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Great. Well, hi, everyone. Um, er, I would say it's nice to meet you but obviously we're all staring at a computer screen. My name's Nico. I'm an orthopedic surgeon in London. Um, I work in Barts Health, which is one of the biggest trusts in Europe. Um, predominantly I'm based at the Royal London Hospital. Um, and this little picture at the bottom is, is a view we get from one of our wards. So it's based in East London. Um, and it's one of the biggest trauma centers in Europe. Um, so I've been given the task of talking to you about orthopedics. Um, it's worth mentioning that with orthopedics tends to go trauma. Uh, and they're quite distinct specialties and in many countries, they're split into different, um, specialties altogether. But in the UK, they're very much, um, the same. Um, so to start with what, what is orthopedics, um, and trauma for that matter. And it's, we could categorize it in many ways, but perhaps the easiest way is talking about what tissues we treat. Um, so we treat not only bones but also muscles, tendons, joints, ligaments and increasingly peripheral nerves. I think there is a a hang up that we treat bones as orthopedic surgeons. And I think that's probably because you can see bones on an x-ray and you can't really see muscles and tendons. Um But there is an old A O saying when we're treating fractures, that a fracture is um a soft tissue injury with a bony component. And increasingly, we're recognizing the importance of treating soft, soft tissue injuries as well as bone injuries for the purpose of this talk. And to explain what we actually do, I thought it'd probably be easiest to categorize it into different age groups. Uh One of the benefits of orthopedics is most orthopedic surgeons will treat anybody from a neonate um to somebody close to 100 year old, there are massive discrepancies in what we do for different age categories. Um And hopefully I'll higher that highlight that for you. And as I said, it is both trauma and orthopedics. Um um and I'll try and just in each age category give you a couple of examples of the things we teach. Um other things we treat, sorry um in both bands. So I'm quite happy to keep this interactive. So um I know there's 50 odd people on this but please feel free to shout up or put something in the comments. Um But sorry to interrupt doctor um rather than shouting out if everyone, if you want to speak up, please use their reactions on zoom and put your hand up so we don't have people talking over each other. Ok. Even better. Let's do that then. Um, so this is, uh, something that we see relatively commonly in, um, newborn Children and increasingly as ultrasound scans are becoming more sophisticated, we can pick it up in, in Children in utero. Um, and it's clubfoot. Uh, so it's a disorder of the foot. Um, er, and I said it's relatively common and it looks like this kid is in trouble and, er, he or she won't be able to walk, but actually there's some very famous sportsmen who were treated with Clubfoot, including for those of you who recognize him, Steven Gerrard, who's arguably one of England's best midfielders ever. Um Lots of people have tried lots of surgical procedures to treat club foot but it took this chap here a guy called Doctor Poncet who was an immigrant to America. Um, and he was sent to the kind of outpace of a, a little sleepy hospital in um, in a part of America. Not many people hear of, but he developed an amazing way of treating clubfoot deformity with just plasters and a small tenotomy of the achilles tendon. And what he found that over the course of uh literally a few weeks, you can take a kid from having a completely deformed foot that looks a bit like a golf club into a normal foot with just a little bit of tightness in the achilles, which is then um cut to allow the foot to come up. Um Now this is an amazing treatment really because as the world was becoming more sophisticated healthcare and going more aggressive down the surgical route and treating various conditions with drugs. He demonstrated that a simple casting technique which costs next to nothing um is the best way of treating clubfoot and this is the gold standard around the world. Now, another thing that we see in treating Children um is dysplasia of the hip. Um And what you can see here are two x-rays, one taken from um birth or close to birth where you can see the hip joints. And I'm not sure if my curse is coming up, but this is a normal hip on what would be the left of the patient. And this kind of line here is not a fracture, it's actually a growth plate. Um So that's what looks like a normal hip, but you can see on the hip, on the right, the hip's dislocated. And again, this is a really common um thing that we come across in the UK, if not around the world and left untreated, it can lead to really poor hip and lower limb function. And if you look at this image on the right hand side of your screen, this is an adult with an untreated dysplasia of the hip and the hip joint is not formed to the point that the hip's not even sitting in the socket. Um and this leads to loads of problems, right. So the patients commonly have pain, they can't walk. Um, they have leg length discrepancies. Um And it's problematic right now, dealing with this picture of a grown adult with a dysplastic hip is really tough. So it has lots of surgical problemss. Um and there's never, you know, a warm and fuzzy feeling from the outcome. So again, we don't need to go down those routes. If you catch it early and you treat the patient in a, in a very basic um harness, you can achieve a really good outcome from a patient with pretty much normal hip function. Um So this thing here on the left hand side of your screen is a little kid wearing what's called a panic harness. And what that does is it places the hips in a better position and by doing so over the course of several months, it allows the hip to form in a better position and then patients grow a normal hip joint essentially. Whereas his images on the right show what needs to happen in severe cases of dysplastic hips in kids who aren't responsive to uh this type of harness. And you can see that the patients had what we call an osteotomy, which is essentially breaking and setting bones um to try and keep them in the right position. And so again, it's a good example of something quick, easy to do and it's all about recognizing a problem early in a child's life and doing a basic um intervention to lead to a good outcome. No, this brings up a really interesting concept and that is one of public health. So in the UK, we have um a screening program at from birth with kids where they're examined by a pediatrician early and if the hips are found to be clicky or abnormal or they meet other risk factors for developing dysplastic hips such as multiple birth or twins, um family history and so on. They have their hips, ultrasound scanned and if found to be dysplastic, they're put in a P harness. And what that means is there's a whole group of patients who are catching early treating appropriately and it means that they don't have those horrible outcomes where they need surgery or we reduce the risk. And again, this is, this is an intervention which is low risk, low cost. Um with really good outcomes can be done in any country from an AA one to a low resource one. So moving to Children and changing something to talk about something slightly different is trauma. So for those of you who don't recognize this, this is an elbow x-ray looking at it from the side and this is called a supracondylar fracture. Um and there's a fracture just above the two condyles um of the humerus really common. Um And so the enemy of an orthopedic surgeon are monkey bars because most childhood injuries happen from monkey bars than anything else because kids are swinging on them, they fall off them, they landed on an outstretched hand. When you're a child, you can hyperextend your elbows. And that locks your Ronon in the electron fossa, which makes it nice and strong. So the elbow fails at the weak point which is just above the fossa, um which is just there. Now, left untreated kids will heal right if you put two ends of a bone in the same room of a child, um The two ends of the bone will find each other and he heal up and rarely there's a, a problem with nonunion. Um However, untreated, supracondylar fractures can lead to deformities. And this is a child who was seen with a normal elbow on the right and on the left hand side, you can see that he has what's called a cubitus varus deformity. Now, it is unsightly which bothers people a fair, fair amount. But what's really irritating is as he swings his arms from side to side, as he walks, he keeps knocking his hand, which is pretty irritating. Um So how do we treat supracondylar fractures? Well, unfortunately, more increasingly so we're treating them with an operation because that leads to the most predictable outcome. Now, the operation itself can be quite tricky, but thankfully, the only thing that's required are these devices here which um we call Kirchner wires after I think a Russian surgeon who first wrote them up or polish, I can't remember. Um And all they are is they're bits of steel with a pointy tip that you can insert into a bone um under x-ray guidance. Um And once the fracture is put into the right position, they're held in place. Um And so those deformities are less likely to occur. No, putting the factor in the right positioning and putting the wires in, as I said, can present some challenges. But the hardest thing about it is ensuring that we miss all the tubular structures around the elbow, which have quite an important function in the in the hand i the nerves and vessels. So there's three main nerves with cross your elbow. Uh And I'm sure you recognize them from your anatomy lessons, but the ulnar nerve, median nerve, radial and radial nerves. Um So there's lots of areas which are kind of what we describe as tiger territory in the elbow and going about avoiding those is really important. If you iatrogenic injure one, you can really ruin a patient's life. So on the left, sure, you'll recognize this is trying to depict what's called an ul of nerve lesion or a paradox where a patient loses function of their small hand muscles and some of the forearm muscles and really injuring an ulnar nerve um can cause significant problems later in life. So avoiding it is kind of the art of performing um a fixation of a supracondylar fracture. Now, hip pathologies also affect um Children as well as neonates. And this is a really good example of something called Perthes disease where there is avascular necrosis of the femoral head. So again, looking on the right hand side and you can see the physis, the growth plate and the epiphysis of the radial head of the radial. Sorry, you can tell I'm an upper limb surgeon of the femoral head. Whereas on the left hand side, you can see this fluffiness here and this happens um for an unknown reason where essentially the epiphysis of the fema dies. And a patient's left with really potentially a poor outcome, recognizing Perthes in a patient who is young and presents with hip pain is really important because again, you can do a lot in young kids to prevent this becoming a huge issue later on in life, but left unrecognized can cause problems. This is um another thing that we commonly see in um young boys who are particularly uh a bit chubby and it so the x-ray on the right shows what's called a slipped upper femoral epiphysis if you're a British or slipped capital femoral epiphysis, if you're American. But again, the growth plates here and what happens is it slips off the back of the femur like so and left in this position, you lead to problems with movement, early arthritis and pain. So what we do is prevent it worsening by putting a pin in it and you can see that these images are flipped. Um but a pin put in one side and then on the other side, uh this side because it's quite common to happen. Bilaterally, that side of the hip was prophylactically fixed to prevent it from happening. Now, one of the most important things in treating kids with orthopedic problems is trying to prevent something serious happening in the future. And I hope that's come across in the in the last few slides. One of the hardest things to diagnose and treat is infections in Children, both infections of joints and infections of bone, of not doing so has terrible consequences and this just highlights it. So this is a kid who presented to hospital. Um and the dates are there 26th of June and often, you know, it's not like taking a history from an adult symptoms on specific specific patients come in, you know, Caris temperature and can't localize their pain, but often they present with a limp and that's the only clue that you have to an underlying infection. So this is a patient who unfortunately, um had an an an unrecognized um septic arthritis of the hip and even to a non orthopedic surgeon, it's quite clear how dramatic the outcome was. So, going back on the right, this is a normal what appears to be a normal hip within six weeks, you can see flattening of the femoral head which which suggests collapse, which would be super bad infection. We then move another six weeks down the line and you can see a worsening of the function and move to January and the whole hip is completely destroyed. So this poor kid will have a terrible outcome with a likely stiff and painful hip for the rest of their lives. So, recognizing that early and intervening quickly will ensure this doesn't happen, um, with surgery and I'll talk about it a little bit later. Number one rule is do no harm and the art of surgery is figuring out who to operate on and who to not, but a bit of advice. And I'm sure most of you will come across kids with potentially infected hips or other joints for that matter. But, um, you will rarely be criticized washing out a hip which transpires isn't infected, but you could get into a whole host of trouble if you don't buy something like this. Um, I do some medical legal work in the UK and there are very, very few cases around, um, where people have been successfully sued for washing a joint out which didn't end up being infected. But a whole host of cases where people have just sat on hips and kids who turned out to be infected and the patients had a really bad outcome. So it's one time as a, as an orthopedic surgeon, you've got to be really aggressive. Now, the other thing worth considering in kids is dealing with parents, even though you're treating a child, it's dealing with parents. And there are a whole host of normal anatomic variants. Um, that it as an orthopedic surgeon you must recognize and reassure parents. And I could describe lots, but I thought this would probably be the easiest one and it's one of Bolick. So for those of you who've got kids, I'm sure you noticed early on that they, their legs seemed early on to bow quite significantly. And then over time, they became a little bit more knock kneed. And then finally, when they grew up, they looked at what happened, like what looked like normal legs. And so we see loads of parents who bring in their kids because they're worried about what looks like an abnormal, um, start in their legs. And your job is to recognize what's normal, reassure patients and their families and, you know, explain that over time they will get better and, and this is silliness curve, uh, on the left ear which shows the bowing of the legs over, um, uh over the 1st 13, 14 years of a kid's life and what can be considered normal and abnormal. So the ability to recognize that and know what is ok is fundamental if you're treating kids. But on the flip side, knowing when it's not normal is really important and recognizing diseases such as rickets or infections and injuries to the faces that lead to abnormal outcomes and treating people accordingly. Um is really important. No, the next thing I want to talk about which is uh lowering the mood of the conversation slightly, um is non external inj injuries. So as orthopedic surgeons, we regularly, unfortunately, um come across Children who have been the victims of abuse. Um and parents will bring them in with altered histories of falls so on and so forth. Um It's really important to recognize what types of injuries raise red flags. And this is an example here of a, a young child. And if you look at the ribs and you can see clear on, on the left hand side, also on the, on your the right hand side of your screen, but ribs that have broken and lots of callous forming around them. Now, this is almost patho mnemonic of abuse of a non ambulatory child and there are some other subtle x-rays or um, you know, of injuries that you, you absolutely must pick up on often. Unfortunately, parents who don't look like they would abuse their kids do. Um And those are the ones you got to have a very, you know, low threshold for, for calling it up. Um So something to bear in mind. So moving to adults. No, for those of you who don't recognize this, this is a hip replacement. So the two best operations um that have been invented in modern-day civilization are the hip replacement and cataract surgery, hip uh, arthritis is increasingly common mainly amongst Caucasian people, but it's debilitating and it makes people miserable, unable to walk, um, in constant pain. And if you believe the literature and you look at people's, um, outcome scores, it can regularly make people so miserable that they don't even want to be alive. Now, a hip replacement is, uh, cheap, cost effective way of getting rid of people's pain, getting them up and about getting them back to work. And it goes beyond that. You know, if you take a 60 year old person, uh, who can't walk because of hip pain, they can't exercise, their cardiorespiratory function declines, they can't work, they can't pay their taxes, they can't look after their kids. Um, so performing a hip replacement can actually solve all these problems. Um, there are millions of hip replacements going in around the world. Um, as I said, the, if you look at people's quality adjusted life years, um, it's one of the most cost effective operations that we can do that in cataracts. The problem is when it goes wrong. Um, and almost always it goes really well, but from time to time you can cause issues. So this is an example of somebody who had a hip replacement that broke and so we had to go back in and revise it and put an even longer stem and bypass it. And as an orthopedic surgeon, it's obviously horrible when you see that. But these are the juicy fun cases that, um, keep us awake. Um, it's not just the, uh, hip that can be replaced, I think pretty much every single joint in the body has a replacement for it. But overwhelmingly the most successful is the hip, um, followed relatively closely by the knee. And you can see here on the left hand side of your screen, an example of a knee replacement. Um, and on the right is probably the third best joint replacement, which is a shoulder. Um And I'm sure a few of you are looking at this wondering why that looks a bit funny. And actually this specific type of shoulder replacement is quite an interesting one because it's called a reverse polarity shoulder replacement where the glenoid or the socket has been replaced by a ball and the spherical humeral head has been replaced by a socket. Um And what this does is it improves the biomechanics of the deltoid and such that it medialize the center of rotation and makes the deltoid take over from what would be a deficient rotator cuff. Um So this is really biology meeting engineering coming up with an implant that's working really well to improve patient's function. We also do really big stuff in orthopedics from time to time and we treat tumors. So on the right hand side of your screen, you can see an MRI scan of the pelvis. So the sacrum is in the middle, it looks like some eyes there and on the, on the outside is the eye. Um And what you can see is a huge tumor that's invaded the whole of the pelvis and destroyed it. No, what you can, the x-ray you can see on the, on the, on the left hand side of your screen is what's called a hemipelvectomy and reconstruction. Whereas essentially we are replacing the whole of somebody's pelvis with um a replacement that inserts not only into the remaining pelvis, but also into the sacrum and the spine. So this is as extreme as it comes um in orthopedics. Um and you know, these are kind of 89 hour operations with huge risk factors. Um So if you've got the appetite for it, there are a few centers around the world which do these pretty successfully. Now, now, the other side of treating adults, of course, are sports injuries. Most famously, I'm sure you'll um recognize the anterior cruciate ligament. And this is an example of a footballer, an American footballer who, I don't know, I'm afraid twisting his knee rupturing his AC L um tearing your tl predisposes to you to um arthritis in the knee. Not that it necessarily means you need a, a knee replacement. Um But importantly, for sporty people, it also means that um uh participating in sport becomes very difficult because what the AC L does is it stops the back and forward translation of your femur and your knee, but also the rotation and so running in a straight line is doable, but the moment you try and twist and turn your knee gives way. And so playing field sports or any sports for that matter that involve pivoting and twisting becomes increasingly difficult. Thankfully, um we can reconstruct people's cruciate ligaments and I'm sure you all will know countless professional athletes who've had AC L reconstruction and got back to a really good level of sport. Um The operations can be performed as a day case and most commonly now is um well, in fact, what this image on the, on the right hand side of your screen shows is taking up part of the patella tendon um and moving it and using that as a graft for the torn cruciate ligament, um More people now will take um a part of the hamstrings and use that as a graft instead. Um And there are some people who even repair in cruciate ligaments, which is unusual, but um it seems to have had good results. Here's another example. So back to the shoulder and this is a, a dislocated shoulder. Um So the shoulder is an inherently an unstable joint and the benefit of that is you get a huge range of movement. So, from an evolutionary standpoint, when um we started standing on two ft and using our arms as arms rather than to walk on, we've realized that you can reach up and pick fruit from trees and now, this this instability of course has its downfalls. So the shoulder is the most dislocated joint in the body. Um And uh we see it most commonly in young men following sports injuries. Now having an unstable shoulder is bad for two reasons. Firstly, it means it probably will continue to pop out. Now, if you look at the studies, if you're an 18 year old guy and you dislocate your shoulder, the chances of you popping out again within two years are over 95%. Whereas in a, a female patient who's over around the age of 30 your chances of popping out again are under 20%. So I do this, we can treat patients and fix up the deformity or the, the injury as required. And but it's not all about sport. A lot of people who need their, excuse me, need their shoulders for their job. So people particularly in manual jobs and that includes surgeons and need to be able to lift their hand above their head without the threat of their shoulder dislocating. And so again, treating these patients with pretty simple, cheap and easy approach to do can be life changing. Um when the simple operations don't work, we also do really weird things. So um for those of you who remember your shoulder anatomy, the coracoid is a little projection from your scapula where the conjoint tendon and also the pic minor tendon attaches to. And I always find it funny how somebody came up with this concept, but two people did a French surgeon uh called LAA and a British surgeon called Bristol decided to take the chond tendon with a bit of bone and attach it to the front of the glenoid plugging in a bone defect. And that did two things. Firstly, it filled a bit of bone loss which helped prevent further dislocation. And because the conjoint tendon had moved, it now acts as a dynamic slit in helping to push the humeral head back into the correct position. Um And this is a really good way of treating people with um recurrent instability, even though it's a bit of a wacky idea. Now, trauma can get a bit spicy. I forgive this horrendous photo, but this is something that we're increasingly seeing and these are big nasty open pelvic fractures. Um days gone by, this is a life ending injury because an open fracture with um tearing of the rectum or vagina in women lead to horrendous outcomes for patients. But because prehospital care has improved so much patients survive in these types of injuries and they're coming to orthopedic surgeons for us to fix their pelvis. And, and we do crazy things like this where we're putting in a huge number of plates and screws to reconstruct the pelvis to put everything in the right position, save with the hip joint and lead to a good outcome. Um when I first started training pelvic surgery was done by a couple of people in London. Um, and it was pretty rare and, but your chances of getting that kind of an injury fixed were largely dependent on what hospital you ended up at. But with the formation of major trauma networks and trauma units, we're seeing pelvic surgery really um explode. And so these types of operations are being done increasingly and again, you're taking somebody who 2030 years ago would be dead to maybe 10 years ago with modern resuscitation techniques and good general surgery survive but basically not be able to walk. And to now these patients are being able to walk, being able to get back to work, look after their kids. Um So the public health side of orthopedics can't be underappreciated. This is another example of a type of injury we treat and this is a fracture dislocation of the forearm. So you can see both the radius and the ulna are broken and the ulna has dislocated um from the humerus, we fix this with plates and screws as you can see here. And I want to bring your attention to an organization called A O which is a European, I think, born from Switzerland or Germany. I can't remember what A O actually stands for, but they're a really great organization which pioneered fracture fixation and use really important principles and of biology and engineering to mean that we can treat these patients effectively. And so that patient had, he not had his fracture fixed would have basically had an absolutely useless forearm that wouldn't rotate and he wouldn't have been able to bend or extend his elbow. But with, you know, pretty cheap implants and relatively straightforward surgery, forearm rotation is restored. Elbow, anatomy is restored and these patients can get back to normality. Um I think that in this series you have a lecture on, on treatment of fractures. So I'm gonna leave this one here, but just wanted to bring the a a organization to your attention. And if you look on their website, there are phenomenal resources that you can use for treating fractures. Now, moving on to the elderly. Um and this hip back to the hip, which is um um probably the orthopedic surgeon's most um love joint um is an example of a hip fracture. And this is something we are increasingly seeing mainly because our population is aging. So these are graphs depicting the distribution of age in the UK and between 1966 recently by 2016. And what the expectation is in 2066 on the left, on, on the vertical axis is age and on the horizontal axis is um is the number of people. And you can see that if you just draw a line at around 80 held between 1966 2016. And the expectations in 2066 the population is not only going to expand but become heavily concentrated with people who are elderly. So in the UK, by 2030 we expect that half the population will be of a retirement age when the NHS was formed. Um, Postwar, there were half a million people in the British Commonwealth. In the whole British Commonwealth that were of a retirement age. By 2030 they will be 50% of the population of the UK alone. So the population is expanding and aging and having to deal with that is becoming increasingly difficult with elderly age comes an increased risk of hip fractures. And this is um a graph which shows that literally after the age of 70 or so, the incidence of hip fractures per 100,000 population takes a huge turn to the worst, more common in women because the bone is more sensitive to the hormonal changes. But um not that it's uncommon in men also. Now, what's interesting about treating patients with hip fractures is you have to get them up and about straight away. So if you take somebody with a hip fracture and you leave them in bed, they will catch chest infections, they will develop bedsores and their chances of survival are very slim. Even with the best treated hip fractures, the mortality rate at about a month is around 8 to 10% and around 30% a year. And this represents the fact that fragility fractures or hip fractures in elderly should be considered a failure of the bone. Like you get heart failure, kidney failure, liver failure, bone can also fail. So it's not because of a mechanical fall, how you or I perhaps would sustain a hip fracture. It's because people get old, their bone gets crappy and it breaks. The best thing that we can do for these patients is get them up and about straight away. And what this graph shows is that the survival of hip fractures is a pretty rubbish. But b if you operate early on people, people get them up and about, they do better. And that's one thing that we are um increasingly doing in the UK. And within the trust I work for, we actually now have a hip fracture unit where anybody who fractures their hip uh in our patch, which has a population of over 2 million, they will get sent to one specific hospital and we're doing 7 to 800 hip fracture operations a year to get people going as quickly as we can because as I said, that's one of the most important determinants of their outcome. Now, one thing worth bearing in mind with hip fractures is the anatomy of the hip and most importantly, the blood supply. Now, the femoral artery gives off circumflex, femoral arteries and these form an anastomotic ring around the base of the neck and send vessels up. Now, if you fracture it along where the curse is going on the neck, these vessels are disrupted, which means that the blood supply to the femoral head um is compromised and the femoral head dies. So even if you fix a femoral neck fracture perfectly, there is a good chance of avascular necrosis, a poor outcome and the need for further surgery. Whereas if the hip fractures further down between the trochanter because these vessels aren't disturbed, the femoral neck is maintained and people have a good outcome. So orth pods are simple creatures and life then becomes binary. So do we either replace it or fracture it or do we fix it? And so these are the, the basically the operations that we do on the left hand side of your screen, you can see a half a hip replacement. So compared to a total hip replacement, you saw earlier, we only replace the femur and we don't do anything to the ace tablet. And this means in people with low functional demand, they can get up, they can walk. It's a quick and easy operation. Um with generally speaking, very good outcomes. On the other side of the screen, you can see hip fractures being fixed. And so um uh where, where it is a, that's called a dynamic hip screw and B and an interim and dully. Now on the two kind of main ways of treating hip fractures, there are nuances of which we use when, but I won't bore you with that today. And interestingly, well, not interestingly pretty miserably. When a hemiarthroplasty goes well, patients get up and about and do well. But when they go badly and they dislocate or they get infected, the mortality thereafter rises significantly to almost 90% over the first three months. So when a hip replacement, uh for fracture goes wrong, patients die. So days gone by, it was an SHL or a very junior doctors operation where the consultants or the registrars would be off doing other things because it was so common and an easy one to do. But increasingly, we're finding that you got to get it right because it going wrong can lead to a patient dying pretty quickly. Now, this is the problem. We're seeing increasingly a little old Doris who's 85 years old comes in with a broken hip. We look at the x-ray and think, ok, half a hip replacement will do her fine, an 85 year old should be sedentary, but the demands of our aging population are increasing and you are seeing 80 90 year old people playing tennis going on long walks, hiking and giving them half a hip replacement doesn't really allow them to return to this level of exercise. So increasingly we're performing complete hip replacements in these patients and and having to manage their expectations. So I hope of kind of giving you an overview of the types of things we treat in orthopedics. I think that variability is what keeps um the majority of orthopedic surgeons happy. Um One day it's kids the next day it's adults, sports injuries, big traumas, you know, treating normal variants or treating the parents, as I say. Um, so it's a hugely fulfilling specialty for that reason. Um So I hope that's come across. Um just some things that I think are worth considering, um, from kind of my time in an orthopedics. But the first thing to says, not every patient needs surgery to just because modern medicine has developed answers to things doesn't mean that we can fight evolution. So most injuries, most problems can be treated um without anything at all being done to them and recognizing when to intervene and when not to intervene is really important. And our um uh and um PAC harnesses and the Poncet technique for treating clubfoot and dysplastic hips is a great example of where we've tried to meddle with operations, but actually simple and effective treatments are, are easy to come by. And of course, the same as trauma. So this is a, this is an x-ray of a kid's wrist. 10 year old girl who probably fell off some monkey bars and you'd look at this. And for those of you who can spot the fracture thinks it looks absolutely horrific and this poor girl definitely needs an operation. But three weeks later, her fractures in a bad position. Six weeks later, you can see the fracture healing up nicely. And two years later her, oh, her hand is almost straight. So the body has an amazing ability to heal these types of musculoskeletal injuries. She'd be stiff and she wouldn't have much rotation, but she healed up just fine. Um, cliched statement. But the hardest thing about being a surgeon is knowing when not to operate on people, it's knowing who will do fine without surgery, who importantly will have a bad outcome. And that's based on people's physiology, their biology, the pathology, but also even their mental health and their attitude towards surgery and recovery and rehab. Um And this doesn't just apply to orthopedics, it applies to any surgical discipline. This is another tool which can aid you particularly in fractures. Um And anyone who's going to work in an accident emergency or within orthopedics, I encourage you to get a copy of this book because it's a really good description of how you can treat common fractures without an operation. And having this in your army means that your ability to not operate goes up exponentially. So, um when we go through training in the UK, we, we are basically told to buy this book and read it back to back and commonly get examined on it. My next little pear is not to pathologize normality or aging. Uh And this is a concept which is becoming increasingly important when we get old, we get arthritis, it's normal. It happens, our bodies weren't designed to live to 80 to 90 to play tennis at 90 years old. And when we lose our cartilage and develop that arthritis, it is a normal part of life. It's a normal part of the aging process. When we pathologize it, when we make it into an illness or a disease, people want treatment for it when otherwise they wouldn't want to. And actually, quite commonly when people come to terms with the fact that it is, you know, things like arthritis and tendon and muscle injuries are a normal part of the aging process. They feel they, they need to treat it less. So, you know, it sounds like a bit of an odd statement, but it's important not to pathologize everything. A great example of that is rotator cuff tears. So I'm a shoulder surgeon, I deal with a lot of tears of the rotator cuff. And if you look at the, the incidence of cuff tears in the elderly population, it is extremely common. So Bruce Willis is 68. Now, 30% of people in their sixties will have a rotator cuff tear and not know about it. Elton John is in his seventies. So 50% of people in their seventies have a cuff tea and don't know about it. And Morgan Freeman is in his eighties, 80% of people will have a cuff tea in their eighties and not know about it. So, detecting a cuff tea is not a pathology, it's not a trauma, it's not a disease. It's normal if it becomes a problem. Yes, we can do something about it. But that mindset is an important thing to overcome for your patients. The next thing is about not under underestimating the burden of Mr Sk disease. And I've, and I've touched on this already, but it's really important to know that treating people with musculoskeletal disease is cost effective and a huge benefit to society. So, if you have a, um a manual worker who has that horrendous forearm fracture, you're basically meaning that he cannot work for the rest of his, you know, adult life with that arm, but treat it with a simple operation which is relatively cheap compared to other operations. And people will have a good outcome and that works the same with hip replacements with knee replacements. We're treating spinal deformities. Um The biggest killer of people in the western world under the age of 50 or under age of 30. Sorry is trauma. So investing in trauma resources in, in a, in a country again, can have a really big impact um into morbidity and mortality. I am I sit on various committees um in the b way from which I'm here. And one of the messages we try to plug to governments to official listen to us is this very thing. It's very easy to plow resources into diseases which are well, I forgive me for saying, but sex, things like heart disease and cancers, which of course are hugely important to society. But in terms of cost effective treatment, you'll find it hard to beat orthopedics, something a bit more anecdotal. But whenever treating patients with orthopedic disorders, you're going to get an x-ray. But it's also always important to get two views. One x-ray is never enough. You must always get an A P and a lateral. And this is a good example because if you look at one snapshot picture, your mind will determine the outcome. When actually if you look from a different angle, you can see that what you expected at first wasn't really the case. Another example, this lioness is eating her cup, but she wasn't just carrying it. And this guy is on the loo in the middle of a shopping center, but he wasn't, he was just on a massage chair. So whenever you're treating patients, always make sure you get multiple x-rays. Um Last thing to say on that notion of MS K and burden of disease prevention is always better than cure. So, in an aging population, which is becoming unhealthier and fatter, stopping the development of arthritis is important, stopping car accidents with better regulation is much better than treating the sequelae of it. And I think as orthopedic surgeons, we've got to remember this and appreciate the fact that there is a public health burden um associated with musculoskeletal disease also. Um So that is the end of the presentation uh which is uh timed. OK. Because we've got 10 minutes or so, um, to answer any questions if anybody has. Um, so I'm not sure if anybody wants to a message, uh, into the chat. Um, uh, all the moderators want to jump in. There's nothing in the chart currently. So if anyone wants to write a question, I can read it out in you instead, or if you want to speak up, you can raise your hand using reactions done silence. Uh Someone has said thank you in the chat. But uh, ok, no questions so far. Um Does anyone wanna speak up or shall we leave it? Uh Right. Everyone's saying thank you so clearly. It was so good that there were no questions left to ask. Bit of a vague topic, but I hope you've enjoyed it. As I said, I just tried to give you a bit of a snapshot about the kinds of things we do. Um, happy for my email address to be shared. If anyone's got any problems interested in coming to the UK um to visit or, or work here by all means, reach out. But um, would you be able to write your email on the chat, please put it in now? Thank you. There we go. But otherwise thanks for your time, everyone. Thank you very much, Doctor Cheers. Bye.