a muscles to cover from the local area, that's good like this one, um that you can also put the Peroneus bravest muscles as a park and to do and that the fascia tetanus flab or sometimes if you have a big fashion tennis flat, that the proximal ones, you can deep, it'll allies the tissues society can bury that one as a tack and the remaining party can use as a cover. So that's also another good issue to cover the shallow area or the cavity. That's also another issue. So for this patient time that after bring proper development doing fashion Catanese flap pack that one's and put the skin graft on donors. Uh Later, I'm that as, as you see on the, on the left side, uh the flap was good. Uh The the areas properly. I'm that packed and that recently the last two days we opened that one, we put the, the bone graft, we removed the, the ex fix and the auto petitions working with me. They put the plate and screw with the bone graft. So that's also another different these are some of the classical challenging case. Um that uh in fact, I could have brought them that cases from the middle insert. But I just want to discuss the most challenging one and uh really problematic cases, particularly in a, in a case in, in uh in institutions where patient's are coming late with infected bones or semi debrided or sort of conservatively developed. So that the messages that 11 important thing is that still, as everybody mentioned, uh debridement, aggressive department is important. 11, the second is we have to um that as much as possible uh cover the the area with soft tissue, whatever available, soft tissue, either the muscles with fast pakistanis and we have to proceed with with the other ones. And in a patient who are coming late, that is 11 issue and that we're using on and off uh with, with limited uh vacuum dressing, but we have a limited them at one or two. We have and one of the Vacco's supplied by. Thank you very much with Kieran is uh he, he donated one of the back. So we are using that once. That's also another issue. But the problem is that usually when you are using the Vac and honey dressing, we are uh really going for feeling by secondary intentions. And in that case, tissues around the endured area is Ida Mater's fibrous ones. And uh the, the secondary and that flap coverage is usually a little bit challenging compared to the primary so that uh we shouldn't miss the best chance that is in the 1st 24 40 40,000. Thank you very much, Doctor Abraham phenomenal cases. Um I just had one question actually, it's from the chat uh for the Calcaneum in the first case, what was the soft tissue flap that you used to cover it? Was that a reverse Cyril flap? No, that's not. Uh there is what's called the crane type of flap. And the crane flap is that you cover the area with sort of um that the flat part of the flap when it graduates. Partly, I'm that you take the flap as uh flap for other area but the graduation tissue you put with with the the skin graft. So that is because initially we couldn't make the whole thing to be covered by the what's the rapper flap? So we managed to cover the rapper flap, the whole tibia and think the Calcaneus. But the Calcaneus was, it was graduating so that we just put a skin graft? I see. Okay. All right. Wow. Truly, truly remarkable cases. Uh Sorry that we were almost not going to hear them, but I'm so glad that you jumped in and were able to present and you know, the number of people who stayed on the call to hear them, I think is testament to how fantastic cases work. Um Doctor Abraham, I wanted to also thank you for all the work that you've done to train so many plastic surgeons because I think these skills are so valuable. Um We have had other presentations of several flaps and uh and, and these crosslegged flaps, but none presented by a plastic surgeon of your level of expertise. So I really thank you for, for going through sort of tips and tricks on that. Um Thank you so much, everybody again um for participating in this. Uh Thank you, Doctor Abraham for finishing the conference on such a high note. Um I'll remain on the line and uh for anybody who has any comments or questions the floor floor is open. Otherwise we'll say thank you and, and have a wonderful rest of your day for those of you who want to uh log off now. Thank you so much, everybody. Thank you.