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OK, so, good evening if you want. So we start um our January monthly Journal club under um Egyptian Orthopedic Association and Ortho. Uh we have two hot topics today. So we the theme uh this evening will be arthroplasty. So we're speaking about uh management of Nick Feur and Ali will be starting to tell us, shall we do a total hip replacement of he arthroplasty fracture? Nick Femur and his lease. Uh uh Good evening everyone. Um Thank you for inviting me and allowing me the chance to speak about this topic. I've been asked to put uh present um this, this study about neck a feur mister has said, and I wish I can tell you an answer. And so far, uh There is no steady answer to this question. Um So the, the, the, the, the title of this paper is Total Hip Arthroplasty or Hemiarthroplasty for Hip Fractures. And this is a um uh an article that has been uh published in the New England. Your Novel Medicine in December 2029 sorry. Uh 2019. So, just a quick background. Uh we all know that hip fractures are represent a major health burden to all health systems um across the world. Uh The health system is, is faces a lot of hip fractures every year. It is estimated in the UK alone. There is about uh 76,000 hip fractures annually and this is from the NA National Hip Fracture Database. Um is also estimated about 70,000 in England and Wales annually only. Um Also we think that above the age of 51 in three women and one in five men will sustain a hip fracture. A certain at, at in a in a in a given point and and therefore it is a major issue. Um and sorry, so sorry for interruption. Uh You are sharing your screen, you are going through the presentation because it's still on the first page. Oh, all right. OK. Yeah. So I moved to the second one. Did not that show. No, still on the first one. OK. Can you see that now? The second one? OK. You can start uh just a slide show. Yeah. Yeah. Thank you. Mhm. Now can you see that that this this slide? Now the background slide. Yeah, I can see it right. OK. And, and as as any any big major issue uh or major health problem, there will be a lot of guidelines and a lot of recommendations and a lot of uh um policies and stuff and, and therefore in the UK we have the nice guidelines, we have recommendations from National Health uh from the National uh hip Fracture Database. By the way, it's a very informative website, it's a good platform. Um and it can tell you if you work in the UK, you can, especially if you work in England and Wales, you can uh log on and have a look at your own uh trust and see what they are doing in terms of parameters, the goals achieved and the recommendations and all of that. Sorry, excuse me. Um And every year they come, come with some recommendations and a report which details uh the the the uh the progress of each trust in England and Wales. So we know from the nice guidelines now that the main dilemma is the displaced intracapsular neo feur fractures. So not the whole, not only the hip fractures, it's it's a big issue but also the subset of the displaced intra articular intra articular fractures or intracapsular fractures. Sorry. Uh These, these are the one who can represent a challenge when we make decisions and um their, their uh the nice guidance in in in in particular in this area. They say that um in terms of the surgical procedure that is uh to be offered, you can offer a replacement arthroplasty in case in people with displaced intracapsular hip fractures, then they come to this point where they ask us to consider. So they are not telling us to do so, but they are ask us to consider to give total offer a total hip rather than a he a in patients who first able to walk independently outdoors, um, without or with one stick only. And then they added also that they don't have any comorbidities, condition precludes that surgery. But recently in 2023 they've added another line which I think sheds the light about the ambiguity of this problem, uh or ambiguity of this answer where they said that also are expected to carry on activities of daily living independently beyond two years. So if you think these patients are going to be able to carry on the D LS independently beyond two years, then you, you may offer them total hip replacement. And again, in the, the in their guidelines, the nurse says that it is maybe a good po point and uh to be uh addressed in future research, whether it's cost effective or not to use hip replacements, in particular, if you are going to use hip replacement, we know that many pa many surgeons prefer to use large hip, uh large heads um and do a mobility in order to add more stability and reduce the chances of dislocation as we know it. However, some recent studies suggested that functionally there is no difference, statistical difference between using normal small heads and large heads, albeit there is there is for interruption again, II think so still the skin is still freezing on the first stone background. Now, in our guidelines. OK. How about this one? Guidelines now? Yeah, guidelines. Nice future research needed. Yeah, you need to share the whole screen otherwise it would be the same problem every time. So share the entire screen so you can make it a slide show, then you can go through it. So OK, so I I've re now I've stopped sharing and then uh tried to share again and it wouldn't so share the entire screen but it's not, it's not letting me share. It's not letting me share. Uh No one is for you. Uh So OK, I don't know what to do really uh present now and share the entire screen. OK? And then do that. We do this. I'm sorry about that. I really apologize but don't worry, share the entire screen. OK? Uh If you want, I can share it from my side and just fully order. Y Yeah. Yeah. Yeah, that's fine if you, if you would like to. That's fine. Let's check. Is that moving there now? You you can see it now. You, you can see my screen now. Um Yeah, I can see your screen now. Yeah. Yeah. Yeah. Yeah. This is the page you want to present now. Uh So if you go to five please and the the one afterwards. Thank you. No, next one. Yeah, next one please. Thank you. You can see the screen now. OK. Yeah. Move to my research. Come on on chair for a minute. I can see it now. Yes, ma'am. OK, you can start that right. OK. So what I was saying is that it is important now. So the future research of, of, of noise that suggest it is to look into that specific point. However, there has been uh in the literature, some some uh many meth analyses have been done and systematic reviews recently published to look into that uh that question and they, they, they agree in in many on many things, but there is some bias or there are uh some limitations to these studies and mentioning the details of the surgical approaches, prothetic choices, the surgeon experience, type of of the femoral fixation, all of these things can cause chaos to the conclusions and therefore um the ideal research. Can you next one? Next one, please? Yeah. Mhm. Now have on just a minute. Don't share your skin. I will share it from my side. OK. You have to do the entire skin otherwise you will never have a control. Oh, she had a daughter. OK. This one. All right, next one please. So this is just an introduction to the importance of this uh topic. And and therefore now we talk about the paper. So the paper is investigated by a group of investigator, investigators that call themselves health. Basically health as, as the North American really fascinated with abbreviations, hip fracture evaluation, alternative total hip arthroplasty versus hemiarthroplasty. That's, that's the group of investigators and basically they are a group of surgeons who look into um the alternatives uh uh in cases of hip fractures. Uh Next one, please. So the study design is that it is an International Multicenter study. Um It's an team. So it's a randomized controlled study but expertise based. So that's a di different to the normal randomized control. And I'll speak uh speak about that in, in a few minutes. It, it, it took place in 10 countries across 80 centers and the recruitment of patients were all across these centers and they were funded by the Canadian Institute of Health Research and National Institute of Health. Um Next please. So their inclusion criteria or their population where basically anybody who was above 50 that presented with a low energy displaced intracapsular neo feur fracture and they were planned to have a replacement. So it's not those who fell and they were thinking about fixing it or the minimally displaced and they think they thought, mm we're gonna fix it. Those ones are the ones who were thought to be to, to receive a replacement, a hip replacement, a sort of a hip replacement, either a hemi or a or a total. And lastly that those patients were able to ambulate prior to the injury without significant help of any other person. So they could use a stick before the injury and still qualify and can be recruited to the to the study. Ok, next one, please. So the procedure is, and, and the idea is uh that uh so what they did is they assigned those people or these patients to two arms a total hip replacement or a hemiarthroplasty. Uh and randomized them. OK. And uh this randomization took place in, in the main center in Canada uh online. And then they received the randomization and they go ahead with the procedure according to the randomization, they didn't specify what sort of hip replacement that you would receive or what sort of he so non cemented, cemented uh more block modular. It didn't say anything about that. It just mentions total hip or hemi a a minimization process occurred at the level of the centers that operating center. So the centers where, where they're recruiting the patients and minimization to uh is, is a process by which I didn't know that uh by the way before. Uh So it's a process by which you try to balance your uh or, or maintain a prognostic balance to your patient groups or treatment groups uh according to certain uh core varieties uh or, or, or, or, or variables. So basically, you know, when you randomize people, you randomize them according to the computer, it randomize them completely randomly uh to either arm of the uh of the trial. However, there are certain variants uh like age, prefracture, living settings, prefracture functional status. And uh there is a grade uh um that can play a role in your uh prognostic balance meaning that um for instance, if the computer randomizes too many people towards the arm of the total hip replacement, who have higher A SA group or higher A SA level, that could potentially have uh some sort of bias within it. Um Or many patients who were randomized to the hemiarthroplasty group who were having a, a very poor uh prefracture functional status. Um Even though it is randomization still, there is a bit of bias within it. And therefore, the minimization process is, is a, is a mathematical process by which you try to make sure that there is a trial of making sure that this randomization though it is randomized, it does not accumulate those confounding factors to one arm more than the other. Hence, you're trying to have this prognostic balance between them. Um So back to the design again, there was also blinding. So they blinded these studies, uh this study or this trial. So this blinding did not occur at the level of the surgeons, neither the patients nor the uh researcher coordinators. But it happened at the level of the final analysis, uh analyst um uh analyst who was analyzing the final data. So basically means that um uh the patients knew what they are going to have or receive either a total hip or a hemi. The surgeon knew that the uh the researchers who um recruited patients and then came, came back with the, with the, with the randomization result knew it. But more importantly, the ones who were Rando, who were analyzing the, the, the the data at the end point didn't know which this data belonged to a total hip patient or a hemiarthroplasty patient. And lastly, this is a, as I said, is a expertise based randomized controlled study which recruited 503 patients. So what is the difference between uh uh uh A B RCT and normal RCT? So, next please, next slide, please. So basically the expertise based RCT is is where you set a standard or a threshold for experience or expertise of the performing surgeons who are going to outperform these uh either the total hip or the hemiarthroplasty. In our case to a certain standard below which you do not recruit these surgeons, you do not allow surgeons below that level to operate on these people to operate on these patients recruited to the trial. And this is good in a sense that you don't have the bias that can come due to or occur due to. There is uh due to differ difference in the expertise of the performing surgeons and uh that avoids that sort of bias. Um Also it has a good ethical value uh ethical point in it because basically you get experienced surgeons who are able to do either procedure in a, in a good way in both sides. And these surgeons have no ethical problem to perform either surgeries when they under uh the question comes back to them. So if they are, the patients were randomized to do a to do uh to have a hip replacement, this surgeon is able to do the hip replacement as good as he would do the hemiarthroplasty. And therefore the, the, they don't have an ethical problem in that that and that also does um reduce the, the, the, the bias. However, it has a drawback as everything in the world there is, there is also a balance to strike there. So when you, when you get a, an expertise based randomized controlled study uh or trial, um uh you um uh you need, you need to be in a setting where you have more experienced surgeons and obviously that reduces the symptoms that you can uh recruit from. And secondly, uh you can generalize the, the, the, the whole um uh the, the the the results to the whole uh general uh public of surgeons. Uh because you, someone can argue saying that these, these expert experts are giving us these results. But how about the less average surgeon, what they are going to do? So there is a bit of bias there, next one, please. So uh and then these patients were seen at week, one week, 10 and eight months, nine months and intervals until 24 months have passed. Uh And the follow up is either in person or via telephone. Next one please. And, and basically there, there are endpoints. So the the the main endpoints or the what we call the primary uh outcome measure is return to theater within two years for any unplanned, unplanned secondary secondary hip procedures. So that was the main or the primary outcome measure or the main endpoint. The first primary endpoint is to look at the number of patients who returned back to theater to have a secondary hip operation which was unplanned within the first two years. You, you can name it. It can be an open or closed reduction, revision, wash out spacer insertion, uh soft tissue excision of ho fixation of a fracture, fracture implant adjustment, et cetera. The secondary outcome measures were the number of deaths, the serious side effects that ca uh that occurred with with each procedure and the hip related complications and the function outcomes. So, function outcomes were assessed by the Walmart score, the uh European quality of life five dimension score and pain management, pain scores by the visual analog uh scale and uh time up and go to school next one, please. So what did they do? They did the uh to start with? They did a, a pilot study at 2006 which gave them an idea about the sample size that they should have. They started with a big sample size but they managed to use it. So and therefore they were the, the the the the the the the the best sample size would be um 1434 patients with 717 patient patients in each arm. And they used a, a pro proportional hazard model to judge or anal analyze the primary outcome. And you use the Kaplan Meyer curve for the primary endpoint. So for those who do not, not familiar with the Kaplan Meyer curves, uh and if you are planning to do the FRC S exam, you should, you should know that by heart. Really. It's, it's really important question, the exam, it comes in part A and part B, I've had it in part A and part B myself, but there is some sort of a survival analysis basically. So you, you, you, you have, it tells you the survival ship of uh an implant most of the time or um let's say people in this case, it will be the survivorship of a total hip replacement versus he arthroplasty. And how, how long do they survive within a given period of time um over a period of time or it could be a life period of time. And this is usually what they use to determine the uh the, the uh the longevity of, of an implant when they, when they give it um a 10 star or whatever the, the, the scale that the, the, the score that they give it to the implant. So the Kappa Micro curve is based of that and uh studies and uh or shows you the survival ship of an implant over the other. And they used that couple of mild curve mi curve for the first uh for, for their primary outcome analysis next slightly. So what are the results? So the results uh basically the between the, so they've recruited, recruited 100 sorry, 1495 patients to start with. And then this number has reduced to become one h 1 441 patients that were included in the final analysis of this study that was further subdivided into 718 patients who received total hip replacement and 723 patients who have received hemiarthroplasties. Um The number the fine, the the number of patients who were um uh uh able to survive or uh live until the final analysis was uh one hun 1243 patients. So they've lost 11, 198 patients died during follow up within the first two years. And 85% of those had avail available data for the primary endpoint analysis, which ba which to reiterate again was the number of patients who returned to theater for an unplanned hip procedure within the first two years. Um Looking at this, this um uh table there which includes or shows you the their demographics uh of their patients. Uh quickly 70% were ma uh female and 80% were were above the age of 70 74% were able to ambulate without any assistive device before the fracture. And 61.4% of their fractures were subcapital neo femur fractures. Just a quick observation that I've observed from their table. No, I'm saying it is statistically significant but just an observation that the number of patients within the. So all of these patients sustained the neck of femur fracture. Yeah. Uh and they have comorbidities but the most common comorbidities, comorbidity to exist within those patients where high BP and heart disease. So if you look at the, the lowest bar or the lowest line of their demographics, you'll find that about 400 plus of each arm of these patients had high BP had uh and 250 around 250 of each arm. So that means about 500 had heart disease. Then the third common common morbidity was diabetes and the third, the fourth one with lung disease and osteoporosis. And this is just an observation of mine. It's not, it's not something that, you know, uh uh s statistically, you know, significant. Just an observation. Next, next slide, please. Yeah. Oh yeah, sorry. Uh So heart time is very tight. Yeah. Yeah. Yeah. Ok. So as, as a also from the results, we know that we have about 7.5% crossed from the hemi to total and about 2.9% crossed from uh hemi to total hip. But that was not statistically uh significant coming to the results. So the results are or show that 7.9% of the patients who received total hip replacement did come back to theater for a secondary hip operation within two years. Whilst those who have received hemi 8.3% of them had to come back to a secondary procedure within two years. Ok. Next slide please. And this is, this is the Kaplan Meyer curve. I'm not gonna through, go through it because of the time. But basically what I want to say in this Kaplan Meyer curve of them that there is a, a bit of a change. So in the first year, up to the first year, the the, the, the, the he arthroplasty, I would say we were doing better. So uh in terms of return to theater, whilst the total hip replacement were uh doing worse. So they, they had a higher rate uh rate of going back to theater within the first year. But after the first year, the, the, the, the there was a flip. So the total hip replacement plateaued and they maintained an, an um a lower incidence of going back to theater following the first year. And the hemiarthroplasty start to creep up and to return to theater after the se uh within the second year after the first year. Next slide, please. If that makes sense, I hope that makes sense in terms of the secondary outcome measures. Um The, the, as I said, uh they lost about uh 198 patients died um uh uh during the follow up. Uh But there is no statistical difference between the uh death rate between total hip or uh hemiarthroplasty. Um in terms of the serious adverse events, they were higher in the total arthro uh total hip arthroplasty group. However, that not represent, did not represent a statistical significance. And over lastly overall, um uh complications were, were more frequent in the total hip replacement uh group. With the mainly as we know, all I would expect the instability or dislocation is the most common uh problem. Uh Four point f uh 4.7% in the total hip replacement in comparison to 2.4% in the I arthroplasty. Next one, please. Um uh the function assessment tests and the Walmart score were consistently higher in the total hip arthroplasty group. So you can argue that the total hip arthroplasty group did better in terms of functions of physical and mental scores as well as pain scores. But again that on the statistical significant significance le level was not uh important. Next, their results, they compare the results to others. They are slightly different to multiple me analysis that showed that the the the return to theater is is lower in the uh total hip replacement groups. But that could be due to the fact that their study is short study. It is within the first two years only. It's not uh uh a longer period of time and that might represent the, the, the difference between the meta analysis of the others and, and their, their, uh their study next, please. And what, what was similar to theirs is if you pull out the data from the Australian Joint Registry, uh which has about 17 to 8, about 18,000 femoral hip fractures over a period of 16 years, we know from the, from their data is that uh after two over a 10 year period of time, the uh revision rates are similar for hemi versus total, right? And also in, in Scotland, they had a uh um a, a big study, multicentral suggested that there is no significant difference within the two years period of time between hip total hip replacement and he arthroplasty as well. So what are the strength of the study? Obviously, it is an expertise based RC that there was randomization. It was multicentric. It has uh it had a large sample size and uh the, the referees or the uh judges for the primary endpoints were uh were independent. So they were not involved directly with the trial. The the the limitations that the blinding as I've explained before was not fully. So patients knew um uh surgeons knew about the what they are going to receive and that can ha uh ca cover some uh bias within it. They had about 15% loss of follow up within uh at, at, at the primary endpoint. Um Also um data of fun of function during the follow up were incomplete in, in, in uh at the, at the first two years. And they had also, and lastly is a short period of follow up next, please. So in conclusion, uh statistically, these finds that were not significant enough to draw a conclusion that one is worse than the other and, and therefore, and independently ambulating patients with displaced neo femur fractures. The incidence of secondary uh procedure within the first two years does not, does not significantly differ between a hip replacement, a full hip replacement and a hip arthroplasty. Um That's it. Thank you. I hope that uh I give you a bit of more questions. It was really great. Thank you so much. Welcome. So, any questions guys, so you can put in the chat and we can answer it. So her side is very, very common. So all the people who um who's doing arthroplasty or hearing the people who are dealing with, make a femur fracture. Um This question is a difficult question to answer. Um The bias will be there all the time because there's a lot of surgeon decision which doesn't follow the evidence. Um There's a difference between the graph guidelines between the nice guidelines and it's, it's, it's this always uh it's nearly every trauma um MDT and every trauma handle. Exactly. Yeah, every trauma meeting in the morning. You'll have this, this uh debate practically. Yeah, practically it is unfair um unfair for active um whatever the age we don't care about the age but an active person to give them a hemy. So uh the hemi at the end of the day. Yeah, is, is a valid option is very, more safer than the D hr but still the patient who, who deserve a good function, it deserves ad R uh regardless all of this, all these trials are still uh ignoring the cost which is all the uh energy is about. Yeah, but yeah, but it's a, it's a, it's a very good nice lighting of this problem. Very well done. I thank you any questions guys? Ok, great. How much reading? So Hamed will answer uh the second question. If we're doing ad R or a hemi, will we, will we cement or go for cemental? How much? Yes. And on the second limb of he also blasting not total. Shall I show my screen? Yes, please, but share the entire screen, there's no option for sharing a team home it down just beside the video will be present now. So see where the video down or go to. Yes. Yeah. Can you see my spin now? Yeah, just make it slight show. What, what now it's coming in the Yeah, perfect. Go ahead. Ok, so uh good evening. Uh Yy. Uh Thank you so much for giving me a chance. To present to tonight. Uh I am Hamed Mahmoud uh specialty doctor at work hospital. Hopefully over the next 10 minutes, he will be presenting a me analysis of randomized controlled uh trials on the effect of cemented and uncemented uh hemi in the neck femur function and daily. So we just will be focusing on the second uh control t that highly mentioned. I will not add much for the back go. Um I think for all those uh colleagues working in UK, one was that the neck or feur fracture is almost the common in that we see every day, rough estimation in the UK is about 7070 hund uh seven hip fracture per year which cost over 2 billion lbs. And I think this is the same situation in Europe and even in USA um with aging was more osteoporosis. Was he mo patient with? He also blasting? As ali mentioned is one of the like standard ointment for the elevation? Of course. Uh If you are saying uh total type also blocks would be the other or an capsule neo feur fracture. And this is the main intention from this meta analysis is to find and to assess the effect of using cement or uncemented type of fixation for the hemoblastic. Uh just focusing on this elderly patient with necro feur uh and by my focusing of mortality uh rate at one year and to assess the also for the other possible uh complication, uh which could be like an operative fracture or even postoperative fracture and other complication like infection and the systemic complication that we will go through for the methadone. Uh It's a, a meta analysis of uh well designed randomized controlled trials uh to ensure high quality uh evidence. And they have fo followed the uh a uh 2020 statement which is the preferred to aborting item for uh system for systematic review and meta analysis for the software. During their analysis, they have used uh for uh 45.4 and um uh tri sequential analysis uh 0.9 for the selection criteria. Obi uh again, it's randomized controlled trials, population even her fracture underwent of uh helas. So the main intervention that you were cemented uh to 10 I and for the second, the other medication like flu or infection or uh problems, do you look at? The data is mainly through the midline in base uh history and the clinical trial, glucose and the eyes are uh CTN nausea uh as well. The uh BP, they look for all the um randomized control trial over five tickets. So from to 2023 and there was no language restriction just to make sure that that there's a global presentation of initially, they have identified over 600 study on trial which ended by just her uh one control included in the analysis uh and overseas house patient. The reasons for exclusion was whether it is uh duplication studies or um it does not meet the uh the inclusion criteria or even the follow out of the study available. Uh This is just enumeration of the um name of the status, including the number of the uh of the patient in the cemented and TED and the E as we can see most studies from the UK and from you and one study from USA as well for the primary outcomes, the assess of the mortality rate at one year for the cemented group, those uh 244 death per 1000 patient and was quite the uncemented. So it's up to 81 the 1000. So the risk ratio here 0.87 and 95 constant from 0.77 to 0.97. So the overall effect adhere from the first uh plot the diamond shape on the cemented uh group favoring uh you mean to decrease the mortality rate and the um B value uh was less than 0.05. Uh So those clinical uh signi statistical significance for the second outcomes. Uh again, then we're using the cemented uh hemi should decrease in the risk of enteral o and post uh fracture and implant loosening later on, but did not show it didn't show any significant uh different uh and the other complication like infection with a deep or superficial dislocation or other issues like a chest infection, blood clotting or uh even duration of hospital operation. During the analysis, they have divided the uh main uh patients to subgroups according to the age, according to the sample size and the publication rate and even they have excluded the trials was very small number of patients and the other with very large number of of uh patient. And this has not changed the outcomes from the meta analysis uh so quickly going through the strength of the study, it's uh short comprehensive analysis. So it's highest level of evidence. I mean, it's analysis of what designed uh control uh talk and they have the uh great or rating of recommendation, assessment, development and evaluation uh just to generate uh the absolute un question of the outcomes. Uh during the analysis, they have uh used the uh sequential analysis which was performed to exclude the type one errors and to, to add more accurate for the outcomes of the meta analysis there some limitation. So they did not account the involvement in the cementing technique. Uh As I mentioned, the study included five decades. And of course, there's a lot of change in the cementing during these five decades. This study is just applied for the neo feur fracture in a daily patient and the average age was around 80. So it's not applicable for younger patient and of course liable for the uh elective patients. Uh They did not account the location uh bias because by the end of the inclusion criteria, they have included only 13 randomized controlled trial. So it was quite difficult to assess for the location bias as well. So for the uh discussion uh cement fixation, um both that it has reduced the mortality rate at one year and it has reduced some implant related complication. It should uh results on terms of the infe for the infection and for the other systemic uh complication. Uh and act is recommended for using cement uh fi type of fixation. And he also blasting in the patient with neo feur fracture and it is due to risk of an O and post a fracture, as I mentioned. So take a message from this meta analysis uh cemented and also reduce the mortality uh rate at one you and to use uh some other complication and it has added another support uh to use the cemented Islas in comparison with the uh uncemented also blasting. I hope this was quick and clear on evidence. Perfect. Thank you so much. Any questions? Yeah. Very nice and informative guys. Keep your questions. Um all your questions in the chart so we can answer it. Uh So Ahmed is asking any comment on cementation syndrome, implantation syndrome. No, they didn't specify any uh um cement related complication and the and they did on that. Yeah. Yeah. And this is a, a part of the weakness. So they, they look into the good side only. So the bad side is implantation syndrome. And with uh it's, it's, it's a balance bet between be because with such an uh elderly patients. Yeah, the bone quality is not that good. So risk of fracture is there. But on the other side, they are frail patient, very high ac. So they are they are at higher risk of getting implantations in the room while you cementing. Uh This doesn't say that the cement is not is is yeah, cement is still the gold standard. So for above 65 still cementing is um is the best option uh if uh avoiding any intraarticular, any any operative, I'm sorry, intraoperative fractures and good functions. Uh Any other questions guys. So the nice guidelines support that. So the study is it just enforce it, the nice guidelines which supports uh cemented over uncemented hemi. Uh And this does make sense because yeah, cementing. Yeah, gets you away from intraoperative fractures and give you a good, more good results. Patient is walking day one. It don't depend on the bone quality by any mean, even if the patient has uh um any problem still cementing can solve this for you. And it gives you the option to use different sizes of the stem. Um For especially for the for the slim patient, the sle small patient, if you, if you opt to use the uncemented, you will end by using a small size which which the evidence showed that it has a higher risk of loosening. So, but with cement it, if you even need to use a 35 5, you're still safe to do. So I think practically the B is very good, enforcing a a really a good idea. So, and I think all over the UK, this is a normal practice. So the normal practice all are doing cemented hemi. So any comment guys, even if no question, if anyone have any like uh experience something to add to this. Uh Can I just say that adding to your first point, Mohammed is uh when you mentioned the cost effectiveness as well, I think noncemented um uh implant, hemi arthroplasty would be more costly uh costly to these cases, of course, uh as well. And, and not to forget that these patients have sustained low energy fractures and, and uh that is due to poor bone quality. So you're, you're trying to, you know, rely on this bone quality, this poor bone quality to get osteointegration and, and uh osteo and, and, and bone growth. And again, that defies the logic to to it, to my, to my opinion. But again, as we say, all that is uh this is why the there is, there is a research uh you all the research helps to help us to sometimes uh answer some questions or even ask more questions. But uh uh uh at least it sheds more light on, on things. Thank you. Yeah, regarding the cost of of, of um I came across a recent evidence that the cost is nearly there. I've, I've asked myself before the striker people and the cost is nearly uh comparable because using two mix of uh of cement and the time you wasting because uh in, in Belfast, they operate the last P HS uh in Belfast, they operate six joints a day. The difference between cemented and uncemented in the operative time for them is about nine minutes. So nine minutes for six cases. So we speak of nearly an hour of theater time added to uh the cost of two mix of cement. This makes nearly the cement, it comparable to uncemented in the price. So I don't think the cost is, is is the main point but is is to give such an frail patient a safe and um and a and an operation with less complication is the main point, especially intra uh for these patients, especially the high risk patient, intraoperative fracture is a determinant problem. So I think uh of operated at 99 years old last week. So for this lady having an intraoperative fracture means she will die. So I think cemented is a safe option. Uh But the cost point as as I explained, I think is nearly comparable. Yeah, but you can argue also that this hour is, is gonna be uh uh spent anyway with the current NHS. Uh Now that's why that's why blood is an example because they, they, yeah, they, they bay it by bay it by case. So that's why they do six twice a day. Yeah. So it makes a lot of difference for them. Another means another case. Yeah, that's not. Yeah. So uh surgeon and uh stuff, all of them are paid by case. So uh every minute makes a difference for them. But if you come, if you come, if you come to the conclusion, I think the cost point uh is nearly comparable in both cemented and uncemented. Yeah. Agreed. Agreed. Uh II think Hamed, if you didn't count that the patient who was having uncemented, who higher risk of interoperative fracture or even postoperative fracture, they will come back to theater and will have another operation which should have more cost as well. Yeah, Mohammed is asking a question regarding the outcome is the difference between hemi bipolar and Thompson. Uh I don't think uh Hamed has had the study went through the types of hemi. No, I don't think so. Yeah, not, not, not really. They had like very specific outcomes. Primary outcomes was uh mortality at one year and second outcomes a fracture or, and, or the infection. But they didn't like focus in a lot of points. As you are saying, the cement generation has been used. Uh which generation, what type of implant? No, they didn't go through all of that. Yeah. Uh But I think guys even, yeah. So from the point they are looking uh into so the locking interoperative fracture and postoperative complication. Um And I uh my, my believe in, in 2024 this all of them, this, I don't, this is some areas that still operating in Thompson. And I understand that and, and uh a more but I think most of them are, are, are doing either or um extra unipolar. So um and I don't think this is the point we were looking into, they were looking into the complication, especially the interoperative uh fractures and the complication, postoperative. So, um and I think this is the same way the nice locked in. So a lot, a lot, a lot of evidence in this point, but I don't think there is a lot of in there. All the people agrees that cement is a safe and effective option. OK. Guys, if there is no more question, we should come to a conclusion. So, uh thank you so much for attending and we uh promise you of, of, of every time of a AAA hot topic to discuss. So, uh Mohammed would be preparing for us another hot topic next month. So what do we have next month? It will be upper limb. So uh we will be uh uh Romi and me will presenting the next two. Perfect. OK. So uh next Friday of February, we'll be discussing uh a limb. Um 22 novel papers, very well structured evidence and you'll get something from it I hope today was uh fruitful for you and you'll get something from the two papers much for our presenters for Ali and Mohamed. Very well done. And um wish you all a good evening and see you next month. Thank you everybody. Ok.