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we can see your screen now. Oh, okay. Let me start. Osteonecrosis of the family had was first described by French a surgeon almost 200 years ago. Since then, the disease has been called as the vest clinic rhesus who are ischemic necrosis. However, I could recommend the user osteonecrosis. The disease involves young and middle aged agent adult on the incidence is increasing in a couldn't with increasing use of a starter for Logan transplant patient on. But you want to carry a therapy for leukemia patients in the United States and South Korea, we have more than 10,000. You patient every year. Yeah, I heard you have more than 1000 your patient every year in the United Kingdom. I've been a member of our course since 1994 and I have publish it. Six people papers about us, the necrosis. Today I will talk about it. Urology. But the genesis. That's where history I cook. Lesbian could criteria with steroid and I'll call associate osteonecrosis Do aqua staging system classification system off size in early stage or so necrosis on treatment. I prepare my turf to my best on. I will be happy if you enjoy it? To understand the pet official, you shouldn't know too important concept. The first one, the disease is has multiple really itchy ology Jack defectors on exposure to respective such as alcohol and strike. They played through it together in the pathogenesis the second the first event in the Meadows place Not inside the best. This is the reason why our could he commends the use up osteonecrosis in step off best clinic OSIs This is a normal marrow, right? Robert? Cells fest cells in the marrow space on small doc cells. Tomato point it sells. This is the marrow patient who are treated with steroid. What is the difference? Just cells are swollen or must doubled in volume. And there's no, um, atopic cells. Yeah, this is our scripts. Intravesical A coagulation, of course, is which is followed by, um, Ischemia. Med office cell Die within several days, usually a thrombolysis and angiogenesis. Because the ischemia and the giving legions not progressed to osteonecrosis. However, when the patient has defected with normalizes and or impaired angiogenesis, the skimming legions progress to osteonecrosis. Oh, pull on the injection by several days. These to bond us on also size completely disappear from the like mom within several weeks and then her sickest from his form. Dad ball. It is not our body anymore. It's a kind of foreign body and footing body duration. Hookers around the the bomb, forming a fiber attention scepter appears as a band. A lesion on MRI. Definite diagnosis of us, a necrosis made at this stage. The data bonus reek of fortical fracture because usually at the suburb of the contract fortune and this is a fracture appears as a crane sign on X rays. Then family had a collapsed on both osteoarthritis of the year. Now do you have Oh Chris the first decorative reasons. Growing size like a tumor or second the size of necrosis does not change. You turn this correct. This is the answer. The legions size. That's not change with time, sec and natural history. Small legions, too, not collapse even without an intervention. Yeah, most of a lot of religions are progressive to collapse A with a family hat on, so scan arthritis of the hip. So I tried to treating us a necrosis the size of the neck with portions doing better it on the MRI. There should have been no treatment in small leaders. Five years ago, I called Mai cholesterol, Asian criteria or steroid induced osteoporosis. Um, call in just necrosis. If a patient have a history of, uh, steroid use more than 2000 mg, or PT or actually we don't durational three months, and the A certain courses was diagnosis within two years, then the patient can be doctors as having, uh, steroid induced or two necrosis. Likewise, when the patient has a history of alcohol abuse, more than formula litters off at, um, a poet for more than six months on the disease was detected within one year. Then the patient can be diagnosed as having on alcohol induced osteonecrosis. Next topic is new. ICoast aging. The order to knock your staging was made in 1994. Well, most 30 years ago. It was based on Ficker. Staging goes that the vicar will see a founder off our car. Three years ago, our co revised the staging system. Stage one exploring that out there. Yeah, on the MRI shows of vandalism stages to X ray shows scleral the green three, a Onley collapse less than two millimeters Stage three B late collapse more than two millimeter collapse. This is the stage off. No return state before was the arthritis of the head. Okay, Yeah, um, from that long I like to say about the cholesterol Asians systems over size. Currently, three systems are used first, one Steinberg, if they're religion are called the necrosis of volume is less than 15%. It is small. If we this between 15 to 30%. It is a medium sized. If it is a larger than through, the perceptive is a larger lesion. Second on the scope, um, metho they measure necrotic are on Medicare A and B to search for MRI's. They calculate the some to Akron Arts. If the sum is less than 1 90 in this small is, um if this between 1 92 to 40 it is a medium sized. If it's larger than to 40 it is a lot larger size leisure. The final one, these JIC Japanese Investigation Committee system they used to Not that I imagine off the necrosis. If the margin is media to one third of the video establish, it is a small lesion. If we dislocated between one third and to search it is a medium sized lesion. If the imagine extends outside the toother, it is a larger lesion. The new uncle system is based on the generously system. This is the apex of the family have. If the vaginal is media to this point, it is a small legion. If the Maginness located between the apex off the family, um latter actual was an established, um, it is a medium sized vision. If the Mahdi extends outside, the latter imagine, with a stable, um, the Xeloda later we intestine the reliability and valid itty of the system and more than 400 all the stage patient on We found that it is a very reliable and belly on our could recommends using this method as a unified. The question is your system for all the stations send a crisis. Now I'd like to talk about treatment Several medications were tried to prevent were trip as the necrosis and we're suffering step ins. This possible knees bother the lighter, such as well oppressed and aspirin. Years ago, we conducted a systematic review articles. During last 20 years, we found the known of medications were proven to be effective by convincing evidence and Most of them have side effects. So at the moment, no medications are recommendable. Quite a compression. It is not done in Korea and Japan. 30 years ago I conducted Renda. My skin got trial to evaluate the efficacy because the compression in terms off prevented collapse. There was no difference. It was not effective. Stand cell and 2000 to Dr Phil of Hunger in France is a very active member. Our society. Here you go to 534 years who which were treated with the stem cells 13% completely solution 69% reduction in size and the only 80% require the total about progressed it. So we are members were very excited, however, that clear from South Korea. He reviewed 128 hips and found no difference in the five year survival. Centrally, Doctor Young is a colleague of my reviewed 5 51 hips and city total 453 years from nine random, I think a try. Um and he found no difference between the stamps. I grow and control graphs. So stem cell treatment is not supported by convincing evidence. It needs further investigation. I am at the moment. Mint. It is not a commendable well tell to me we have a beautiful 113 years which was treated with osteotomy. Kanye Survivor was only a 63%. Yeah, older age on high B. M I appeared as a risk factor for the failure. This lady, 34 years old, was treated with osteotomy. This is 18 your full of X ray. There's a little collapse. She's doing very well without an 11 without any pain. However, another patient for the five year old gentleman his bm I was 29. He had a class on. He was treated with totally water plasty vascularized bone graft. It is technically depending it is associate with donor side morbidities on on certain long term outcome. So, to my understanding, it is not done anymore. I have used to send me bearing since 99 A. I have a publishing through the papers about seven culture of arthroplasty On this is very recent study from our girl which appeared only this year. We reviewed the 400 that report for about a rusty which was done using elements and we bearing the follow up period was 10 to 16 years. Noise was noted in 6.8%. However, it was not a produce a ball on it did not limit the activity of the patient. Said I had a fracture occurred in two point of poor question or something. Fractures in Barbeque 28 doing Makashin MCA. There was no seven line of fracture. 16 year survivor was 96%. So the four year old gentleman. This is a 15 year follow Best way. There's nowhere. There's no little Isis Patient is happy. Another patient who was operated with Tony eight millimeters on the hat he had the sentiment had a ball fracture, which was revised in the study, which was published in 2008. We found that for the aid must hope my hat is there a risk factor for summer? Had a fracture. This is the cost surface of 28 minutes on the cat be named the world. So fist distance This distance was only a 2.4 millimeter and Shaun that hair. So all fracture occurred actress in push up. So do not use to on the eight million because shown that cat five years ago, we reported medium time was also felt that ceramic Totally What repressed? Really good. 286. Then sesame hips. The fall a period 5 to 7 years scale was note here in 2.4%. There was no seven. I had a fracture. However, once said, I'm lying. A fracture. Okay, this gentleman where the bilateral advanced was the necrosis this a 70 or fall over this way? Nowhere know what's the license? Another patient in this patient. Seven line of fracture broker At 10 months after the operation, this is the initial postop part of X ray. Be There was a step up between psoriatic liner on better shell. This means marketing over the salary liner however we missed. This is the obamacare can study years ago. Medicine Hell's have what you know Taper angle to contact with matching Linus. This anger is named by, you know, taper Angle. There are two kinds of taper angers and currently usable metal shells. One is 10 degree and the other one is 18 degrees. In the study, we found that tender e taper angle was associate with high risk Open my sitting and slime, a line of fracture so do not use can t we taper angle if we use the same bearing today are several studies reported long term results off Same Put our arthroplasty The survival was more than 95% at more than penny. A follow up decease. A very center study of mine, which was published in general about the press here month Just more month ago, we reviewed the 40 in studies which operated with height highly costuming. Good. Pull it to them at a minimum of followup. Kanye's accessible Where and fuckin possum was still licensed in a percent to summarize. Do that. Um, I first on classify the sites necrosis do not touch your small lesions. Do not try medical prevention medical treatment called the compression and stamp cell. What's still to me has a very strict narrow indication. The patient should be very young or younger than 30 years, and he saw her game. I should be a lower them. 24. When patient has pain class to a totally about the passivity use ceramic bearing or the use of highly cooks links to pull it clear. Yeah, and to not touch cholest Femara hat. If the patient had no pain. Do not use 28 minutes a show in the hat to not use 10 degree matter shots. Another issue is a square. Uh huh. Uh, this is a trident car from a striker. It is Pressure e with another baited women. It is associate with high rate over a script, up to 20%. So I do not recommend the user. But this a patient with the shots if you, uh, use, uh, some weight bearing and done your patient. That squat, cross length police line is not perfect. Not like long durable. They're associating with where and what's the less a long time next cycle meeting real behind and soul coming October. You guys are very welcome. Cheers. Thank you very much for a physical for your talk. Um, if you do we have any questions at all. Any questions? Just leave them on the chat box. Anyone from the audience have any questions for profit? Cool. What? I've got a question. So? So between the east and the West, we've seen a lot of core decompression is in the west, and it's is that east west divide type a practice or what's the What's your consensus So several studies. Can you hear me? Yes. We got it. Yes, as you mentioned. Cool. The condition is ah practiced in the United States and Western countries, and several studies reported very satisfactory. We just, uh by so men's, uh, you know, an ache in the stage up ischemia and all the collapse don't bone marrow edema, because on the liquid push in on bone marrow. Pre present is elevated. So quite the compression is ah, the compressor or high marrow present. So it is effective and terms. Oh, paints off site. However it is, it doesn't prevent collapse. So yeah, and, um, some studies which have showed very excellent results and flew in the class these studies might have some selection bias. That means the study environment, small legions, which she have a good natural history. So we're not, uh, quite the compression with you. Um, any other questions from the audience? It'll get. I know. Okay, so, um