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OK. Uh So I've included this session mainly because in the exam, when it comes to the adult pass station, if you get a periprosthetic, you get a periprosthetic infection. Um You get an aseptic loosening case, you need to be able to describe the x-ray, you need to be able to make a plan for how you're going to manage that patient. And you want to, if you're trying to push to get sevens and eights in those stations demonstrate some higher order thinking. So looking at what are the challenges to get into this hip or how I'm going to approach this um revision or what are the challenges of whatever complication is going to happen or next? So we often know that these are often a, a series of events that take place, isn't it? So that's how you're gonna kind of push towards your sevens and eights. Don't forget adult path comes up a lot in basic science and arthroplasty lends itself to those types of cases. So lots of reasons why someone might need a revision, kind of the big headline ones are infection and that might be acute or chronic. Somebody might have aseptic loosening as a result of wear. And we discussed uh different mechanisms of wear last time or as you said, a periprosthetic fracture and these three main ones have some element perhaps of bone loss that you might be dealing with. Sorry, I MIPA it, I'm not sure if it's just me but I can't see your slides. It just says click to exit. Oh, ok. Let me thanks, Kim. Let me try again. Can you see it now? Yeah, I can see it now. Ok, cool. Just let me know if it's not working. Um, so, yeah, this is where we got to, um, other reasons that somebody might need to be revised is instability, which is often quite an unsatisfying reason to start revising someone because the more surgery you do, the more likely they are to become unstable, um, you might still be seeing some metal or metal revisions being done. There's still some lingering around knowledge, for example, and beware of the patient with unexplained pain who, er, is presenting wanting a revision again, quite an unsatisfying situation. Er, I'd have a very guarded conversation with that patient about what kind of outcome to expect. Uh, so along the way through this, we're just gonna start thinking about, um, how you're going to get in, how you're going to get things out and then what you're going to reconstruct with. Yep. And then what your postoperative plan might be for a patient. So that's when the MDT ones come up, the kind of things that you want to start thinking about and how you would structure your answer if you're being asked to talk about a case of a revision hip in the exam. So if we start on the femur side, because often when you're getting into a, a hip, you might deal with taking the femur out first to be able to get access to the acetabulum. So you might have an uncemented stem there or you might have cemented. And the kind of textbook answer for trying to get out an uncemented stem is what's known as an ET O or an extended trop enteric osteotomy. Um And that's when the stem is well fixed and you're going to struggle to take that stem out of the top. Um We'll go through a little bit later on how you do an ET O. you, I think if I look back over the last kind of 12 years of training in revision hips, I see a lot less ET OS being done now, um than I did at the beginning of my training. And that's a slight geographical difference in er, the type of implants being used in our region. Um But also I think people are trying to keep the femur as a tube and intact because it is a, it is an easier recovery for the patient afterwards rather than waiting for that ET O to heal. So, ET O is your gold standard. If you said it in the exam, no one's gonna say that you're necessarily wrong. Um But there might be ways that you can make that recovery better for a patient. So in the cemented stem options, we talk about taking it from the top and that might be loosening the stem up in terms of your uh proximal cement and then using er taking the stem out from the top and then taking the cement out, using a series of osteotomes and ultrasonic devices a bit like Oscar, right? So um just reiterating um those of you that haven't seen it, you take the cement away from the shoulder of the stem and around the anterior and posterior aspect, pro proximately. Um my preference, if it's a modular component, like an extra is to take the head off and then I put the rasp handle over the exeter er Trion and then you can just gently tap the stem out and then you've got your option of if you're taking the cement out, you can go ahead and do that at the time when you're ready. So if I need to take a tabular side of things out, I will leave the cement in. And the advantage there is that you haven't got a femur that just continually bleeds. Yeah. So another kind of higher order thinking thing, you're going to get your stem out so that you've got access to the acetabulum. But actually you're not going to address the cement yet because you want to try to preserve or reduce as much bleeding as possible for the patient. You might say, what would you do if you've not got a modulus system to say it's an old Charley type stem and actually there's stem and extractors that are available. So you would slip that over the um component and then it is effectively a a flap hammer type approach Most of these extractors. And then you again, you just gently knock it out. Once you've removed that pox more cement, you can see here they've taken out a section of cement. The reason for doing that is, is that you don't want to cause a fracture of the greatest tricantha. Um And we kind of said already with our uncemented stems, we're gonna do an ET O and effectively, this is just opening the femur up like a book. OK. You need to know the length of the extended tropic osteotomy that you're doing because you've got to bypass it with whatever stem you're going to put in. Um And so you know that you need your stem to be longer. So you measure your ET O out uh before you do it, anyone seen these techniques being used some of them? Mhm et O for example. Yeah. Um And removing the uh cemented implant from the top using Oscar and fine nostos and flexible osto tos uh mhm Good. Yeah. So cement removal we've kind of touched on a little bit already. So a cement removal toes are, um again, it depends hospital to hospital. And you've got your flexible osteotomes, you've got cemento toes, cement drills. Um up north. Um when I was on fellowship, they don't really use Oscar at all. Um They will drill into the cement and then they have a device that they screw into it and then they back, flap it out and actually big chunks of cement come out that way. Um There's regional differences um in how these things are done in the same way that different implants um choices as well in terms of the ultrasonic devices, um often Oscar, but there are other brands. So just be careful about saying Oscar in the exam, the ultrasonic devices um has everyone seen Oscar being used or smell Oscar being used? Yes. Yeah, it doesn't always smell very pleasant. I like it. Yeah, it's a bit stinky and it makes a very high pitched noise if you're cutting very fine to the cortex in terms of cups, what kind of options have you got? Georges for getting uh cups, cement cups out? Uh You mean the cemented ones? Yeah, you can start with cemented. So we have flu carbs, we have uh non flue carbs. Um Then um if we go for um uncemented ones, um we have Breastfeed cups, we have Jumbo CS for revision scenarios. Um We have augmented acetabulum cups. Um How are you gonna get them out if you need to get them out? Um, so what I've seen so far, if we're talking about, um, cemented cups, um, with very fine after, after, after removing the, the stem then with very fine noos, we keep going all the way around across, try to preserve as much bone stock as possible and then we start retrieving the, the cup out in cases where we're dealing with a cemented one. What we were doing was going in the interferes between the cement and the bone and try to gently knock the cup out. It's not as easy as it sounds. I haven't seen many cases. Uh but the cases that I've seen this is what we were trying to do. Um, the, the trouble that I've seen a couple of times is when we were revising cement, uh uncemented acetable of cups with screws, then it's always a bit tricky first to remove the polyethylene from the cup. And in these cases, we use a big large screw where we drill inside the polyethylene, we pull out the screw and sometimes it works. Sometimes not and then get access to the underlying screws untie the screw, gently, knock out the um, uncemented cup. Um, um So there's two different ways of taking out the, the cemented cups. So one option is, is that you can actually just ream the polyethylene out. It does produce a lot of debris, but it is an easy and very safe way of taking cups out or somebody who just needs to mute. Yep. Your other option is, is that you could eccentrically drill and then put a corkscrew into it and then you loosen up around the edge with cemento toes as far as you can and you can sometimes get the cup out that way as well if you don't wanna create too much debris and um, some of you may seem, um, may have come with me and you might see, er, apple pie uh for want of a better way of describing it. Um You might thin the, er, cup out with reaming it and then you might physically starter making some lines in it, either with osteotomes or, or um equivalent of a Midas rex or a bur and you make er, effectively your slices of apple pie and then you can take sections of it out and then you can do the same with the cement as well. Ok. Um With your uncemented cups, I think George's has given you quite a good uh example. If it's an uncemented cup with no screws in, it's fine. You can use something like an explant device and I've got some pictures of that for you in a minute and that's a blade that slips around between the implant and bone and you can turn that around and it loosens the implant up. Uh, problem with that is if there's screws in, obviously the blade can't get all the way around. So ideally, you need to get the liner out. Most, um, implants have got a device where you can, um, get the liner out. It doesn't always work. Alternatives like, um Georges has described already using a screw or the corkscrew technique and then take your screw out if you can and then uh go round with an explant and once your cups out, you need to look at what kind of defect you've got. So there'll always be some bone loss when you're taking something out, particularly if it's already being taken out because of a problem like aseptic loosening and some bone loss. So once it's removed, you then need to have a look at what defect is already there, plus whatever it is that you've created. So these are the explant devices, ok. So you put the head size on of the inner diameter of the liner, ok? And then there are different length blades, so small, medium large and, um, the length go up. You can see here how it fits around the edge of the cup and you're basically keeping the ball concentric within the liner and you're taking the blade round. It actually takes quite a bit of force to get it round. It often gets stuck. Um, you can use a, a mallet to try and gently encourage it er, out as well, but this is a reasonably safe way again of taking out an uncemented cup in the exam. Well, in real life, you might see people use an explant, taking out a cemented cup. But in the exam, I wouldn't really say that as a kind of gold standard technique. Um So once you've got your components out, then you're having to start thinking about what it is that you're going to do to reconstruct it. Ok. Now, first consideration for me is often that based on what I have done to get those implants out. So, if I've done an ET O or if I've taken it from the top, so if I've got my ET O, then I know I need to bypass it. So I know I have to go long on my implants and that might be a long un cemented revision stem or if I've managed to get my periprosthetic or my et O anatomically reduced, I might decide to use, um, a long cemented stem again, long cemented stems in the presence of, er, et Os and fractures. Probably a little bit more controversial for the exam. If any cement got into your osteotomy or your fracture, obviously, they're not going to heal. Ok. So examples here of ones that you might see in region being used will be things like the restoration system or Ar Os. Um, there are, there's plenty of other options as well that you might be seeing if you've taken your implants from the top, then your options. You've got a little bit more flexibility. So you might be doing a cement and cement revision. If there's no concern over infection, for example, you might decide to take all of your cement out and that there's poor proximal bone stock. So you're wanting to go along anyway, and that might be a long cemented stem. Um If there's poor bone quality, for example, so automatically by how you've chosen to take your implants out, you're already getting a rough idea as to how you're going to have to reconstruct that patient. Second consideration for me is the, the bone stock that I've got. So if we think of the femur, if a proximal um loss of bone, I might be thinking about doing femoral bone impaction grafting or thinking about if I need to go long or if I need a proximal femoral replacement. If there's no bone left, OK. If I can salvage the greater tranter, if there's no risk signs of infection or tumor, then I will because obviously it's going to improve the ABDO function. If you've got a femur, that is a Dorsey. Anyone know what Dorsey is? It's the thickness of the cortices, it goes A to Z. Mhm. So, so I see good or bad, the thickest I believe. So that means you have to read more. I think C means less thickness of the cortices in A and C is the paper thin cortex and very wide broad canal, right? Yeah. So in the Dorsey it's a femur that has got very thin cortices and a very wide canal. So, if you're trying to get something with an isthmic fit in a long revision stem, for example, uh, you're not going to get there, you're never going to ream up to get any form of isthmic. It's a bit like doing one of a femoral nail that just kind of wafts in the wind when they've just got no isthmus at all. Ok. So um dors is a contraindication for uncemented implant, right? Miss Spacey. Yeah. Yes, that's where we're going. So in a dose, you're not going to get an isthmic fit with um the types of long uncemented stems. So you either need to go long cemented or you need to start thinking about if you need a distally locked stem. So something that isn't relying on isthmic fit but has got is distally locked in the same way that a, a femoral nail is. Ok. So again, you start looking at what bone you've got and what and not just what bone you've got, but what quality bone you've got. OK. So these are examples of distally uh a distally locked stem here. OK. So a long stem not relying on an isthmic fit and then you've got uh screw options. So some of these have got three or four screw options, not just uh uh you're not just relying on two screws like in a, in a nail in terms of your bone stock on your acetabular side. Often you might need a CT scan to plan that. Oh, sorry. I thought I had on sliding out. But you have options in terms of how you reconstruct your acetabulum. And again, that comes down to either using bone to fill a void or using metal to fill a void. So if you've got an implant, if you've got a defect that is contained, you can impact bone graft into that and then carry on as you normally would. If you've got an uncontained defect, you might start thinking about using things like ace augments or um rings or even custom made implants depending on how much bone you've got on your right. And then my final consideration is, is this patient gonna be stable enough once I've done this to them or how am I going to increase their stability? So I'm thinking about, am I going to be using a dual mobility? Is that going to be uncemented or cemented? Am I going to be using a constrained liner? How am I going to increase my offset if I need to? Um And I think we did mention plas last week for instability. Um This, I don't think I had a picture of it for you guys. So I just put this in for you to see it. Um This gets screwed down and you end up with a little plastic wedge on a cemented cup only you can do that for and it's again, it's just like creating a lip, a a lipped cup, right? So just giving you a bit more coverage wherever you need it to make it stable. Ok. So if you were thinking about a stability issue, that would be your stepwise um kind of approach, you're gonna increase your head size so you uh can increase your head neck ratio. Uh So you increase your jump distance as well. If that's not enough, you would start thinking about your mobility again, step up, constrained and your plad is not really a step up, but it's just an alternative if you've uh got a cemented cup in, in there already, everyone happy so far. Yeah. Yep. So in terms of er, other considerations when you're reconstructing, we've talked about defects to fill and if there's any defects that I need to bypass the femur type and stability. Ok. So these are your higher order thinking points that you want to get across in your Fr CS if you're getting a revision station. And the last one that I've put up there is, am I coming back into this hip? So, if this is an infection, you might uh see people using non articulating spaces and you know that, that hip is going to rise up and you're gonna come in and that you've got a, a much bigger issue to deal with trying to get the leg length back down and they're much more complex second stages, you might be doing an articulating spacer and doing something called a Kiwi, which is a, you know, poorly cemented in implant so that somebody's got an art effectively an articulating spacer while their infections being cleared. So there's little things there again that you can kind of pull in for how you're going to think about that higher, higher order for the exam. So that was just a, an extreme whistle stop tour of just some concepts so that if people haven't seen many revisions, er, they feel that they can hope green. Um, yeah, she's green just worked for me. So if you want. Ok. Yeah, let me just allow it now. Yeah. Uh, can you see my screen or? Excellent. Um What about now? Yeah. Can you see my screen now? Excellent. Um, er, I'm gonna present to you an interesting case of a periprostatic femur fracture, er, that we treated in our, in my hospital a few years back. It's a really interesting case and I hope you all enjoy it. Um, so this is a case of an 84 year old gentleman presented to Ed following a mechanical fall on his right hip. He had a really complex past medical history of hypertension ischemic heart disease with triple bypass. Four years ago. He's type two diabetic on insulin. Uh stage three chronic kidney disease, COPD bronchiectasis and long standing liver cirrhosis from our social history. He lives permanently in Germany but he has a daughter in the UK, which he tries to visit. Once in a year, he came to UK to visit his daughter and he had a mechanical fall landing on his right hip. We know that he mobilizes with two sticks indoors and outdoors over the last two years due to query poor balance. Um, so he had previous operations. Unfortunately, he lives permanently in Germany. We don't know anything about his previous operation apart from the fact that as he tells us in the A&E but he had a total hip replacement on the right side two years ago. And then another operation on the same hip 10 months ago, both operations in Germany and the second one was following a similar fall to the one he, he had this time in the UK, his blood showing increased white cell count, 14,000, um moderate elevated CRP 49 HB 84. And you can see that he has elevated liver function due to his chronic liver cirrhosis. Um On examination, there was a injury to the right hip, swollen bruise, the limb was short and extend. I rotated in compression to the other side. Capillary feel time was less than two seconds. So there was no distal neurovascular deficit. This is the x-ray from the A&E. Um as we said, the fact that we know about this patient is is that he had a primary to hip replacement on his right hip two years ago, 10 months ago, he had a mechanical fall landing on his right hip. Um He had another operation for that second fall and since then, he's under regular follow up in Germany. Senior citizen scan was ordered mainly for pre op purposes and the CT scan was reported saying possibility of bone loss at the level of the fracture site. There is a panic fracture starting around the femoral stem going distally to the stem. There is no, they do not mention anything about any collection in the right hip. The right hip joint seems to be fine. Um No signs of loosening of the acid tablet cup. Um And on examination, as we said, we applied directly a skin traction uh for comfort and we requested an anesthetic review due to the complexity of his uh past medical history. Medics were involved mainly during his COPD and ectasis and optimization of his diabetes preoperatively. Um Good. Should we um let's go back to the X ray? Um Peri exam wise. Um Sorry, I'm just going to ask the one of the peri exam guys to have maybe just prescribe the X ray. Is that the list and there as well? He's come to your rescue. Go on. What do you think? OK. So this is an ap radiograph of the right hip which shows a periprosthetic fracture with an uncemented total hip replacement in situ as well as a previous um locking plate cable, suggesting previous periprosthetic fracture, which has also been told to us in the history um on reviewing the implant itself, there does appear to be some loosening in kind of green zones, 12, as well as uh probably in kind of six and seven as well around the, the um near the um media Calcar. Um and it looks like it's a collar implant. Um So that's probably where I would start off. And then obviously I can say as per the Unified classification or the Vancouver classification, this looks like um an A but I sorry, an A AC but I would get a CT scan to get more information. Ok. We won't talk about why this has failed because I suspect George is gonna go on to do that. So sorry, the CT scan is already done. Unfortunately, I couldn't retrieve the CT scan from our system, but it's a long spiral fracture a which starts from the mid portion of the stem extending all the way down as you can see distal to the stem. So I think it's a, it's a bit too. So I'm on my phone so I'm zooming in. But yeah, yeah, it probably goes up. Ok. No worries. Um a little bit more though, isn't it? So it's not just a periprosthetic fracture, is it? No, the plate has failed as well. So, so it's a fracture. And um could you can you still use the classification when this has already been plated previously, Kate or should you avoid using that terminology because at the moment, I guess my question is, did this fracture ever heel or is this the same fracture that was plated or has he fractured? Has he's fallen because his plate broke a fracture? Not he? That's why I specifically picked up this case, MS patient because also the presentation of the patient is very interesting. I never forgot this case, to be honest with you. And one last thing radiographically, you will see that there are some fluffy appearances around the fracture side. There are some appearances of like atrophic union or hypertrophic union to be more exact raising concerns. This is a case of atrophic non unions last delayed union. And that's why following that mechanical fall, the implant failed and the and the fracture occurred. Um So these are the higher order thinking points when you start describing it. So um nice description, critic of the implants. So you describe both components, uncemented cup, uncemented stem proximately coated, collared. OK. It's got a standard um bearing surface, hasn't it? It doesn't look to be dual mobility. And then you've got a plate in situ that's failed. Probably not the type of necessarily we haven't got the full length of the, the femur at the moment, although we might see it in a bit. Um but there's a, there's a lot of screws, there, isn't it? This has been a really rigid fixation. And you can see that there is an attempt at callus formation. So your higher order thinking here is that you suspect the fracture 10 months ago has not united this and that that's led to the failure of the uh can I ask you a quick question because of the callus that we're seeing around? We'd probably be thinking more of kind of a hypertrophic um nonunion, wouldn't we? Rather than an a in this case? Yeah, definitely. Yeah. Um And if you see these things, what is your always you wanting to prove before you do anything that there's no infection? So that there's that this is obviously, um, aseptic rather than any aseptic loosening or a fracture, secondary to infections. All right. Well, let Georges carry on and tell us what. Um, so skin was applied, er, medics were involved as we said and then, uh, the case comes to the Trump meeting for discussion the following day. Um, er, we went to review the patient once more because we have no information because she came from Germany, as we said. Um, he tells us that, uh, following the primary hip replacement, she was quite happy. There were no clinical concerns. She was discharged five days later from the hospital, no complications, but he required blood transfusion, two units. The surgery was done due to mechanical fall and he was treated at the same hospital, he was discharged 10 days later because he developed some secondary chest infection probably because of his complicated past medical history with COPD and ectasis following the second surgery though he always used to complain about poor balance. That's what the patient, the patient kept saying. And since the second operation for all the periprosthetic fracture, he's been using walking sticks. Since then. He has no pain though around the hip or thigh and no episodes of instability, no episodes of um, hip dislocation was ever recorded and never had to take anti, never had to take antibiotics since the operation and he still remains under the local team in Germany because as we said, the second operation was done only 10 months ago. So what is um I think this, this is a really interesting case and it's not only about the complexity of the case, but it's also about the complexity of the, the how the patient presented to us. Um So at this stage, the um we discussed the case with the lower limb revision guys and there were lots of different discussions. What is gonna be the optimal surgical management and then just what to discuss with all of you guys? What do you think it's gonna be the next step? What would you do? What would you recommend? Are you thinking about revision fixation? Are you thinking about revision fixation with longer stem revision? Just fixation plus minus growth. Are you gonna order any other scans? Does anyone think about proximal femoral replacement options? Revision using modular stem. The option about using a cemented stem does the CT confirm it's loose. So the C the CT scan unfortunately couldn't upload on the on the on the presentation. Sh sorry, but the CT scan shows some mind loosening around the distal part of the stem. Just the distal part. Yeah, the the proximal where the fixation is, is going to be proximal. It looks pretty well fixed. Yeah. Um and assuming he's fit for surgery, I would lean towards fixation for this for this patient. So I have the anesthetic review later on, but since you mentioned it, now he's an AA four and he's a very high risk for bleeding. But again, anesthetic team is happy to go ahead with pre anesthetic assessment and well, that reinforces my plan. I don't think I would go for a, he's got pretty good bone. I don't think approximal on the only thing that's quite interesting though I was going to say is that he's obviously had a hypertrophic non union. Um And you would expect that that would occur because there would be too much movement, but the structure looked like it was a fairly rigid structure to start with, didn't it? So I think I wonder whether it's worth also just ruling out infection just because of the fact that his markers were slightly raised. Yeah. Yeah, of course. Yeah. Yeah. Get, get your bloods done. Um Yeah. So blood we we, we repeat the blood, I have some repeated bloods later. There is no upward trend in the CRP ESR is within normal limits. So there is no significant concern about underlying infection. But of course, he's a very elderly patient who is going to be admitted. He's already wait in the ward for 34 days with a big periprosthetic fracture. His HB keeps dropping. He's around 8480. I remember we had to transfuse this patient at least a couple of units before the surgery. Um The discussion that we had back then with the hip revision guys was um I think the biggest concern in this case is the fact that we all suspect that this failure is a result of a hypertrophic non union or some sort of non union of the fracture site, right? Otherwise, I suspect this thick rigid fixation should, should not fail from a yes if there was a there was a fall. Uh but the radiographic appearances and the history of the patient, I think raises concern about failure of the implant due to secondary hypertrophic um non union or infect or, or infective non union. So at that stage, the uh the conscious of the hip revision guys was in order to avoid the possibilities of uh another non union or delayed union. And because even during the actual operation, we didn't know what we're gonna encounter. The plan from one of the revision guys was for consideration for revision stem uh plus plus minus fixation. So his way of thinking was I have an area which is really bad. I don't trust this area, George. I still remember his words. I'm gonna use a longer implant to bypass the area of weakness. And then I'll see improperly how it goes. I might need to use some augmented fixation using some sort of plate and see how it to an hour or a restoration stem, something like that. You mean? Yes, at that, at that stage. But the reason why presenting this case, because honestly, this is by far one of the most impressive cases I've seen and I'll show you the X rays afterwards because what that hip surgery end up doing is something that I haven't seen since then. And that's why I decided to bring this interesting case for the mock entity to hear your opinion guys and see. Um, what do you think was went well or what went wrong? Judge? They, uh it's not the issue with removing the stem. I think it's a JR for Long Stem. It's going to be really difficult. It's well fixed to take it off with the et and then, uh take it off. Um The fact the fact that the fracture is not united is, I think it's gone for hypertrophic non union and the whole weight is fallen on the plate and the plate has broken. Correct? Yeah. Um Yeah, so, so, so from, yeah. Um Can I just ask, can I just ask one question guys? Because I think we all suspect the same thing. We all suspect that this is infected until proven otherwise. Right. Yeah, you need to rule it out. Yeah. Yeah. How are we going to rule it out? So, ideally we could try and take care if you think that the markers because the markers were raised, weren't they? They could just be secondary to kind of fracture. Um, you could, you could take an aspiration, you could do that. Um Sorry, say that again from where you could take a hip aspiration. See if you got any further to spend off. That's why that's why I tried to help you. The CT scan shows that there is no collection in the right hip, the right hip is dry, there is nothing there. We can try to aspirate the right hip. But this is what II wanted to present this case because I encounter still now the same concerns I had a few years back when I was looking at this interesting case would be sorry. The other way would be just to do a needle, a true cut biopsy. Yeah, me too. Possibly. We did a, we did a, we did a CT because he's elderly and he also wanted to exclude malignancy. We did a CT C which I think I have um sorry. Uh it might be a bit ticky. So we did a CT C where we uh checked the whole chest abdomen pelvis and we couldn't see any other lesions any concerns about any other underlying malignancy or anything? But I'm just, I was thinking, would any, any of you consider a mark sequence MRI scan, for example, he could, but you'd only really see like you wouldn't, what would you be looking for in that, do you think? Because it, exactly, exactly. So this is one of the discussions that we had back in the MDT, one of the hip guys suggested, should we do a mark sequence MRI scan? But then it gets so complicated that you can't understand what is happening, right? You will see fluid and hematoma around the fracture site. Yeah. Yeah, it would, it would rule out, it would rule in or rule out. Yeah. So out of curiosity guys, do you think that it's a, it's a good option to go for a revision longer stem unreasonable and take samples intraoperatively and send them off anyway, right? So you can, but the other thing I was going to say with regards to, I agree that it would be difficult to take the stem out, but your fracture will actually be your friend with that because the will give you access to kind of the bottom of the stem. So that can help you in trying to extract it because you can kind of work from the bottom and the top to try and get them out. So I think in a way it might be, it might actually benefit you when you're trying to get out the stem. Yeah. So guys, let me very, very nice. I think we are all on the same level. So all we agree we will go for a longer revision stem. I think the vast majority of, of us we will suggest a revision modular and cemented stem, right? If that makes sense. Yeah. Uh judge what about because his multiple comorbidities. Yeah. Remove the implant the plate. Yeah and fix it again with a graft. Like how do you do for a for a B3? How do you do? Like, so the, so this, this was one of the options that was discussed back then in the MDT. So a couple of the trauma surgeons suggested leave the blood as it is revise the fracture using Strat graft plus bone graft, the defect like like the all graft. Yeah. And use dual plating um New revision hook, long hook plate on the treated, treated like a fracture. A like a like a bes Yes. Um But uh I don't know, no one will know ever if it was wrong or bad, but I'll show you now guys what we did and was one of the most impressive cases I've done. Um And I'll never forget. It was one of the I was working with one of the hip revision guys in London back then and he was trained with the Proud in Leeds. So we did that. So as you mentioned, uh he uh there were significant concerns over the factor side with non union delayed union infected non union. As I said, the repeat blood show similar trend Marsan not perform. As my previous boss that I was working for said it would just add delay and no further. A clinical benefit. Anesthesic assessment reveals patient is a a four high risk of bleeding plan for spinal and hope for the best and a revision. He said that he was working with in leeds comes in the meeting and said, I'll do this case and I will use um cement revision uh stem with impaction, bone grafting and deep samples at the same setting. So what we did was plate comes off, stem comes off and he was a big fan of ET O. And to be honest, I think as NAF said, uh it was really hard to remove really because it was so well fixed proximately. I remember he tried initially with some flexible osteotomes. Nothing was going between bone stem interference and he did a short, we managed to take the stem out. And then what he was doing was he was using the, you know, the, the big Charley curette. He was putting inside the canal to grossly uh use the femoral canal. And then he used a bladder serin, a 60 ml bladder serin, he cut it, he cut it off the top parts, he opened it longitudinally and he used it as a tube to go around the femoral bone. Then he used femoral allograft for impaction grafting inside the canal. And then he cemented afterwards, firing this long uncemented stem, uh, cemented stem. Sorry. And let me show you the x-ray. 14 months later, he sent me this x-ray in his clinic. The factor is united. He mobilizes with, uh, sticks outdoors, but he's confident mobilizing indoors with stick. He's been discharged from Germany and he still goes to his hospital to visit him and say hello. All right. How much time did it take the whole surgery? 2.5 hours. Ok, too. Uh It was really II, I've never seen uh impaction grafting and cement of L stem. And it's the only time I've seen it and I still remember that case. So uh once um uh M Spacey sent, said that the option for presentation of MO II said I'll do this presentation of periprosthetic fracture because I think it's really impressive. And II would like to say to see what M Spacey has to say because it's really controversial the way it was managed. It was really difficult concept. I've read about the, the impaction bone grafting my space and cementing with long implants. Uh but it sounds a bit challenging. A bit complicated. His way of thinking was I'm gonna use a cemented log implant because he was so high risk of um of um bleeding that he also wanted to reduce the intraoperative bleeding loss by using a long modular uncemented stem. That was his way of thinking. I don't know if it was right or wrong, but at least I think it was an interesting case. It's worked for him, hasn't it? So, yeah, it has. I think it was necessarily wrong. Um, I think, um, kind of take home messages from this kind of case from. I'm going to come back to a kind of exam side of things as well as kind of clinical is that if something hasn't worked in a patient, there's not very much point probably reproducing the same thing and not changing tact, especially if there's patient factors here. So this, this patient is not a good host, is he? So you doing exactly the same thing doing a repeat fixation for me doesn't seem like a logical approach to take if you're going to start using structural allograft, um then yes, you are changing taps. So that's a reasonable thing to say. So if you have somebody whose fixation has failed and actually they've got a really good fixation. There wasn't, you know, you couldn't improve their fixation, then I would change tact and go down the revision route if somebody has had a fixation. But actually, it looks like a suboptimal fixation. And there are things that could be improved on or you could slightly change tact and use structural allograft or by, by colum, then that is a change of tact. And so yes, revision fixation would be appropriate. Um So just be mindful that you're not just saying I'll repeat the same thing that's already been done and failed. So change, you should think about something probably needs to change for me. That seems like a more logical approach because it hasn't worked once. Why is it going to work the second time round? So I would have revised this patient as well. Um I think femoral impaction grafting II personally would want to be pretty certain that there was no signs of infection. And so, um yeah, it's difficult, isn't it? Um Can I just ask there was that of you? I would have like when I was looking at that case, one of the things I would have potentially thought about was by column fixation um and like putting a longer, like an N or like a longer stem in as well. So you kind of bypass the fracture. Would that be something? Because I've not seen it done a lot? But just from like if you're doing a long arco, you need, I don't need to because you think you can increase the rigidity just by putting in the LR and then that would increase the kind of environment strain environment around the fracture. The other thing is that obviously to do by contemplating you're stripping a lot of soft tissue off, aren't you? So then you're adding even more issues by union. Union factors, aren't you? So you're making your biology even worse if I can So what would you have, like you personally, in this case, what would you have done if you had seen that kind of case? Where would you? Yeah, I would probably have gone for something. I would have gone long. Um, I do try to go long cemented where I can, uh, looking at that canal, I may have gone distally locked. Um I think the bold move there was that you've got a cemented stem in, but there's not actually any kind of rotational stability necessarily to that fracture. So for me, um implants out restoration or ARCOS, if I'm going distally locking through the fracture site, so I know I've not perforated out the front through the bow of the femur. So uh when you're going long, actually having an ET O or a fracture is useful. So you, you can use a bowed implant. But if you use a bowed implant from the top, your risk of coming out, the anterior cortex is still quite high. So if you can go in through the fracture, you know, that's much more controlled cos you're at, you pass the isthmus. Yeah, you're not gonna come out in the front of the femur, I'm not gonna perforate. So I would have done that and then I would have built the femur back up around the top end. It doesn't have to necessarily be perfect, but then I would have CD it just to have some form of kind of rotational stability to it. Would you have taken your samples just intraoperatively? Um, like you would with like a single stage revision and waited for the results or do you think you would have tried to get something beforehand or kind of? No? Um, definitely blood cultures beforehand, if there was any fluid that could have been taken and you would have taken, it didn't show it. I would have taken it. I always think with these ones just because, you know, in theory, it doesn't mean that the hip joint is infected, does it so a negative aspirate, it doesn't really necessarily add anything only kind of, if it's positive it's helping you, isn't it? Um So although yes, in those who have been through knowledge, a very mild MRI heavy on any painful hip replacement or, and, you know, people coming in with painful hip replacements and fevers and things like that. Uh That's a lot of metal work to subtract, isn't it? And actually still have anything for them to, you know, see. Um, so you could consider things like ultrasound to see if there's any collection at the fracture site, I guess, you know, it is 10 months. In theory, there shouldn't be very much in the way of hematoma seroma left, I guess. So that might have shown something that you could to have aspirated more local to the fracture site. Definitely intraoperative samples. Ideally multiple, you might talk about frozen section in the exam if that's something that you guys have seen being used. Um, but yeah, I think if I opened up there any concerns over in gross infection, I definitely wouldn't be putting dead bone in the bone impaction. Yeah, it's, uh, one of those things, isn't it? Yeah. Nice case Georges. Thank you. Thank you so much. Uh, I think that was a reasonably good demonstration of some higher order thinking going on there in terms of how you're gonna get sevens and eights talking about these kind of cases. And that actually is, um, a reasonable case to come up in an adult pass station. Yeah, I had something not dissimilar around uh, a revision knee, er, in my exam. So, um, it, yeah, it's, they give you something complex so you've got lots of things to talk about and they might just hone you in down one element of that. Yeah. Uh Lovely. All right. Um, so, uh, we haven't got Oscar cos unfortunately he's not able to come. Er, so we're gonna skip, unfortunately the instability one. Um, and so we're gonna move on. I think we've got Maio and then geh just a couple of things to think about from an infection point of view before we start their two infection cases, um, acute versus chronic, um, su on what in terms of infection would you consider a periprosthetic joint infection as acute? What kind of time frame uh, within uh, six weeks of the, of the index procedure, uh, any advances pretty. Mhm. So, I don't know why I've got three weeks in my head. I don't know if that was on the, like, the, um, the new, what's it called? A little bit on the three or four week is kind of your window of opportunity of acute, uh, why, why is it pretty? Uh, we always think about biofilm and, like, so beyond four weeks we start being concerned about biofilm formation and then obviously it changes what options you have with regards to like a dare compared to a like a a full revision, etcetera. Yeah, good. Um And just for perhaps some more junior registrars who haven't had basic science hip to come round to them yet. What is a biofilm? So I probably would say this in a very exam way, but via film, it's you don't have to do any exam just in general. Yeah. So basically on an implant, it's kind of a layer of kind of bacterial colonizing forming units um that forms either beneath the implant or kind of beneath the rim of the poly, et cetera. That then is not because of the fact that there's no blood supply around the prosthesis, you can't just use antibiotics to get to it. And if you were to go in and do, for example, a washout, you may not be able to kind of reduce the bacterial burden in those areas because they're not easily accessible. Um So for those particular cases. Um, kind of less invasive uh intervention doesn't really deal with the infection. So that's why you have to kind of do something a bit more invasive. Any advances, Suman. Um So yes, there's a layer of bacteria which are connected by type type. I can't remember what kind of junctions they are, but they're tightly folded to each other. So it makes a layer that's to antibiotics and to antibiotics. So, yeah, that's pretty. Is that the whole three months? Yeah, don't dig yourself a hole. So if you don't know, know something, just don't bring it up. So easy way of kind of thinking about a biofilm is effectively that these bacteria are communicating with one another and they're able to build a shield over the top of themselves, which is a glycocalyx and it's impermeable to antibiotics. And so if you do a dare, which is a debridement and implant retention at say two months following onset of symptoms and its onset of symptoms, not, not their surgery date. Um You're not going to get rid of those organisms. Yeah, they'll still be there. Ok. So, first off when you're thinking about these cases, is it an acute infection or is it chronic, what non favorable factors are around? And that might be the host like Georges patient. So, um renal failure, cirrhosis diabetic uh steroids, uh immunosuppression, it might be bug factors. So, actually resistance and how virulent it is. Uh actually whether you even know what bug it is obviously factors into it cos sometimes we don't know what it is and then you know what's going on with the bone, is this actually already dead bone? And we're dealing with Osteomyelitis as opposed to just um say, um aseptic arthritis type picture around AAA total hip replacement. And then what are you gonna do about it? So what kind of temporizing measures might need to be taken? So, Christi's already mentioned debridement and re implant retention. And then she kind of alluded to whether you're going to do a full revision. Now, that might be that you take everything out and replace it in one go because you've got favorable host, favorable bug, favorable bone or it might be that any of those things are a bit off and you think you're not going to be able to clear the infection and you don't wanna put final implants in. So then you'll do what we call a two stage revision. And then you might be thinking about articulating spaces, non articulating spaces. And would anyone like to explain why there is a picture of a Kiwi fruit up there? Anyone there, anyone heard of a Kiwi procedure? No one, a temporary spacer is called Ki spacer. Was that Joe? Yes, it is. Yeah. Hi Jose. So, so what is the Kiwi? I mean, it's a fruit. It is a fruit. I'm not like an antibiotic, impregnated ball of cement. Basically that you're putting in like a spacer, is that not basically what it is? So, Kiwi procedure was actually a New Zealand fellow that was over. I can't remember which unit it was. I think it might have been down south. But yeah, so it's not Kiwi because of the fruit. It's Kiwi because of the fellow that a person really came up with it. You basically do a poorly cemented uh cup and stem so that they have an articulating spacer while you treat their infection. And then you go back and you do your second stage, you take out the poorly cemented er, components and then do your final implants at the second stage. But it means that if that patient's too sick to come back, actually, they've got something reasonable to wait there on the problems with these articulating s er, the articulating space is like these cement ones is that they often er, dislocate or they can fracture or if you have a non articulating one where actually it's just a ball of cement in the cup and a, a like a car stick of cement that you put down inside the femur and they're not actually joined the femur obviously migrates up in the same way that a Girdlestone does. Yeah. So you've got that extra challenge at your second. Sorry. Can I just clarify? So it's not just so I, in my head, I always thought, OK, it's just like basically a, a cement spacer um, uh, like with, with antibiotics impregnated in it and then you put cement down the canal with this. Is it actually the, there is implant within that cement? But it's just poorly cemented or is this? Yeah. Ok. All right. Ok. Perfect. It's easy to take out at the second stage, but you're not pressurizing your cement things that fine. Thank you. Um, and then I guess the other thing to factor in. Who's that? Oh, gay Fair. Um The, what we see here sometimes in cultures is what they call like a 1.5 stage revision. Yeah. Yeah. Where it's effectively a total hip that's used as a space and I'll touch on it in my presentation a bit, but it's good enough for us to kind of go with it and, you know, at about um 12 weeks after we see the patient, it kind of have a patient led discussion about if we want to go ahead with that um that implant that they have or if they want to come back uh for a second stage revision based on the bloods and et cetera. Yeah. Is that the similar kind of thing to a kiwi or is it? Yeah. So dro is actually, so I thought you were going to talk about something slightly different. So, yeah, that's similar to a kiwi. Dro is um something that sometimes um Mr Wimhurst for example, does at the No, no. So that's he might be doing a dare but he will do a little bit more than a dare. So it will be a, a deprivement and retention of cement. So he'll take out the exeter stem, wash the cement in the implant interface, but leave the cement itself in and then put in the new stem. So, rather than just taking the head off and changing a liner if you've got a hybrid hip, um, he takes the stem out as well, so it's a little bit, it's like a, a dare plus. Yeah. Er, in the same, yeah, similar kind of way you can have AAA Kiwi or as Gits described, it's, it's a very similar process that you, you do your first stage, you put in a poorly cemented hip and then you discuss whether you want to redo it and it depends on the patient factors and how well you've got on top of infection and things like that. I would stick to kind of typical principles in the exam. Er, there are obviously things that you will see in clinical practice that are done that you might want to draw on in the exam. But um kind of gold standard practices is probably the best things to stick to. Um for most people for infection, er, that would be a dare in the acute side of things or if it's not favorable, a two stage revision, you know, if not favorable or chronic infection. A two stage revision is gold standard. Ok. You can have the conversation for higher order thinking in exam about two stage versus single stage revisions and when you would do either of them, um, but it depends if you want to open that, that kind of conversation up to try to push towards a seven or an eight. Depends on your interest. Depends on how much reading you've done around it. Ok. But they're your higher order, er, thinking points for infection, ok. Um, homework for all of you guys in case it doesn't come out in the um, um, in the cases that we're going to discuss now is that you need to have a look at the MSI S criteria, right? And that's about how you go about diagnosing infection. Ok? Er, lovely. Um, Mario. So I did have you down as first if you want to go first or uh happy, happy to go. Hello? Yeah, cool. Why don't we do Marius's? And then we'll have like a 10 minute break and then, and then we'll do gits. Yeah. Ok. Do you want to slide? Do you want to share your, I'll share it. It's probably easier than if I share them for you. Can you see my slide now or not yet? Sorry about that. Oh, there it is. Is that working or not really? Um, I can't see it. Marius. Have you gone for um, sharing entire screen or? Yeah. Uh I'll do that now, see if that changes things is that working? I can't see anything. Can anyone else see anything? Uh No, not yet. Yeah. No, sorry about that. Uh Your entire screen maybe I'll um um if not Marius, we could start with gait and then it will give you some time in the break to try and do it. So don't stress. Do you want to try and see if you can screen share? No worries. Me. Sure. I'll, I'm good man. And the weight loss journey. Yeah, I see. Is that working? Ok, cool. Let me slideshow. They can start. There you go. Can everyone see that? Yeah, amazing. Uh So there's a case that um that recently occurred in our practice. Uh a patient who, and it, it's a unique one because it's a trauma case that has kind of gone wrong a little bit, but you will, we will come and see it to that. So it's a 71 year old male, er, who missed the last step in the garden trip and fell on his right side, no loss of consciousness and had he had CK you on dialysis uh three sessions a week gout immobilizer without any aid. Otherwise, C RP is 103. But as you, as you can expect it, trauma, notably, the eg fr is reduced, the right leg is short and excellently rotated and has a, as you can see a right side, the intracapsular neck of femur fracture, it then goes on to have a right hemi arthroplasty. Can anyone tell me what kind of hemi it is based on that? If you work in Cols, you probably know it's a cold because it's very right, like it's very, in 90 degrees the stem, did you say CPT? Yeah. Yeah. 100%. Yeah. It's a CPT. Er, Hemi Cos, that's what we use in cultures. We've recently converted to UNI track. But, yeah, CPT. There we go. So perfect. So it was all going well, he was discharged and uh after a year he then comes back in um complaining of un being unable to weight, bear um short again, his right leg, as you can see on the X ray, it is kind of short. It's mi it's migrated superiorly and there's some subluxation of the right hemi is there and the CRP is noticeably 244 white cells are 10.5. Can anyone if, if anyone saw this patient, what would their immediate management plan be? What were they suspicions of infected infection and a dislocation? So a septic doesn't cause in. So is that, is that? Yeah, it's pretty. Yeah, sorry. Uh So yeah. So um tell us what would you, how would you, what would be your immediate management plan plan for this gentleman? So, looking at these particular radiographs, obviously, I'd want to get a further view, but it looks like there's quite a lot of destruction of the acetabulum. A lot of lucency seen in Charnley zone 12 and three. can't really see around the stem very well, but there looks like there's possibly a bit of lucency around Charnley zones. Er, sorry, green zones 12. But again, I can't, I, II just can't see the radiograph that clearly. Um, we want to obviously assess the patient, make sure the sciatic nerve was. Ok. So, kind of your basic assessment with regards to, um a dislocation, um you can try and reduce it. Um because obviously that's kind of acute management for pain, pain relief. Um But again, you have quite a lot of destruction there. So you might find that the hip is not well contained. Um So I don't, I don't think there's any harm in attempting to do so and seeing if there is any success, but if, if that doesn't happen, then it would be having a chat with my hip consultant colleagues um about potential options here and obviously ruling out infections. So looking at possibly taking an aspiration, yeah, at the same time. So he goes on to um it's, he says it's been like this for a while. He's not been able to weight bear. So they immediately try and get him to the theater and uh do an aspiration for which there's a xray or improve aspiration. And basically, it grows c diff uh which is quite a virulent organism. So it has a, he has a discussion in the hip MDT. Um After which uh at this point, Chris, what, what would you say? It's about a year now. Uh Where, where do you think this is going? Ok. So given the fact that it's a year, we're kind of definitely out of that acute window, we know his symptoms started well before the dislocation. Um So sorry, how did you, what's his A sa did you mention his comorbid he's got go on dialysis egfr eight. So yeah, it's like a 34, then it's really having a discussion because he may even be a candidate for a girdle and a removal of the implant. Um But obviously, that would be shared decision making either with him if he has capacity or with his family. Uh looking at what his baseline mobility and function is like. Um But I think the main thing is obviously source control of the infection. You can obviously use chronic immunosuppression if patients have kind of a chronic infection. But in this case, the CRP was fairly raised, I believe. Um he obviously has a dislocated hip. Um And I'm guessing he's got pain associated with that. Um So it would either be doing quite AAA large reconstruction procedure, which you'd have to most likely do this as a two stage. Given the fact that it's quite a, you know, it's not like your straightforward Staph aureus, it's ac diff uh is your organism. And in that case, you'd be looking at quite a lot of reconstruction, particularly of the Aceta based on that X ray. But I'd get further imaging if that was the kind of route I was going down. Um, but if not, like I said, it may just be in his case that we start antibiotics and give him a girdle stones, um, just give him pain management and relief. Yeah. II think that's reasonable, you know. Um, so they had discussion with the patient and because he mobilizes actually quite well, he's been treated on dialysis and although he has complex comorbidities and it's quite a virulent organism that other people, you know, that we go involved in this case was microbiology, er, in discussion about whether to do a, er, about, er, targeted antibiotics. So they decided to do a first stage revision, er, sorry, two stage revision with this being the first stage and you can see there, I think, er, er, the consultant doing said that it was a augment that was used as well to fill the space that we talked about before. Um, I think it was a cement. Oh, no, sorry. It was, it was an augmenter which was screwed into place to fill the void and give that superior lateral coverage in the hip sliding up. Um, and a, I guess a 1.5 stage type of revision, to be honest, I can't, when I take a look at these X rays, I can't tell if it's poorly cemented or if this is how it should look, uh, I, it looks like a, like a well cemented hip to, to my eye but, uh, I don't know if anyone else can comment, er, that it isn't the case. But, um, yeah, this was the first stage revision. He was an ivory or a penem, um, gave oral ciprofloxacin um, for six weeks and then an antibiotic holiday for two weeks for which we saw him in clinic monitored the RTP levels, which was um down in the boots less than five. And we discussed about potential management options um because the stem was giving him, um he, he said he wanted a full procedure and because of the fact we'd already teed him up for a second stage revision, we had the discussion in the MDT and I think there's the other point I want to raise is super important to have these complex discussions documented at MDT forum and we have that clearly documented so that everyone can follow along that he then had a second stage revision, which again, it was a cement augment that was used IV meropenem oral clo and um the stem was inserted in um like a proper hip and now we're just currently following them up. So can you just show me the previous X ray because it didn't look that different to me? I'm just seeing what they did that's changed. So, no, I think it was just literally, they took out the, the stem. Yeah. And they placed the same thing back but they basically divided everything and it just place the new ones. OK? What, as in like he could have gone with this and he would have been fine, but it's a patient that discussion. That's why we do a lot, 1.5 stage. So some of them just kind of stay with uh with that operation if they don't want to go back for a second stage revision, and we just kind of monitor them for a long period of time. Why you guys ended up needing uh that cement augment. Uh because of um because of on that superior lateral edge, there was a marked portion of osteolysis and therefore needed further coverage super laterally to prevent this subluxation from happening. So often when a hemi dislocates and if you guys ever go in and you do um girdles stones on these or, or whatever you're doing to them, you'll often see that there is a superior rim fracture from where the hems come out. So you can see that there is something abnormal in his bone here, which is required filling. But actually on top of that, you'll probably have been an element of a, of a rim fracture with the dislocation as well. So sometimes you see that with dislocations without the infection as well. Um Can you just show us the last X ray um pretty if this was kind of your um also whoever is there. Um If this was your kind of fr CS adult path x-ray, ignore everything else that you've been kind of told already other than the fact that this was done for a hemi that dislocated. What are your kind of thoughts when you look at this X ray in terms of what risks are there to the patient? What might be their next complication apart from infection? So, in, yeah, you know, I I'd, I'd be concerned that uh you know, he may have a prosthetic fracture, sort of a can bending type fracture because he's got quite a thin fe stem. Um And looking at the zones, I can see zones six and seven, possibly one and two, the cementation there were not as good as the other zones. Uh can also, well, this is a uh supposed to be concerned about the bone stock that's holding that augment down. So there may be another, he may have loosening of the augment further down the line as well. Failure, a any advance, anything that jumps out at you about those implants, he's got a skirted again, instability. So he's got a skirted head. Um So why is a skirted head if you see that in your FACS in one of your xrays, why are you going to pick up? Why are you picking up on it? And why are you going to say there is a skirted head? So that reduces your head neck ratio. So it makes you more likely to lever off and dislocate. Essentially, it reduces your rock of motion. Yeah. So you will have a smaller range of motion before the neck impinges and levers out. So um if you see a skirted head in your, in, in your e x-rays of your exam, it's, it's probably there cos they want you to have that conversation about stability. Yeah. Um yeah. So it's a good thing to mention if you see it, if somebody's been revised for, so hang on for the Junior Suan. What is that skirted head? What is it trying to achieve? So, essentially, they've had to add more than at least 8 mL on the wall to the head. Reconstructing plus eight to the head or more to achieve that you need to increase the depth of your trial and you do that by adding the skirt essentially. Uh Yeah. So that could affect both your leg length and your offset when you, when you have the skirt as well. All right. Um So it's usually a sign that there were problems with stability at the time of the operation if somebody's ended up using a skirt. Ok. Um And when you've done this for, um you know, a dislocation, you know that the tissues are also probably not, not great from the dislocation, aren't they? So just things to bear in mind for your higher order thinking when it comes to your exam scenario side of things. Ok. Yeah, I mean, I mean, we did a revision today and it was a similar kind of dislocated hip and the short external rotators and the hip flexor were extremely contracted, especially it was out for a long period of time. So needed tono as well. So that's another thing to consider as well. Uh, yeah. Uh, discussion points, er, so principles followed here MDT, uh, input throughout, er, red flags, er, were, were highlighted and the on call team was on call team was called in a, in a quick fashion. Again, the ICM 2013 criteria. It's good to be aware of and definitely infection was the top priority. OK. That's fine. Um And because C RP was abnormal, we went straight for aspiration, biopsy and theater um even in case of aseptic loosening uh in a aseptic environment as well. Uh We used the antibiotic holiday. Well, so for two weeks, we wanted to uh it's, it's something I wanted to discuss here. I don't see it that often where they talk about doing a antibiotic holiday for two weeks prior and then aspirating again. I've seen that in other practices but here we don't, I haven't seen that happen exactly. Um But regarding biopsy, five separate samples were sent er, for urgent microbiology, extended culture protocols and for histology as well. And as the case, it was a virulent organism and uh the patient wanted the best gold standard quality of care, a two stage revision was applied. Er, however, I have to come out that with, it was after thorough MDT and micro discussion. Can I, can I just ask, is it actually a true? I was gonna say this is more like a stage 1.5 because I was gonna say I probably wouldn't call this a two stage. I don't know what other people think because in my head, if I was saying something was like, you were doing a two stage revision, then in my head, the first stage would be like a cement spacer, debridement, etcetera, and then going back in and putting an implant. Whereas in this case, they basically put in what was it called ad or whatever when you put in like a loosely closed implant. So I don't know, terminology wise. Uh I haven't here in cultures, I actually haven't seen a cement spacer as it were. The spacer that we use is a total hip uh off the shelf there. It's just poorly implanted, it just gives and I guess is the, the reason being that these patients have multiple comorbidities uh going through another operation might not be the best thing for them. So if there is a chance through one stage that you can uh you can clear the infection and have a functioning hip, then we go for that. But I personally haven't seen a cement spacer. I mean, I've read about them but I haven't seen one here. So I would say is still a planned two stage revision, whether you're using cement spacer or you do a poorly cemented. So you could, you could still call it a two stage, it's a two stage, but you could in the exam say that your preference is to use a cemented, a cement spacer. Ok. But this would be because you're still go back in with the final implants in. Yeah, absolutely. The kind of 1.5 type thing or Kiwi, whichever you're gonna call it is more kind of a clinical application of, is this patient gonna be fit enough around two or even want round two, if we clear the infection and things are ticking along. Ok? They might like to stay with that. So I would say that the 1.5 leave it out from the exam. Ok? Stick with your, for your two stages. Um And for some people, this kind of 1.5 isn't necessarily the right thing to do. So you're using, you're often using small stems if you've got high BMI patients, um they're at risk of problems like periprosthetic fractures or even prosthetic fractures. So you can make, there are occasions you can make life worse for yourself. Um and kind of put them at risk of another procedure before their second stage is ready. Um So the gold standard for a two stage is cement spaces still. And was the option of a Girdlestone a reasonable option. Obviously. I know it was. Absolutely. Yeah. Absolutely. My head was where you were at to begin with. If it's that the patient is, um, you know, of reasonable mobility and they don't want the Girdlestone, then. Yes. But this is the alternative if I had c diff. Yes. Absolutely. It's true. Stage, I wouldn't be thinking about daring it. Um, I know we've said that this is a year down the line. I don't know if that's a year down the line of the operation. The hemi just be very mindful that it is onset of symptoms, not when the hip replaced or hemi was put in. Yeah. So a hemi could have, you know, a hip or a hemi could have been in for like four years. Somebody has a dental abscess and comes in with a week of, um, hip pain. Yeah, that's an acute infection that can be treated with a dare. Somebody. I think he said it was slightly longer. The only reason I mentioned it was, but you're, it's to do with the symptoms, isn't it? It's not nothing to do with, when the operation has nothing to do with the date of the operation or to do with the onset of symptoms. Ok. Um, or if there's significant cement bone loosening, then you know that it's chronic, you know, or if there's bone loss, you know, it's chronic. Yeah. Unusual with C diff to be chronic because patients should usually be quite unwell um and present early. So, yeah, just to summarize. So can you just go on to the first x-ray? So, so it was a heavy CPT stem. So what was done after that? So they did a debridement as and then aspiration stage? And then, and, and so the stem. No, no, the first stage is the CPD stem still kept or taken off. No, that's taken off this B 40 I think. Uh the last M space space. What do you think? Oh, sorry, this is an exeter. So the, so they've been taken off and they've put a new stems with cement with the augmentation around the uh and a and a cemented cup is it? It's Yeah. Cement. OK. Fine. Oh That's the first stage. And then next stage, what did they do? Basically just took it all out, washed it, debrided it and put it back in again. Uh I didn't understand that. So they took out the stem again. Yeah, they took out the stem again. This is the same component but they washed it out divided in between because why would you, why would you change components if they were stable in the first place? So you just se it further and, and they put more, I think that loosely fitted cement thing they were talking about. So like basically they put the same implants but they just fitted it very loosely. Initially. Took it back out, debrided it all again. And then did you know proper cementing? Basically the second time around by the sounds of it. Yeah. The kind of process behind that is number one, putting in definitive implants and number two is when you first put those implants, if you're going to put a poly cemented implant in and you're treated with antibiotics, there's a risk, isn't there that if there's any residual infection that a biofilm falls? Ok. So when he's gone back to his second stage, it's removing any implant that might have a biofilm on, right? Ok. Fine. Ok. Yeah, sorry, I didn't understand that. Sorry, sorry. No problem. Yeah, that's fine. Yeah. Uh any other questions for gee about as well? Perfect now? Ok, perfect. All right. Why don't we take um 10 minutes? We'll come back at 340 hopefully we'll give Marius a bit of time to figure out his screen sharing. Um I have to say that uh Mustafa's upstairs currently doing a he I'm gonna relieve him. So uh he should go around to, to do one. Ok. Ok, cool, perfect. Thank you. Bye Maria. See there. Hey, yeah, happy to start if, if you Yeah. Do you want to see if you can start screen sharing and success? Cool. Success. Um OK. Everyone. Let's restart them off. Go Marius. So I have um a case um it's an infection case. Um I wasn't present uh for it, to be honest, it was before I started in Colchester So let's, let's imagine it's the 20th of July. Um You have a patient presenting to A&E feeling unwell feverish uh with a noted swelling on the right hip extending down to the right thigh. She's a 61 year old female, um referred by A&E with CO PD depression, fibromyalgia and uh high BM I uh has an allergy to doxy. Um So, um Ortho team go and see her. Um So this patient history of presenting complaint uh underwent an elective T hr on the seventh of March. So we're in July now, it's the seventh of March in a different hospital um which subsequently became infected during her admission at that hospital um and required a wash out on the 31st of March. Um at that parent hospital stayed in hospital for IV antibiotics uh until the third of May 2023 referred to a and discharged and had ongoing antibiotics uh which were converted to oral um as long term antibiotics, but the infection had uh uh as pres presumably settled. Um And she was on the antibiotics two weeks prior to presenting to the presentation to Colchester uh social history wise, independent of Ad Ls housewife, nonsmoker, um drinks alcohol, socially. Any, any thoughts of um what you'd like to do moving forward anyone or should I just crack on? Is, is the patient septic or are they just presenting with pain? So, OK, so their uh bloods were done. Uh HBs 123 white cells of 13.3 CRP is 408, lactate 0.8. And this is the X ray at presentation and I'll tell you the S in a second. So these are her observations. Uh rest for 20 sats, 95 heart rate, 95 BP is stable, um slightly um feverish using a two basically pain score eight out of 10. So they examined the patient good range of motion in the hip wounds healed, but there's a potential discharging area distally with a warm marathon. It just poorly localized swelling over the right hip, uh extending down to the right thigh. She reports she has been weight bearing but in pain uh for a few days. So they, they started the sepsis bundle uh by the A&E team given a stat dose of tas uh because they assumed she was septic and they wanted to get it on top of the infection. Um Anyone wanna think of thoughts and process thoughts of what they would, what their thoughts are, anything they wanna do, anything they wanna do. So, just to clarify from your story, you said there is a discharging area, right? So that's a sinus. Yes, that, that, that will be one of the major criteria. So we know this is infected. It sounds like it's had a dare. Uh that failed. Correct. Yeah. Uh So I think we're heading down the the pathway of a two stage revision here. Uh So it's just about information gathering, obviously speaking to the parent hospital if, if possible to get all the data and the uh pathogen. Nice. Yeah, exactly. Yeah. Thank you George. Um So the, the, the team on on call decided to do a, a quick ultrasound which was done on admission, um which identified a A 105, 105 by 71 by 92 millimeter mixed echo echogenicity, hyper coag lesion query um infection. Um And they had requested an M MRI but the department was unwilling to perform it due to the um uh due to the prosthesis basically. So, as you said, as you said, George, uh the TN O SPR discussed with the consultant in the parent hospital. They identified the implants and the operation done including previous culture results. And this was the information obtained. So it was a coral stem by the pre um 28 millimeter plus five head in a pinnacle uh cup. Um And they did do it there. You exactly. Uh and the cultures came back as strep IAC sensitive to van and op plain and amoxicillin, which is probably why she uh she was on Comox for so MRI was done as well, but uh in a, a couple of days later, um and we can talk about well, whether it really benefited or added anything to the management. Uh But essentially, it said that there was a metallic artifact, minimal fluid seen uh in the subcutaneous tissue just lateral to the right hip replacement, which could be post surgical postprocedure in nature. And that's pretty much everything they added marrow signal within the bones of the pelvis is normal. And then we're an MDT now. Um So what, what are our options? Um Essentially, we know they've had ad done and that was uh that that's failed. Um And they're coming back with, with an acute infection again, basically, or acute on chronic infection. We can say fit and well, patient. Um Any thoughts I would have thought that we got there that's failed. It's a chronic looking picture. Now we know the antibiotics that she's got and she's fit in. Well, then you're looking to head down towards a two stage revision type picture. Um I guess you want to do the first stage and kind of reassess what the um organism is. Um and take antibiotics to that as, as appropriate. Um And try and clear as much of the bacterial load as possible. Yeah, thank you. I can't, I can't see her speaking. Sorry uh because of the of the screen. Um But thank you. Sorry. It was Ken. Hey, Cam. Thank you. All right. Hey Mars. No problem. Hey, no Fall. Hey. Um Yeah, you said that there is a sinus but the MRI showed just superficial collection, isn't it correct? Yeah. Right. So, well, we don't know. So this, this was the, the documentation from the ed nodes, uh wound healed, but query discharging area distally uh warm is poorly localized swelling over right hip extent. This is literally what the um ed nodes said, right? So I'll still discuss with micro uh about the organism and the antibiotics. Yeah. Um So the, the question is whether it is a superficial infection or is it a deep seated going up to the prosthesis? Um So on, that's, that's what we need to know or when we open, we need to decide. So that's, that's going to decide the management or uh we can still do another there if it's just a superficial infection or are we going to go ahead with a proper two stage revision? Yeah. Take out the implant and everything. So you, you, you're thinking now for that, you decide on the spot, whether you'd open and then decide whether to do, go ahead with a dare or so you can use the MSI S criteria and, and based on the points you can decide. But uh uh I don't know, should ask Miss Spacey. So, um I've got a question, Marius at the time of the da have they documented that there was pus in the hip, the samples that they've taken was that all of the deep samples? Was that one out of say five? Was it a superficial sample that was positive? Um To be honest, there was not, we, we didn't get the, there was nothing from the notes that showed that we got the note from the other hospital. But this is, this was literally that the discussion that happened and this is all we got from the other hospital is what my understanding is. So let's for argument's sake for this conversation, say that four out of five of the samples were the same organism. Yeah. So the patient was dared for a single organism that had, it was sensitive. So you've got a favorable organism and you've got a favorable host because they're fit and well. And then a reasonable time frame has gone by more than three weeks, hasn't it? And then she's come in septic again. So in terms of what options you've got on the table there is off, isn't it? Yeah. So she's one, got a sinus which um is one of your major criteria. So, you know that there is either a superficial or a deep infection. Now, in the presence of a proven deep infection, I think you have to assume that this is a sinus collecting to something deep. Ok. Yes. If it was in the acute setting, you could just have a superficial hematoma that has broken down and come to the skin. Um But in that kind of deep dare situation, you know, it's, it's a little risky to assume that it's superficial, isn't it? So that would be my first thought. Second thought. I come back to my same take home message from Georges case when something hasn't worked, do the same thing twice. Yeah. Unless it's, that somebody's only gone in and done a wash out and they haven't done something done the dare properly. Yeah. So, for example, someone's really septic, comes in seven o'clock in the evening. Septic and hand surgeon is on call. They do the right thing. They take the patient to theater, they wash it out. The hip surgeon comes along and does the death sometimes that has to happen, right? Um That would be one reason for repeating. OK? But if uh a period of time like this has gone by, you're out of that realms of doing another dare. OK? If the dare fails, you're going, you're going for a full revision. You can have that conversation around single versus two stage. You've got an organism, it's a favorable organism, you've got a favorable host. So for some people, they would argue single stage, OK. Gold standard has and still remains to be a two stage revision. So you won't go wrong in the exam. If you're sitting across from someone who is very pro two stage and start talking about two stage. But if you start arguing your case for a single stage and they're a two stage type surgeon, they might give you a little bit of a harder time over it. Ok? If you want to show your sevens and eights, then having that conversation around the evidence. A single versus two stage and there's lots of different papers around it. I did actually park in the chapter. So, you know, the kiwi paper from it, if anyone wants that as a side point. So for me, this is a stage revision. Um my preference is still to stage, there are a small group of patients and again, it might come down to that conversation with the patient about what they want, um how fit they are. Um So if actually this was a really poor, lots of comorbidities, you could say actually, it's better to do a two stage because the chance of having good host biology of clearing it are low. But you might say actually they're not going to be fit for that second stage. So I'm going to do the single stage. So it's that conversation with the patient, isn't it as well as kind of surgeon preference between a single and two stage? But you have to have a good, a reasonable host with a good organism if you're going to do a single stage. Ok. Um So yeah, II would go two stage for this one. Yeah, which is I think I because II went over on attention. Thank you. No. So exactly. So a two stage revision was planned. Um The first stage was organized for a hip specialist, obviously as early as possible and that was day five of admission, uh patient prep to theater and discussed with micro. So it was a full MDT approach. Um with a patient centered approach as well. Um And then this is the note and the findings of the first stage of the revision, uh routine lateral routine prep and drape incision through old scarring extended approximately and distally. Um So their findings were um to by something, sorry, I should, should have something diameter sinus with underlying three by three centimeter cavity and infection was tracking down to the implant behind the GP to superior aspect of the acetabulum. Um So what, what did they uh what did the consultant do as a debrided and removal of the implants done? So how did they remove the implants? Uh And I'll go back to the X ray in a second. So the posterior structures were detached from the GT sinus was debrided, including the skin edges, um debridement around the implant and the femoral component was exposed, hip dislocated head removed. And then the femoral component was loosened using AK wire uh and a flexible osteotome then used to remove uh then removed using um a femoral extractor. And the femur was debrided and washed and then the acetabulum was exposed and debrided and the cup was removed using a cup X um and there was minimal bone loss. So, multiple sample samples were sent to micro from various sites and washout was done with Betadine and Saline. Uh and then the first stage implants were implanted using, using the Kiwi procedure. So, a 4836 Muller Cup cemented lightly and a size one exeter cpt stem cemented lightly as well with a Cobalt chromium head. Um and then they, they closed it with um usual closure. Um And with, and the cavity in the subcutaneous subcutaneous tissues was back, uh had a back drain placed uh and then closed over it um in a PICO dressing to the skin. And then the fact that the POSTOP plan um was continue the IV type complaining, which is um the plan for micro as well as chase the results and rediscuss with micro uh monitor inflammatory markers and then back drain to be removed in 48 hours. Um and a picc line for long term antibiotics. And the plan was for an aimed uh second stage in 6 to 8 weeks, but the patient was quite keen to get it done back home uh or in her local hospital and that's essentially the POSTOP x rays of the first stage. Can I ask you a question at this point? Uh Don't, don't these implants get colonized more easily as opposed to just leaving free space or, or just a cement spacer? That's the, that's the risk with doing this, that you end up with a biofilm forming on them, which is why it is still a two stage procedure. But then even when you put the second stage in, you can still leave stuff behind, right. So it's, it's not like a true first stage ever happened, but it, it's a happy medium in those, it's not very common that you end up with a failed two stage even using implants like in this manner. Ok. Um I can't remember the numbers off the top of my head, but the um there is a small risk when you're doing it, which is why the gold standard is cement spaces. No, this is very similar to what git presented, isn't it? Keeping the stem and cup loose and then coming back and uh doing this one. So in this case, so the cementing thing, are they using any separate kind of cement with antibiotics? I think it's revision cement they use, which is an antibiotic impregnated as well, isn't it a space? Yeah. So you might use like a gag basement and then add in bank. The other things that you might think about for those of you that came to the tumor workshop where we used DAC, we were talking about DAC, weren't we? 00 Yeah. The colloid that you can add antibiotics into as well on to implant it reduced by formation. OK. OK. Um Micro results came back. Um Different organism. Yeah, that was, that was the organism actually. Um And it was sense of psych and type was continued and then the second stage was planned in the future as per patient's request. Um The PICC line was inserted um and they, we continued antibiotics and, and uh transferred care to the parent hospital discharge on the 15th of August days, inpatient 25 days blood discharge, CRP 21 and white cell six. Thank you. Any questions for MRI, the key kind of points for the exam are using your being able to make the diagnosis of A PJ I using your MSI S criteria. And then talking about acute versus chronic, more discussions around DAS and then around single versus two stage. OK? And whatever you choose to do needs to be through an MDT with the involvement of microbiologists. OK. Thanks ma thank you has Ahmed made it out of theater. Let's see. Yes, he has. OK. I'm gonna do um a few slides just as a kind of a setting the scene on osteolysis uh for anyone who hasn't obviously had much basic science exposure just so that it's not too hopefully boring. And then um when Ahmed's ready, we'll get Ahmed to do his uh case. OK. So uh Ostra and bone defects is quite a big topic. So this is really just kind of a whistle stop tour and will hopefully act as kind of a prompt for you to go away and do a little bit of reading on these topics. OK? Um So aseptic loosening, uh we're gonna talk about in a second. I am not gonna make you guys describe this because I want to catch up a bit of time. So we've got time for Nick's Journal Club at the end as Well, so you're looking to see if there's any anywhere on the liner. So you would describe this as an uncemented total hip replacement, uncemented cup with one screw, uncemented stem. OK. Uh You've got a normal bearing surface, no features there of a dual mobility or constrained liner and the ball is not actually perfectly concentric. OK. So there is some signs of some superior wear of the poly because the, the ball is not in the center. OK. And then you can see that there are some changes behind the cup here. Uh To suggest that there is maybe some lysis behind the cup as a result of that acentric polywear. The other common place is that you start seeing it is in the proximal femur up here. OK. Um One of the things that can come up is what is the effect of joint space. So does uh Suman, do you know what that is? So the effective joint space would include any areas and the interface between the implant and the bones as well? Good. So on this implant, don't forget it involves the screw. OK. So it affects joint spaces anywhere where implant has contact with bone or where you fit the drill. OK. So um pretty. Are you still there? Yeah, I'm here. Yeah. How does osteolysis occur? Somebody might just need to mute themselves because they can hear a lot of stuff in the background. Um So from what I remember back, I had a good description before. So it's a macrophage um lead er reaction where you get wear debris or particles um that then cause the macrophages to set up a response uh in which they kind of activate your. Um I believe it's like your CPS, et cetera that then cause the osteoclast activity to occur. Uh And that in turn then causes the osteitis to occur. Uh I think there is also some neutrophil involvement as well, but it's predominantly macrophage lead. Yeah, predominantly macrophage driven. So you've got a, you've got your bearing surface. Um We talked about where last week. And uh so here we've got a ceramic head on a poly and over time, uh poly debris is formed. OK. So we'll see that these are the, the little bits of debris, macrophages love it. They uh the smaller the particle they're able to um their toes. And by doing so they become activated. OK. So these are biologically active when particles, when they're less than a microm, when the macrophages are active, they release osteolytic factors, which are your classic three here that will come up TNF alpha interleukin one and interleukin six. And these, we talked about, I think we might have talked about in the tumor term, actually activate osteoclasts. OK? And they do that through the rank lichen pathway. So by doing so, osteoclast is then on and you get osteolysis occurring and that usually happens at the cement bone interface. OK. So as that happens, these activated macrophages have released um those um signaling pathways and you can start seeing that there's osteolysis forming around the affected joint space. OK. Now, as that happens, the implant becomes slightly unstable and you get micromotion occurring. And so as that happens, you get even more particles forming up debris and they're able to get down through that gap between the implant bone interface or cement interface depending on what kind of implant you've got. OK. And guess what that causes even more activation, more osteolysis and more micromotion. So it's this kind of self perpetuating cycle that then occurs. So that is your, you know, two minute description of what osteitis is in your basic science Viber. OK. Now, it causes problems like acetabular defects and the kind of things that you can stop doing are going to be impaction grafting. If you've got a defect that is contained, you can contain trabecular metal augments. If you something more structural using um specialist revision table implants like reconstruction rings or getting onto the using things like custom implants depending on what the defect is in itself and your homework. If you're interested, certainly, if you're coming up to the exam is that if you're talking about acetabular defects, you want to be talking about the Prosky calcification in the exam. OK. Uh So something for you guys to go away and have a little read of. I thought I'd just go through impaction grafting of the acetabulum because it's a nice thing to kind of talk your way through in the exam if it came up as an opportunity. Um And the first thing you do is you divide your defect back to stable bone, you then want to look and see is it contained or not? So if the medial wall is breached, that's not contained, you might want to use a mesh. Ok? It might be that you've not got a superior rim and you're wanting to use a mesh to create an area of containment. Once you've got a contained defect, whether it's that you've had to create that or it is already contained, you're going to select the type of bone graft that you want to use, that most people would use um bone chips. If you come through knowledge, what you'll see being used are femoral heads that have been taken um to the bone bank from total hip replacements and you get these kind of croutons for want of a better way of describing them, ok. Um And you guys definitely need to be able to talk through the different types of bone graft in your exam. Once you have got them, you fill in the defect and then you gradually impact them with increasing size factors. And then there's some separate tools here that you have that you can work around the rim as well as a sieve so that you can er wash. But without taking your bone graft away. OK. So that's, that's the very basic principles of impaction grafting and the kind of tools that you'll see being used to do it. These might be some pictures that you might see. So you can, you can see here they've got this superior rim mesh that they've used. OK. You can also wrap it around the femur if you're trying to contain a proximal femoral defect. Great. We kind of discuss that. I thought we'd kind of just do a couple of. Hi, Ahmed. I'm five minutes. Just five minutes. All right. No worries. I sure. Yeah, no problem. So, um, pretty panel. So, um, coming up to the exam, how do femoral stems fail? So they fail according to this room, they can fail in a number of ways. So the main categories would be pistoning categories of bending, media, cal pivot, pivot. So, pistoning is where you get higher. You, you can talk through it. Yeah. Ok. So, pistoning can happen either at the implant, cement interface or at the cement bone interface and that's where you have essentially pistoning of the implant going up and down the femoral canal eventually leading to more debris and more loosening medium. Midsternal pivot is phenomenon. We'll come to that one. I'll move on. Uh, yeah. So, um, well done to, um, you, you record them all. So that's good. Um, so, yeah, so pistoning ones, er, you see relatively frequently in clinic, you'll see that there's a loosening all throughout all of the zones um of uh of the implants between the cement and the bone. If it's say an exeter, or you might see some lucency between the implant and bone if it was an uncemented stem. But you can, you see the whole, that the whole, the pain is coming from pistoning of the whole implant plus minus the cement. Ok. It's not that common that you see the stem pistoning within a well fixed cement. OK? But it is in there as a possible mode of failure. Um The next one that um we're gonna show I'm gonna show a picture now. Um Pretty. Oh You Yeah. Hello. Yeah. Um I know you, you may not have seen this picture before of one of my little cartoons. What, what do you think is happening on this one? Um So this looks like a medial midst pivot um in terms of your mode of failure. Uh So what's happening is it's kind of levering at the center um due to loosening and as a result, you're kind of getting this. I don't really know how best to describe it but this rocking pattern. So you're getting which you've kind of drawn on this anyway, but you've got this kind of medial migration of the proximal part of the stem. Uh and then the distal part is making contact with the lateral aspect of the cortex. Um So you've got a high risk there of sclerosis or even fracture. Um because of that. Yeah. So often what happens is is that they lose um support in Z in zone seven and the stem falls into it and then you get uh sclerosis laterally distal and natural and sometimes I haven't actually ever seen it, but you're supposed, you can in theory see a cement fracture in that area as well where the implant is pivoting, right? Um But yeah, if this is, if you were looking at an x- and you start seeing that there's loss in zone seven, you might want to talk about whether the positive or negative finding of if there's any sclerosis at the lateral disc or tip because it's just showing that higher order thinking of you've seen this and you're looking for the complication of it. Yeah. Yeah. Uh Good. So that's that one and that would only occur really in cemented implants. Is that right? Yeah. Yeah. Um And then I've given away the answer for this one. So this is Calcar pivot. So pivoting at the calcar it windscreen wipers distally. And so you'll see some sclerosis on both the medial and lateral side. OK? I haven't put bending cantilever in at the moment. Cos if there's time at the end, I'm gonna talk a little bit about how you can take out broken stems. Cos again, it's a really popular Fr CS question, right? Um Femoral defects. I've already think we've covered well enough already. Um, if you've got that Dorsey type Femur, so you've got no isthmic fit. You're gonna be thinking about, um, potentially needing distal locking. Ok. Or using cemented implants. We've talked about impaction grafting already and I'm trying not to speak about proximal femoral replacements, but you all know, I love them. Um, we've talked about some of these already. I'm gonna skip over them. All right. Yeah. Ahmed. All right. Do you want to sorry, you had just some issues with the connection. So, while he's doing that, can I just quickly ask you? So I've learned about the Paros classification for kind of femurs, but so you also kind of apply that when you're talking about acetabular defects. Is that right? You're saying? Yeah, Kate, sorry, can you hear me? Sorry, I was muted. Sorry, tabular classification as well. So have a little look. OK. He was talking about um levels of uh containment and where the defect is. OK. Fine. OK. So you can use that for both the femur and the ace tablet and they're just slightly different? Ok, perfect. All right. Um So um can everyone see my screen? Yeah, great. So, um yeah, I'm afraid um I um I haven't done like hips in, in Colchester and uh I didn't have like specific case to present over. I've just uh made a little presentation about uh just the basics of septic loose of aseptic loosening and just a, a few pictures. Um Just from the internet to be honest. So sorry about that. So, uh first of all, I'm going to just talk about a little bit of basic by science. Um So like uh basics of um um and the the biomechanics behind this and just the types of um uh of loosening and diagnosed in radiological and uh diagnosis and then the the management. So just very briefly here. So um this piece has really covered this um losing starts normally with where sense, particularly debris in the joint which starts inflammatory action cause osteolysis. And this osteolysis um results in the loosening and migration of the implant, either stem or the cup and the the types could be septic or aseptic. And I went to um mention a few things about this. I think this is we already discussed and um the losing could happen in the cemented or uncemented implants. It happens in the cup or the stem or both and to differentiate between septic and aseptic. Uh we know that uh we need to get blood like E RCR P for blood count and uh bone scan like images and bloods. And then in the aseptic, normally these things uh will be normal um in the cement. It is easier to diagnose through the radiographs. Um The stem is always easier to diagnose well compared to the cup. So, normally clinically, they come with pain is it's usually start up pain, um reduced movement. And radiologically, we have to always get ap and lateral. And um we should always look for series of images every six or 12 months. So there's just an example of um of uh aseptic loosening of um stem and this is uncemented. Normally, we see here, substance as we see at the tip of the stem, there is a pedestal um in the cup, you can see broken screws here, osteolysis here um in the cup, we can see loss of inclination as well, which is coming in the next one. So here is the loosening of the cementless stab. Um You can't see broken screws. We can't see um um much red loo lines. The only thing that we can see is the loss of inclination here, for example. And this is a picture of four years apart. So this count as a cup, aseptic loosening and looking at the um cemented implants um on the left side there, there is um the there is calcification for diagnosing the cemented cup loosening on the right side. Uh It's the the ground zone classification for um cemented implant. And this has been already discussed, I think in the previous talks. So this is an example of the cemented um stem there is losing here. We can see very clearly uh some radiolucent lines. Um look um it looks like there are some osteolysis. Um This looks like it's a type of uh distal uh pivoting looks to me like this pivoting. Um This looks like it's hemi. So there is no cup to comment on. It looks like it's just bipolar and uh to rule out infection, we have to make sure that we do uh blood and scans blood will be most importantly what blood cells CRP is R and R and if this metal or metal or resurf and the scan will be bone scan and CT and once we have ruled out infection, so ruled out septic loosening, then um we uh make a decision about the management. Usually it needs to be discussed in hip in the tee and, and uh usually it needs revision if the pain is significant and is confirmed loosening uh radiologically and clinically. And uh for uh just uh planning, we need to make sure that um we have got um good pre planning. We've got uh the right implant, we check the bone stock and um we have to dig deep. So um we have always to bypass the defect um of the proximal fever. So that's just my simple presentation. Thanks Ahmed. Any questions for Ahmed from anybody. Um What, what is the role of a bone scan in in this? Is it really not useful? I personally don't use them. CT is quite a, just a plain CT is quite useful if you're wanting to look at a kind of implant or cement bone interface. Uh And your MRI is quite good. If you're looking at infection, you want to see if there's any signal changes in the bone itself as to whether or not there's osteomyelitis as opposed to just, um, kind of, uh, septic arthritis type. PJ. I, so, um, they're usually kind of the investigations that I use. Uh, I know kind of, uh, a bit more down south like London based. Um, and there's probably a little bit more spec ct usage very, quite difficult to interpret sometimes the results. Oh, yes. yes. So in, yeah, we usually use SPECT CT. Sometimes I see some surgeon they use bone scan. But yeah, I think you're absolutely right. Um Bone scan is not always very helpful. It's just sometimes shows that there is like hot spot, there is like listening for infection, but it's not always conclusive. I agree with you. But um I think CA or CT uh boot can um is usually done here in Colchester. Ok, perfect. Um Why don't we let Nick do his journal club next? And then if everyone's had enough, we can call it a day. If anyone wants to go through how to take out a broken stem for the exam or out of interest, I'll do that at the end. Ok. Are you there, Nick? Hi, Miss Spacey. I am indeed here and I think I've finally found a quiet spot. Fantastic. Thank you, Nick. So, Nick is going to do a journal club looking at the OK. Chaps. So good afternoon. Uh give me a sec just to sort the, it, you can also more. Ok. Can everybody see my screen? Marvelous. Marvelous. Ok, guys. So good afternoon. Um M space suggested, um, a, uh, a general club based on, um, VT E er, for part of hip term on, on the grounds that we know that's a, a significant um complication of what we do. Um, II confess that, um, it's probably not something that we're all desperate to talk about, but it is very important and I'd just like to briefly reiterate why? Because sometimes that gets lost in the noise. So if you think that in the UK, um we do about 700,000 orthopedic procedures every year and we know that um, approximately 1% of our POSTOP patients get either a DVT or a PE. Um Then, then why is that significant? Well, the numbers vary a great deal depending on which studies you read. Um But there was a very large scale study from Quebec in 2013 which went through all of their health records and said that the patients there who had a DVT or a pe 23% of them died. Now, obviously, that includes um, people who are already very old and frail, but that of course, can be the population that we're dealing with. Um There are a number of studies which suggest that um pharmacological therapy can actually reduce the risk of DVT by up to about half. And that's why this is important. So what's, what's the context for the paper that I um sent round um earlier on? So in the context, the overarching piece of guidance is nice guideline 89 which is now sort of three or four years old and notably a very significant um section of this. So 80 sorry, eight of it's 47 pages is actually solely based around orthopedic procedures and it's actually um ii commend it to you because it's actually quite readable because it's essentially split by some specialty. Um, there have been, however, since then, a number of major trials and reviews, I've just listed them there. I don't want to particularly go through them because obviously we're focused largely on elective hi practice today. Um, but II thought this paper was quite interesting because, um, it's, it's a very large, um, trial which was, um, published about 18 months ago. It's the first major RCT on aspirin monotherapy. It's called the Crystal Trial and it was conducted in Australia, um, between sort of spring 2019 and the end of 2020. Um, in all 31 hospitals, um, took part and they were all centers with a reasonable volume of arthroplasty over 250 cases annually. So, um, there were 9700 patients that meaningfully took part in the study. Uh, and anybody who was previously properly anticoagulated was excluded. Although that is an important point that we will come back to later on importantly, pragmatically, they randomized by hospital rather than by patient. And their primary outcome was um the number of symptomatic feces that occurred within 90 days, postoperatively, uh doses were always adjusted and um the patients were actually to confirm that a reasonable number of them had actually taken the drugs as planned. So, what did they find? Uh well, they actually enrolled a lot more people than they operated on. Um interestingly, um but of the patients who were operated on and therefore statistically relevant, um, they only lost about 500 to follow up, um, which is about 5% which is an awful lot less than they had anticipated. Uh And those were largely lost to follow ups. Although a very small number uh opted out and a very small number unfortunately also passed away which I'll come back to, um, interestingly as a result of one of the deaths, um they, er, conducted an interim analysis which they had not intended to do. Um, but uh they stopped the trial early as a result. So, what did they find based on these early results? Well, they found that um, uh 3.4% of the aspirin takers and 1.8% of the enoxin takers um actually suffered from a VT. Um And although the trial had been designed to suggest that aspirin was not inferior to enoxaparin, it did not meet those criteria. Um I note also that, um uh when I was thinking about it. I was like, um, what, what if there's, um, significant difference between hospitals actually, um, any hospitals that agree to be on their sample size then changed over into the other treatment on which, um, will presumably have balanced the results out a little bit. So all the limitations of the study, um, well, we've mentioned lost follow up at 5%. Uh, there were some low enrollment rates although, um, their results seemed not to, um, skew the overall theme of the investigation, obviously the hospitals were, um, were unblinded. Um, and it's possible that some of them did more tests when they crossed over to Aspirin. Although that's not a hypothesis that with the data, we've got, we can answer. Um, interestingly, er, obviously we care a great deal more about pe than we did about, um, just DVT. But sadly, the trial wasn't fully powered to answer questions about that. Um, obviously your study doesn't function entirely normally if you stop early and race and ethnicity were not data that were collected. Um, and obviously this is a study which is only relevant in the context of osteoarthritis. Um, one of the things I found particularly interesting and, and concerns me a great deal about the, um, result, er, is that 15% of the participants were actually already taking, um, aspirin at the start of the trial and they did not have any additional, um, prophylaxis. And I wonder whether that will have skewed the results. Um and from a pragmatic perspective, it doesn't include a cost effectiveness analysis. So, discussion is any of this relevant to us? Why, why should we care? Well, um so firstly, it's um the first major RCT on this particular issue and it is relevant to our guidance if you look at NG 89. Um and I know we're talking predominantly about hips uh this month. Um you can of course have aspirin monotherapy for knees. Uh or indeed under the nice guidance, you can um have uh initially a short period of uh Lemole Heparin and then go on to aspirin. So um this could change people's practice, particularly with regard to knees in the UK, but potentially also with regards to hips. Um I've mentioned my concerns about biased um particularly with regard to those who are already on aspirin monotherapy. Um and relevance of say again, also, it's a shame that we weren't able from the results to distinguish DVTs, er which perhaps less concerning from P ES, which are, of course, more concerning. All right, I hope I find through that quickly enough. Does anybody have any questions? Oh yeah, bring you in the office that any questions for me guys, George's Aer I can't see anyone else from AA on here that I'm aware of any kind of questions, comments on study design. So I'm just thinking here that uh every hospital should, sorry, I'm just thinking that uh you know, an event like this is multifactorial, right? So if, if a hospital has a different policy for physio dead uh stocking usage and all of these factors, then surely that plays into it. So, so I'd rather see randomization within the same hospital as opposed to between hospitals. Yeah. And II would totally concur with that panos. That was one of my thoughts. Um I guess just in terms of conducting a very large trial like this and thinking about the effect on pharmacy and nursing, that kind of thing, they went with something that was more pragmatic, but I agree. Um, it would be within the art of the possible to do what you're saying. Um Yeah, I think, um, I think Nick and Panos if, can you hear me? Yes, we can. Oh, great. So just, um, just to add to that point as well, that the reason so many of these national NIH R funded studies are more pragmatic like that is that if they're not and they're not really applicable to any other unit, really. Um So II completely take on the point that there's sort of differences between units. But if we, if we focused in on one for the study, then really the generalisability and the applicability just goes right down. I thought the 15% already on Aspirin was quite interesting and I wondered if they're randomizing how many of that or what percentage of that 15% ended up actually on a low molecular weight heparin and aspirin. That's a very good question. And it's not that data isn't in the paper, I'm afraid. Which is a shame. And then did they talk about the complication rate difference between low molecular weight heparin and aspirin in terms of say hematoma subsequent return to theaters? PJ. I um it, it was, it was, it was listed as um a, a secondary outcome although I haven't actually seen uh any, any statistics on that, any numerical statistics. And I guess the other kind of thing to bear in mind for any of you that are reading these types of papers because in the exam, if you're suggesting management and they ask you, how are you going to do this hip replacement? And you go through your implant choice? Nice OD En Jr, you talk about your approach and you talk about your rehab, your POSTOP shift period and you talk about what your choice of VT is. That's kind of, that's your seven eights. So you will need to form some kind of consensus for yourself about how you're going to answer that question in terms of what VT that you want to use when you're a consultant. Yes, a lot of it is dictated by your trust policies, but there is still some wiggle room there. So as individuals, you need to know what it is, that's going to be right, what you feel is right for your patients. So um this is why this topic is in here really to make sure that you have a moment to think about it. But when you're reading the papers, Nick's made it quite clear they're talking about symptomatic dvts. Some of these papers actually do dopplers for every single patient and you'll pick up a lot of dvts that are not symptomatic and therefore not. We don't know if they're clinically relevant. Ok. And that comes back to George's point about thinking about a pragmatic approach that's reproducible across multiple sites. So just bear that in mind when you're reading these papers as well. May I make another comment just for the benefit of everyone? Really? Um So nice. I recommend to consider VT prophylaxis even for non arthroplasty surgery if the anesthetic time. So it's not a surgical time, but it's, if the anesthetic time is over 90 minutes and I know of cases where this has been legally tested, right? And the trust has had to pay it out to pay out. So I think even if we're fixing a wrist fracture, my view after I heard about this is if the anesthetic time is over 90 minutes because we have a difficult anesthetic, I would, I would still give uh doctor Bar in my view, uh, just to cover for that really, uh and have a nice day. Um Panas, is that, um, was that a general um, comment? Because I II remember, I mean, obviously the nice guy was pretty long. But I remember that being a thing particularly for upper limb, it, it is actually KK just for the link up, uh, actually a few minutes ago. So it says that in there for, and, uh, I don't want to practice defensively, but I know that if somebody sues you because you haven't given it, even if it's a wrist fracture, they will win. So just, just a simple fact there. So Nick in, in on when you do your BTE assessments, it is one of the criteria there as well to consider as a risk for, for um O BG O BG and he is under nice guidance as well. He doesn't say anything about duration, doesn't say anything about the duration of treatment, but it is cool. Thank you very much. Yeah, I guess the slight concern, isn't it? When, when you start practicing defense like that, is that actually if someone has a complication like a upper gi bleed subdural, you're also possible to get sued, right? So sometimes it's a, you're kind of at risk either way. Um The risk assessments are there to help you with that though, aren't they? So procedure, surgical procedure more than 90 minutes and that being the only risk factor is only going to be scoring one which for most will still be in that category of you being able to um argue which way you want to go with it, isn't it? Ted Stockings? Nothing dodgy. Um I think it comes down to the fact that, have you done a risk assessment? Is it documented, if there isn't a documented risk assessment? Then yes, your wrist fracture that happens to go and get a DVT. Although rare, yes, you are a bit exposed, aren't you? But these are quite rare cases, aren't they any, any more points that anyone would like to make about? Um, the paper? I think it's a reasonable paper to use in the exam for using the nice guidelines. And then talking about this paper would be reasonable evidence to produce, wouldn't it? But you might want to also look at some evidence of say Dodge Piron against the dog. The other way that you can go about evidence in your exam is actually looking at what your local hospital policy is. So you can quote your local hospital policies in the exam as well. If you haven't got firm evidence, you can say what, what your local practice is. Yes. Yeah. If you need it done, Nick, were you gonna say something? I'm not sure if I interrupted you. Yeah. Um Yeah, I was, I was actually going to just say that there was a, a very good um, article in the B JJ uh in the last month. Um summarizing a lot of what I've just said, I'm not sure whether that's the one that I see you've just put up on the, um, on the group or not. No, I literally just dropped the nice guidelines info if anyone wants to read them. Cool, cool. Yeah, but if you, if you want to drop it in there, pop it in there. Um, ok, for anybody who wants to escape, if they feel like they've done too much, um, or have reached their point, that's completely fine. I'm going to just do some like three slides I think on how to take out a broken stem mainly because if you get it in the exam and you haven't thought about it, you're gonna be a bit stuffed. Ok. Um So I'll just screen share, but I do appreciate that. Something very important is happening today and it's season three of Bridgeton. So we will finish promptly. She says she can screen share. All right. So, uh pretty, what do you think about the X ray on the right? Sorry, I'm just walking in the corridor. Um So this is a uh yeah, so looking at the X ray, I can see that there is evidence of a broken stem. Um It looks like a cemented. Uh I don't know if it's a cemented exeter, but that's what it looks like in the X ray from here. Um Looking at any areas of loosening the acetabulum itself looks fairly well fixed with no obvious loosening charly zones 12 and three. However, looking at the stem, there does appear to be some loosening more approximately around the stem um around kind of er, groom zones 12, in particular as well as coming down into three. Um So my concern here would be that this may be a broken stem secondary to a cantilever effect. Um Good. So in this case, that's no, no well done. So, um presentation wise, this is ment total hip replacement. I know you're going to be on the phone, there probably is a little bit of loosening in zone one. What you don't know is whether that's been there for a long period of time. You can see that it was there on the X ray on the left. So it might just be poor cementing technique, but the rest of it looks fine. I agree with you. Uh The moment you see a broken stem, you automatically know that this, how this implant has failed and it's bending cantilever, which I'll go through a little cartoon of, er, with you in a second and that happens because you lose proximal support. OK. And so you have movement at the top and a well fixed distal stem. OK. So the moment you see the broken implant, your higher order thinking is to go and look in zones one and two and six and seven. For that loosening, you can see that there's a massive black line coming down the side here in zones one and two. You can see that the cement is loose here as well and you can see that there's a a lytic line isn't there between the cement and the bone coming down here in 66, sorry, seven and six, right? And then actually your other growing zones down here all look reasonably reasonably good similar to what they did whenever this X ray on the left was taken. Ok. So that's your higher order thinking broken implant licensing zones, 126 and seven, otherwise distally well fixed, this implant has failed most likely due to bending, uh a bending cantilever, right? Um Well done pretty so bending cantilever um happens when you have lost your proximal support. So it's loose at the top and it is well fixed at the bottom and it toggles. OK? And eventually the implant fractures usually around the area of um where the lysis is. OK. Now, if you were to as part of your homework, get hold of a paper clip and unfold it so that you've got kind of that s shape when you've unfolded it and you know, taking it uh by its halves and you hold one end still and you wiggle the other end, it will break. And it is exactly the same principle that is happening in that hip replacement. So it's how you're gonna remember how it works. OK? One end is fixed, the other end moves the metal breaks. OK. So at some point when you see a paper clip lying around on a desk, pick it up and play with it. OK. So how do you get them out? Any, anyone had to take, uh, anyone assisted in a case or anyone taken a broken stem out before? What's the obvious way of getting out an ET O? An ET O? Yeah. So, in your exam, if you got thrown it and you were like, oh, I don't know what to do. ET O, yeah, you're gonna get it out and you're gonna be able to give some reconstruction options, aren't you? Yeah. So ET O is perfectly fine to say for me, er higher order of thinking, I'd like to see it as a last resort. Ok. So what kind of things could you do before you get to doing an ET O? So you can take it out, take the top half from the top pretty easily, we should come out pretty easily and the challenge is getting the bottom half out. So I suppose part of it will depend on whether, whether the stem itself is protruding out from the, from the mantle, in which case can get a grasping instrument around the stem and pull it out or if it's buried, you can use something to core out the cement surrounding and again and then attempt to grasp the stem. One option is to make a jaw hole beyond the level of the stem or the mantle and push it out from the bottom. Um uh or you can use or you can sort of cut one leaflet of or one half of your ET O and again, try, push out, push out from the as well. So I like to refer to that as an episiotomy. Um, so if you've got to the point where you've tried everything else and you're like, oh, ok. I'm going to resort to an ET O do the first part of your ET O so that you've just got a little bit of give and then actually that might be enough to get it out. And then if it doesn't, then you just do the second part of your ET O. OK. So it's like a staged et O to get it out, it just gives you a little bit more space. Um But yeah, hold on one. That's good. Um So I would say that from the top to an ET O is kind of this spectrum that you can go along, you might choose, you can definitely take the broken top end out. It's easy. You just take the cement off over the shoulder and it will basically come out. Usually in your hand, you might then using cement removal tools and Oscar just take out whatever proximal cement is above the broken part. And usually you'll see part of the stem higher than the cement. You could continue to use cement removal tools. And if, if it's reachable, you might be able to get it out with a grasper. Generally speaking, it is relatively well fixed and that's why it has broken at that point. So I have, I don't think I've ever successfully managed to just get it out at that point. But your next option to try is over reaming it. Um So you basically, there's a crown reamer that you can get, that's about a centimeter diameter. So depending on where it's broken in its taper, um you might be able to get that over it. Most I have managed to do that on most of the occasions. One occasion it had broken a bit higher up. So it was wider than that crown reamer. So I took a Midas rex and took the part of the um metal off so that I could get the crown reamer over it. So that one worked. Um But if it wasn't, then I would then go to what we call a lateral window. Ok. So I've got a little cartoon that we go through in a minute of how you actually do the lateral window. Uh And then if that failed, I'd do the episiotomy type move before getting to an ET O with both the lateral window and the ET O. In part of your reconstruction side of that, that exam answer, you know, that you need to bypass um the distal end with whatever you choose to reconstruct, whether that is a long er cemented stem or whether it's um you know, a restoration type stem. Ok. But don't forget to say that as your higher order thinking if you manage to get it out from the top, using these techniques, then actually, um your length of your implant is really gonna depend on how much bone loss you've got approximately. So if we say that this is a, a broken stem inside of a cemented stem that's broken inside the bone, and we're just gonna put the other bit of bone back on. What you would do is distal to um, the broken part you're going to drill, you would drill kind of four holes and then connect them with an osteotome so that you have a window that you can take out. Ok. So through that window, you'll take out the cement and you'll just be seen er, straight down onto the implant. Ok. What you can then do is take something like a midas rex and create a little groove in it, ideally kind of lower down in, lower down so that you can then get uh some kind of trawl in to that groove and then you would knock it, but knock it up so that you make it come higher up into the femur, you might loosen it enough that you can then take it out from the top of the grasper, right? And then you would then replace the window and put a cable around it and then you're gonna bypass that later window with a stem. Usually speaking, if you're just gonna go back in with a standard length stem, it's going to finish not far away from that lateral window. Ok. And I have seen one case er, come, come through um an MDT where about six weeks POSTOP, the standard length stem had come out the side through that lateral window. Ok. So you need to remember you need to bypass it. Ok. Um So that was my kind of just a whistle stop tour of how to get yourself out of jail in the exam if you get a broken stem because it's a pretty common um pretty common station to come up to be fair. Any questions about the broken stem side of things? Uh Yeah, I have a question about the mode of failure. So I've seen a stent uncemented break at the base of the neck. So there was nothing basically sticking out of the neck up. So what mode of failure would that be? So, um that was a particular, it happened to it. I think it was, yeah. So um panel. So if you walk past my desk have a look on there, there's a um there is an uncemented implant that's broken, that's modular and it's broken at the Trion. So you could either have some Trion knows that leads to implant failure or it can be, for example, there is weight limits for some of these implants. And so if you see it happening quite high up at the neck junction, uh it can sometimes be related to patient factors as well. So for example, some of these like, not this necessarily, but some D DH stems, they do have weight limits on them. Um And so a couple of broken stems that I've seen, um, when I was training were actually size zero stems that were put into someone that was above the weight limit for that implant and they sequentially failed. But then how, how will you remove that from the top because there's nothing to grasp, right? Uh So the ones that fracture at the top are much easier to take out because it's, it's close to the top. You can take all the cement out. They're, they're actually easier to do the lateral windows for. It's the, the ones that are further down are a bit harder to get out. I see. Thanks. Mm No worries. Panel. I ask you a quick question. Of course, George, why would you not do that lateral window? Just a bit distal to the tip of the stem and then just tap it out and you don't have to do that extra step of burring and getting a groove to bend. Um So you have to go longer with your implant one thing or I'm just gonna confess, my battery is low on my laptop just if it cuts out. Um So if you, yeah, so if you do it at the distal end and rather than a, a couple of centimeters up, that's another few centimeters of implant that you've got to get past it. Ok. Second thing is that you, then if it moves a bit, but you still can't reach it. You haven't got any more implant coming there to be able to continue to tap up. Yeah. Ok. I'm picturing a sort of a punch following it up the, the shaft. But yeah, that makes sense. Just the angle that you've got to work with George. So if you think about putting something through the femur to knock it up, actually, you're gonna have to create a bigger hole distally to get that angle to drop your hand to keep pushing it up the fairway. Does that make sense? It does. Yeah, sure. Thank you. And also how much of a cement tail you've got to get, you know, cement, you've got a cement tail there, haven't you? So you're gonna have to bur bone and cement and then how you're gonna end up having a bigger lateral window just to get that angle to knock back up. Yeah. Yeah, that makes sense. Thank you. No worries. Any questions, guys. Nothing in the group chat. Well, thank you all for participating. It made it quite enjoyable. Um If there's no other questions, then we'll call it a day and it's on to um Pete's term next, isn't it? Yay? All right then guys, um those of you that are presented, make sure you send OTs um Nick, make sure you send something. So you can document that. You've done a general club? Ok, bye guys. Thank you. Thank you. Hm. Yeah. Yes. Second. Yeah. Yeah. Mhm. Steady. Yeah. Don't come downstairs. Yeah, I'm wondering why. I just don't wonder why maybe that. Mhm. Mhm. Ok. Thank you.