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Yeah. There you go. Can start with that cup of coffee, Right. Okay. Well, I suppose firstly, thanks very much. Thanks for inviting me. It's kind of an honor to be asked to talk to the register, and it's always a bit stressful because, uh, because you almost you know more than I do. So, uh, So, uh, so the pressure is on. I've been asked by Luke and, um, has sane to talk to you about Well, the title of talking to change every time you send me an email. So we'll see how we gon I'm going to try and talk to you about native distal femoral fractures, uh, bit about paraprosthetic fractures around the knee. And then I suppose whatever anyone else wants to talk about, we can we can have a chat. So now all I need to know is, how do I move on? Okay. Click down there. There should be a little area. Right. Okay. So I know I've been around for quite a long time now, so I know a lot of you, but there's quite a lot looking at the names last night. There's a lot of you I don't know. So I thought I better introduce myself. I'm based up at the Norfolk and Norwich. I kind of I suppose, to consider myself And after a plastic surgeon. Um, my career has changed over the 20 years that I've been in orange. Um, I started as a kind of hip and knee revision surgeon. That's kind of tailored into becoming a revision knee surgeon. Really? Um, I currently a member of the Revision Knee Working Group, which is a national group that we can talk a bit about if you want to. Later on. I currently share the primary arthroplasty working group for the for Basque. Um, and I kind of consider myself a part time trauma surgeon. Really? I've been on the trauma rotor for 17 years. I've always, I suppose, had a bit of an interest in it, but I wouldn't put myself down as an expert trauma surgeon. So, um so I think these this talks of dovetails the to really I think if you're going to take on these sort of injuries, you need a little bit of arthroplasty experience, and I think you need a little bit of trauma experience as well, which is sometimes also makes them a little bit bit tricky yesterday. Um, So, as I said, I've been asked to talk to you about distal thermal fractures. Probably native distal for more fractures before anyone's got involved with them and then paraprosthetic fractures around the knee. Um, what I'm going to try and talk to you about, really, is I kind of thought that the other day that you a lot of this you can pick up a textbook and you can read about distant for more fractures. Um, and you're more than welcome to do that. I'm sure a lot of you already have. Um What I thought I'd try and give you is is what I've learned over the last 20 years. Really? Um, certainly things have changed. And things have changed because we've learned more about these sort of injuries. Things have definitely changed because implants have changed. Technology has changed. Um, and believe me, your life is an awful lot easier than my life was when I was a training. If you when I was a training, we fixed distal femoral fractures with DCs plate. But I don't know if any of you have ever seen a DCs plate but it's basically like a D H s, but it's a 95 degrees, and it was a pretty miserable experience, particularly with intraarticular or multi fragmentary fractures, because you really couldn't control what you were doing very well. So So one of the choices we now have implants that that kind of cope with these different, difficult injuries an awful lot better. Um, I'll tell you about how I approach these sort of things, have my thought process, how we talk about it. And I think one of the difficulties of lecturing on on fractures is, of course, that so many of these things are different and there are different injuries are different fracture patterns and there are different people. And your thought process changes based on what sort of sat in front of you. Um, and finally, I'm going to try to tell you about how I do it, and maybe that's different to how it should be done. But is how I do it so you can criticize me as we go. So, um, it's a huge topic. I'm not going to talk about all of this. When I was trying to put the talk together, I thought. Well, what? What? What can we talk about? And how are we going to do it? Um, native injuries in Norwich. We see an awful lot of osteoporotic fractures. So So I was gonna base most of my thoughts on that. Really? Um, those are different, too. High energy injuries. We can talk a little bit about those if you want to. Um, you know, converts. Well, I can. Well, i'll probably start with that just to exclude it. Really? Um, I'm not going to talk about pediatric knee injuries. That sort of talk in its own Really, Um, osteochondral fractures again is it is so specific or peculiar type type injuries, which I'm not going to cover today, but can do another time if you want. And then half of fractures, which again are very, very peculiar specific, which you need to sort of plan for, uh, And then on the peri prosthetic side, I was going to talk a little bit about sort of nature of the problem where we're going with that. And really, I suppose for you guys what's gonna happen in the future? Because And the world is changing. More and more people are having implants, but in, uh, that's changing what we're seeing. So, uh, so native digital firm A friendship. I'll get onto it now, that's a bit of a to longer preamble. Um, so So here you go. Here's my thought process. When a native distal femoral fracture comes into the trauma meeting, how are we going to set about thinking about these things? And I think that this this is really my process, that I'm sat quietly in the trauma meeting, thinking to myself as you're presenting it. Um, so So they're really, really simple things that I think start to send you down different routes of your treatment algorithms. Um, is it are you looking at intra-articular or an extra articular distal criminal friendship? Because that might just change your, uh, your initial plan. Um, as times have changed, I I am hearing more and more towards nailing these things because as the b we have said the whole process now of osteoporotic elderly patient's is trying to get them up and weight very quickly. And I think if you've got some sort of intimate gallery of device, you can almost certainly do that better than you can with with lateral medial plates. Um, the next thing that goes from my mind is which column If you think of the distal femur is two columns, the medial and lateral side. Um, which column is going to be easiest to get? Right, Because you really need to simplify all of it like any fracture. Really. Simplify the distal femur into getting the medial side right on the lateral side, right? And then working around what you've got left, just like you do with a tibial plateau, right? Um And then if you can fix one column and get a a stable fixation, do you then need to augment the other bit? Because you're thinking then of the pattern of failure, if you're gonna get these people up weight bearing on day one, have you got enough fixation, uh, to allow weight bearing to occur? Because in elderly osteo project fractures, they are going to fully weightbear if you let them put their foot to the floor. So I said, that's my initial kind of thought process. I'm going to dismiss this, okay, Because because you don't see many of these. So this is a unique on the fracture. I think This is, uh, possibly one of about three that I fixed in 20 years. So it's a kind of unusual injury. It's an unusual fracture pattern, but because I have been asked to talk to you about distal for more fractures, I thought I'd stick it in So you can see here. This So this is a medial condo fracture. Really? Really Again. First principles, simple fracture. Uh, reduce it. Um, and then we fixed it with screws going across from the medial and lateral side and a plate that kind of acts as a buttress to stop the whole thing shifting upwards. Um, so that is unique on the fractures. Don't worry about them. You'll probably never see one. Okay, so I'm going to take you back. So this is kind of where the story starts. Uh, I'm going to tell you specifically to this chap who who I saw back in 2005. My first weekend on call Just what you want. Uh, and I thought I'd start with him because this is really how things have changed over the years. We could talk all morning about high energy, um, injuries like this, and they are talking themselves. Um, and the reason for that is this comes with the whole caveat of things. Really? So So this guy had an open shaft fracture. I had a possible vascular injury and he had a tibial fracture underneath it. And all of those things before you even got to the distal femur have to be sorted out and organized beforehand. I'm not here to talk to you about 80 less and going through all that, but it's really just to add in that, you know, before you get to the distal femur, think of everything else first, Um, just when you think you know everything, things like this come in and they haunt you a little bit because because the first thing really is organizing which injury are you going to sort out first? Because you've got a kind of flail leg beneath a very, very complicated fracture. Um, like I said, that's a talk in itself. But I I thought I'd start with this because I wanted to sort of to show you my how my sort of thought process has changed over the years. So here you go. Um, So, as I said to you earlier, when When I started, we had DCs plates. That was about it around about 2000. Maybe a little bit earlier, these locking plates really came into play. So this was the original list plate, and I remember going to talk when I was a trainee. Check with Merkel Smith, who literally worked in Leeds, who showed these amazing distal femoral fractures being fixed with with locking plates, things that you kind of now reach off off the shelf. And they're all instantly available, too. And the list play was not the best in the world. But it was a start. And and the modifications that we see with the peri lock and the other things available have have already transformed on me, too. The reason why I'm putting this up and rambling on a little bit is because this goes back to first principles of how you fix the distal femoral fracture. Um, and it's kind of worth spending a minute if I just go back What? I was going to show you. So this is multi fragmentary. You can just about make out here. There is a half of friction here, Um, so if you want to talk about half of fractures we can do. Um, but hugely community metaphase sis intraortic a split up here and a shaft off the side. Um, so what did I learn from this guy? Well, what we learned was, um, fix the block first. So, like I said, first principles. So if you can, you need to restore the articular surface of the femur here. They're screws in here for the whole, for fracture. And there's a screw across here just getting that articular block back together, and then you're fixing the block. There's still funeral block onto the shaft. And of course, we use this locking plate to do that. You're seeing some way a lot of my exes. They get these peculiar screws sometimes. And then this is all about trying to restore one column of the of the either medial lateral side. So making one side of the femur simple, because this is a bit of a nightmare on this side. Um, so you'll see a few of these things. You can do that if you want to, but it just it's just the way my sort of brain thinks. I suppose we're trying to make things as easy as we can. The other thing I learned from this and again, a take home message is knowing what your implant does. And probably at this stage, 20 years ago, I didn't know what this implanted. And what I mean by this is if you look at that X ray and you look at the way the position of these screws here, that that is 90 degrees pretty much to the plate and you'll see what I've done because of the combination Here we fix this without really knowing where in space the block was. And what I learned is if I put those screws parallel to the joint here, that would not have tipped into valgus, which it has done. Um, So if you actually think about this, if you've got a horribly commuted block of the distal femur and you put one screw in here and it's not parallel to the joint, you're tipping them in or into slightly different alignment. Uh, and I remember Look at these X rays and thinking, uh, I've just done that. We've got it right. He's end up in a little bit of valgus and I could have used the plate to tell me where to put this block. So I learned that in 2005, and I still still use that when I'm thinking about things now. Great question. Because you'll be bored of me. Who was this? What implant is this? Mhm. There you go. You see, I knew it. Or diving, Uh, actually see your mouse. So you might have to, um uh, sorry. Okay, So what I'm pointing out is the tibial nail, because none of you would have seen this, I'm sure. So that is an unredeemed a Oh, tibial Now, which we never used again. When I when I was training, there was a huge controversy where as to whether you reme or not or don't re material now, it's, um, probably odd to think of that. Now, has have any of you ever seen an unring tibial? Now I'm down to sometimes do in femoral fractures where they're just so capacious that it just goes down. If they were still. So you're just putting down the nail. But this is this nail was designed to be put in a little hole of top and tapped in. And as I say when you're thinking about how you do these things for me. That was a great little get out of jail because we could make a little hole there once we open the knee, tap that down and you to be as, um, stable for you, then to go on to the distal femur, which would cost us the main event. So So the point of that case was to show you or to start thinking about what implant you're using, Um, and then what it can do. Okay, so this is my learning point. As you say, No, your implant. The the reason why I've put this up actually is because this is what Remy to do when we put plates on the natural side of famous. Um, yeah, The what I learned from this was that if you put this plate parallel to this shaft of this implant when you're doing prosthetic fractures, that will guide us to the vision of the place. Because when when you have an X ray like this is easy and you think, how can that be difficult? But when you're doing the operation, of course, you only see this very dis lend the plate and kind of getting or gauging way of putting this. It's almost quite awkward. Of course, we now use 36 image intensifier flashes, but it's just worth sort of thinking about how you're going to go about that, right? OK, so those that's high energy, um, osteoporotic, distal femoral fractures is really what it talks about. And and I can I think you can separate these right from the very beginning. It's 22 very distinct categories. Um, So when X rays go up in front of you, the the only thing you need to be thinking is, uh, is this a simple fracture or is it a commune ated fracture? Um, and the reason for that is if you've got a simple pair of distance, right? Not purposely simple distal femoral fracture. Um, I think you need to be looking at trying to get them reduced anatomically fixed, stable e uh, with, uh, construct. That's gonna allow early weight bearing if the community you're going to need to do more than what you would do with a simple and I'll try and talk you through that. Uh, so here you go. So it's a hip replacement, But but But when these X rays on the on the left hand side go up, um, you should be looking at thinking, Well, this is a relatively simple, straightforward fracture. I can reduce. Um, I can reconstruct on three cups in my mouth. I'm pointing to this as I go, but on the third x ray, if you look at the lateral and the medial column and if you can restore one column and you can immediately starting when I can start to load, bear this with a lot less metal work than I need. If I can't do and I don't know if you can see that which I wish I could point to it. Summer, Um, but you can see we've got bone loss on the medial side. It's on the lateral side where the plate is, Um, and that's almost irrelevant because your medial columns intact. So your media economy's doing the work of a medial plate. So so with a simple fracture, you can reduce it anatomically, and I think, get away with probably just being a single plate on and still get them up one day. One. So that's point number one. Make them simple. Okay, so simple thing. Girls are simple, so keep it simple. Look for anatomical reduction. Uh, with restoration, at least one column. If you can do that, then you can probably get away with with kind of a single fixation method. Okay, so this is what we saw. See, more commonly, isn't it? So osteoporotic distal femoral fracture, which are communicated, um, in really poor quality bone. Um, these are the equivalent of our sort of hip fractures. The other end up. They are often frail people. Um, but these are just the people that were trying to get out of bed on day one and start mobilizing again. So thought processes I keep saying, I'll tell you my thought process. Um, So what can we do with this? Well, the same questions get through my mind. Can you Can you reduce that fracture and restore one column to to allow weight bearing through that column and then and then restore the other column with your metal work? Um, can you nail it? Because again, you know, the more I see these things, really, the more I think Well, if we can get an intimate honoree advice going up the canal were probably more likely or more happy to start mobilizing them on the intimidatory device rather than on lateral place. And then we got to think about approaches. And I guess this is the key to all this because we're all surgeons. And although we like putting metal work in, we need to know how we're going to do this, uh, in the sort of less in the most stressful environment. So we'll talk a bit about approaches. Um, you're all you're all familiar with. Standard approaches to the medial para patella is what you'll do your knee replacements through. So so that's the kind of approach everyone's confident with because you know what you can do with that. I think, as part of your trauma armamentarium, you need to get used to doing other things around the neck. So I'm a huge fan of using the lateral parapet to approach, particularly for distal osteoporotic. Non paraprosthetic. French is, uh, I'll talk you through why it's worth reading about the the so called swashbuckler approach, which was described by Adam Star, who was a chap in Dallas who was a register in Norwich years ago. Um, it's a kind of modification of the lateral para patella, but it's it's basically getting underneath the vastus lateralis, reflecting that immediately to allow exposure of the holes to end of the distal femur really, really useful in in inter articular splits when you're trying to put the block of the distal femur back together again and then putting a plate on the lateral side, and then we have medial and lateral approaches. Excuse me. Taking down your down direct into the medial side of the natural side of the knee, which again can be useful if you're trying to put sort of small plates on, uh, peculiar fractures. Really? Um, so keep going to move on. Um, so learning 0.3. So this is what this is a conversation I have all the time. Um, what I want to get over to you is not to be afraid of going laterally. Using the lateral power patella you can. You can do a various knee replacements for a lateral parapatellar approach. People fear that the patella is going to get in the way, but actually, if you if you release patella appropriately, you can dislocate the patella completely immediately to give you great exposure of the distal female. It's really quite simple. And I always all my registrars always say to me, Why do you use an unfamiliar approach for your complex cases? Um, and the answer is is because the approach makes the case easier, really does. If you're not struggling with approach and get into the bit that you need to get to, um, then it does make life an awful lot easier. And if you know, if you're really not sure and you don't get exposed it very often, then then get hold of a cadaver and have a go, and you'll rapidly be convinced that it's not a not a terribly difficult thing to do. So we're back to this lady. Um, I could ask you a quick who wants to tell me what to do with it. I'm bored of my talking and then go on. If you're peri exam, um, that would be useful. Or we can have a vote who have a vote. Look, how do you vote polls? Yeah, I can make a poll if you like. Yeah, what? What options would you like? And what's your question? Let's have, uh, So let's go for Oh, gosh, uh, intimate. Let's go for intimate Delery nail. Retrograde nail. Yep. Uh, that's your plate. Uh, yeah. Juul plating. Okay. And Neyland Plate, New York, plus plate. Okay. This is exciting. I've never done this live polling. Yeah, There you go. So that shit, that shit is coming up for me. So that's coming up for you. Yeah, I submit my answer. Uh, yeah, yeah, You'll have to. Yeah, you're so yours will be bundled in with everybody else's, though, but hey, Yeah, Look, I can't high. It's Rachel. I can't see anything at all. Oh, is it just yourself, Rachel? Or is it? It looks like lots of other people have seen it. Rachel. So I'm really sorry. I don't know why it's That's me, then, Uh, the results are not working, so I'm fine. Uh, please say a comminuted extra articular. Uh, distal femoral fracture. From what I can see on here, um, if I had any concern that this was intraarticular, I would get a CT scan just to clarify that it was just a question. What? How would you fix it? So, uh, retrograde nail natural plate your plate nail and plate a dual plate. Your plate. Okay, great. So you bumped up that one 25 response that do I tell if people can see the results? I can see? Yes. Well, actually, maybe that's just my privilege. I don't know. Rachel can use you can't see the pa little can you? If anyone else can see that, uh, we're going to put a retrograde nail up. 12% are going to put a lateral plate on it. Uh, 32% want to do a plate it and 44% want to put a nail and a plate up. So I'm going to ask a question to the dual plate ear's I can. I hope someone answer this because it's going to not work with them. How are you going to approach that fracture if you're gonna dual plating? So whoever of the 32%? Uh, this is not I don't want to I don't want to be nasty, but but it only works if guys respond. So whoever said your plate, can someone now tell me how are you going to do a place? It I I didn't respond for the dual plating, but if I had to do a plate this structure, I would use a separate media and separate lateral approach. Okay, so what? Direct lateral and a sort of medial? Yes, a direct lateral direct medial. Okay, so So the simple answer to this guys is there is I'm not I'm not going to lecture how to do. Well, maybe now I suppose what I'm here for, Um, I there's no right answer is that You know, these things are difficult, and and I think you can take your pick. What I will what I'll show you is what what I would do and why I would do it. And you can take it home with you if you want to, or you can do what you want to do. Um, So I don't like to incision approaches to the distal femur unless you have to. And I can show you cases where I've done it. But if you want to, If you want a simple way through all this, I'll try and show you. So this is what we did. We put a nail and a plate of it. Um, and I did it through a lateral para patellar approach. Probably cause I like it. But but What does that do for you? What it does is it puts your incision in the mid life. So from top to bottom, you open up the knee. Um, you move your patella to one side, and you then have a perfect entry point for your nail. You then got access to the lateral side of the distal femur, and you can put your lateral plate on. Um, what it means is, if you get in there and you suddenly find that you've got into a condo, the split, uh, you can you can still do what you want to do because you can fix the intercondylar split and then put your nail up, Um, equally if you get into a real whole, Uh, and you think I want to put two plaits on You can still do that very, very easily through that incision. Um, the problem with putting two separate decisions is you're working from both sides of the knee and it can be awkward can be really awkward. If you've got an intra condo, the split and you've got an incision laterally and a decision immediately. You can't see the end of the femur terribly easily and it becomes awkward. So I accept there are more talented people than me. But I as I keep saying, I try to get these things simple. And if you do most of these things through a midline incision, you won't go far wrong to us. Um, I'll keep showing you other cases where we do that. Okay, Mr Hopkins, just quickly, Uh, Hassan foid was just kind of asking Could you just swashbuckler lateral plus a medial approach? Would that be advantageous in any way? I can do, but But I put it to you that you probably don't need to. So So I I've kind of moved away from swashbucklers into just go straight up the middle. And the reason for that is if you go straight up the middle and you divide your tendon, you can very, very easy get to the medial side to put your plate off and equally you. Then if you're coming laterally around the patella, you've got very, very good access to the lateral side of the femur. Admittedly, you do need a little stab incision at the top to put your screws in the top of the natural plate. Uh, you can't get that high from from that approach. But, you know, that's easy, isn't it? That's just a decision. Mars higher up. So? So, Yeah. So the answer is Probably wouldn't if I If I was planning on doing a medial plate, I wouldn't use a social worker approach. I go straight in the middle. Um, no chairs. Okay, that's gone. So So, having shown how to do these, I thought I'd show you the kind of history behind it or not. We're not really history, but But these are These are going back over a little bit of time. All the ones that failed and not my case is I want to add that in. Uh, you can believe that. Okay. So, look, this is an almost identical injury. Horribly communicated. Metaphase, sis. Um, probably possibly little again counseled amount. Sorry, but possibly in try particular split, uh, difficult to see as they always are. I always I always err on the side of assuming they're split because they nearly always are. Even if you can't see on the original interest. Um, but look, I'm not I won't I won't labor the point, but there you go. So this is what we used to do. Um, so cable around the femur is try and restore as much as shaft as you can do natural plate, because looking plates with the be all and end all and and we were also under impression, it would solve everything. But if you look at it closely, you can see exactly I said you at the beginning of the talk that the screws in the distal block and not parallel to the joint. So this femur has been tipped into valgus. So she's going to walk a little bit of valgus. Uh, there's a combination of the medial column, so you have not restored that at all? Um, so you've got no support. The medial side, Uh, so when you weight by this lady on day one, she is relying on that plate, and you're on this sort of this roulette sort of race of Is the plate gonna fail before before the bone heals and I ability because it's easy cause I've seen the next one that it's not so they go and you end up with this sort of problem and it's not uncommon to be honest, and this really is how the history and the modification of what we do now it's what we learn that that actually distal locking plates worked brilliantly, but only if you did it right. Um, and if you restored things as they should be and and we saw more and more failures coming through, and I think that's why you guys have ended up in this scenario. Now where Thank goodness you're all thinking we've got to augment this a little bit more. So, yeah, as you can see. So this went on to a non union breaking the metal work distally. Um and there's options for this, uh, and I can talk you through my views. I think the next slide shows you what we did. Yeah. So? So in an elderly person, I'll go back. You've got the option. You know, you can You can try and refix it. You can try and get it to heal. Uh, it's difficult because these are horrible fibrous unions. They're all stuck to everything. Um, you could take the metal, look out and try and intimate on a divisive, divisive. You want to. Um but I'm an arthroplasty surgeon. And so these things, although they are fraught with problems, actually, sometimes quite a good, uh, get out of jail card, because again, this immediate allows you to weight bear and mobilize. Um, and they do. Okay, But as I'll show you later in the talk, we are storing up problems with these. Here's another one. So exactly the same sort of thing. Arthritic knee joint. So that immediately makes you think Oh, crikey. This isn't gonna work. Lateral locking plate again. Look at the Communist on the medial side. You haven't restored the medial column. So is that plate going to work? Well, it's not. I don't think I've put the next one, but that that failed and again had a similar sort of thing. A distal femoral replacement. And here's here's another one that was done recently. Nourish, um, so sort of more of a transverse fracture was shortening of the femur. But if you look closely, there is an entire article split there, and also virtually no bone in the lateral conduct at all. Um, so So I haven't got the immediate post doc film, but fixed with the lateral plate. Sort of the lateral conduct disappeared. Really? Um, so you then got screws in the knee joint at an early stage. She had a previous tibial plateau fracture, actually, which is why that looks a little bit on. Um uh, again, I'm digressing slightly. But if you want to know the way I go about these is really trying to get rid of the metal work first. So So these are these are restored using two separate trips to theater. Um, I have very specific rules about reconstruction after failed trauma, and that if you can get the metal work out easily and through the incision that you're gonna put your knee replacement and then by all means, do it. The problem with things like this is these are these have often been put in through a lateral approach. Despite me telling you, put the put things into the midline, uh, single lateral plate. I still put into a lateral side, which will show you in a minute. But if you're gonna take a play out for a lateral decision, don't then start doing your arthroplasty at the same time, you've got loads of time to take it out. Take lots of specimens and samples to make sure there's no sign of any infection. Let it heal up even if it's not united. People can can cope for a couple of months and then come back in a later date to do your arthroplasty. And this is what this lady did. So you can see we've taken the metal work out on the on the extreme, right? And then we went back in and put a fairly standard knee replacement to her with the stem bypassing a sort of fibrous union. Rick, Um, I don't think I've got a picture, so that so That's my kind of distal osteoporotic femoral fractures. Um, the other, But I started to talk to you about is peri prosthetic fractures, which again, is a lot of overlap. Really. Um, but I'll give you my thoughts on paraprosthetic branches, and then we can we can talk through if you want to. The principles are the same, you know, they really are. You're you've got an implant in there. You've got to restore alignment because you know, we spend hours now is I mean, trying to get our knee replacements absolutely beautifully aligned. Um, I think your your duty bound to still do that when they got fractures. Because they still need to function after us. Um, my thoughts on two columns. Stability remain the same, and we're trying to do that even with this sort of metal implant in the way so the principles are the same. The difference is that someone's put something in the way of what you might want to do, and you have to think that's true, Mr Hopkins. Just very quickly before you move from native to pope Prosthetic. Can I just ask if, what's your selection process for? If they're not reconstruct a ble, so are you showing us a couple of cases of where they haven't worked through trying to fix a native distal femur? And then you've gone on to do a D F R. Do you do you do many de fr straightaway after looking at a CT and just saying that's not going to be reconstruct a ble or do you? Is that more of an on table decision for you, where you just say, Actually, I can't reconstruct the column. It's not going to work. Let's have both kits available or something like that. Well, I've never I've never intraoperatively changed from fixing something to to do a disciform replacement. Um, my view. And certainly with the peri prosthetics, my view has changed. My view on native disciplines hasn't changed over 20 years and that I think you've always got enough pain to to fix something. Well, I say that I've yet to see one where I haven't, um but you got to do You've got to do it right. I hate to say It's an obvious thing to say, isn't it? The failures that we've seen over the years is is because we didn't do it right. Pure and simple. Um, I'm not saying we've got it right now and and Yeah, okay. Do your plating nail place. There's going to be failures of that. I'm sure. Um, but I think my view is that you're whatever. You're a bit like elbows. Whatever you do, you've got to get them up. You've got to get them moving. You can do that. If you If you put, uh, if you augmented. You know, if you if you if you've got a combination on both sides, you've got to fix both sides, or you've got to go with a nail and probably augment that because even the nails the nails failed, I think in some ways, more than the plates did because we used to put big nails into, as you say, capacious canals that rattled around and it was no surprise that they didn't unite. Um, that's why you know, plates took over for a little while. Um, but but we saw failures of place for the same reason. So So, to answer your question, I have I ever done how I do recall one lady that I regretted putting a distal femoral replacement. That was for a very particular reason. Um, the reason why I try and fix them is because people see distal femoral replacement as the kind of end game, don't it? It's It's a pretty easy operation. Actually, it doesn't mean you can get them up and about, But But the problem with them is the complication rate. Um, so I've got numerous d f r s that have dislocated patellas afterwards, despite me being absolutely certainly it was all going to be okay. And I'll show you a case towards the end that that the problem with them is what's Plan B? So? So if you put a de fr in someone you'll think the game's over until they come back with a paraprosthetic fracture, and then you're starting to build a problem. And this is why I alluded to earlier saying that you guys are your careers might be something different to me because because you're going to have a whole lot of revision implants and D F R s that are going to live for another 10 years. And I'm gonna start falling over, I tell you, um, so we need a plan for that as well, which, which I've just started to see. It started to come in. Um, so did I answer your question? Yeah, I think so. Thanks. Sorry. I'm rambling on a bit. Um, the answer is virtually never put a d f r in the native fracture, if you do. Good luck. Okay. Perry process. So? So Hussein asked me to put a few slides in that I kind of gave it to be a a couple of years ago up in Edinburgh. Happening about paraprosthetic. Franch is so so a little bit about the scale of the problem. We will talk. I'm supposed to educate you a little bit. So? So there are classifications you can learn if you if you want to, but they're all in text, but again, a little bit about my decision, making very little bit about evidence because I really don't believe in evidence until why have evidence when you can have anecdotes? That's why, um and and kind of where we're going, you know, what's the future? So So we've alluded to this little band with the way standards that were produced in May 2019 about frail people should be fully weight bearing within 36 hours of admission, and I think that's that is a good standard to look, look to. I don't think it's always possible. But I think if we're thinking of that in trauma meetings, um, that's got to be a good thing. Um, so this was produced a couple of years ago. Now, I'm not sure if this is the Ben Davis whose whose made online today, but Henry, when James is a good friend of mine up in, um, up in writing tongue. Uh, and he kind of wrote this article for the BMJ about the sort of panda or the epidemics of the pandemic blonde. Um, the epidemic that we're looking at of paraprosthetic. Franch is, um and what they showed quite clearly I'll show you a graph. They go is is this is from his his data looking at a three year time frame and really showing that the year on year approximately 13% increase in paraprosthetic French is coming through the door and and of interest is that this bill The bomb, 14% them never returned home after their injuries. So So this is a big problem. Frail people, big injuries, really life changing injuries that we have to start to think about. Okay. I promise you a classification. There are classifications of peripatetic fractures, as I'm sure you all know. Um, Row Rebeck was the one that I kind of grew up with. He was a Canadian surgeon. Um, who who classified? He's according to whether the implant was loose, whether the fracture was displaced. I won't go into. I don't use this at all. But it's there, you know, I suppose for exams and things that you might have to do. I I find it's much more useful. So this is a sue classification and the reason why I find it useful is it? It does guide you a little bit on where to go. So sue classified, period pressing knee fractures into three different types, approximately the implant at the level of the flanger the knee and then within the confines of the knee replacement. And I think it is useful because it does kind of start to direct as to what we should be doing about each individual type of injury. So here we go. Trauma trauma, meeting time again. So this is what runs through my head when I see a pro prostate, a fracture in the trauma meeting, Um, and and it kind of. And I hope each question leads you down a different route to save you, having to think too much about it. So question one has to be. Has the implant failed? Because if the implies failed, you need to be thinking about changing it. Well, you need to change the implant, and and that that failure maybe acute or chronic. So it might be an implant that's coming loose over time. And actually, the loosening can cause the fracture. Um, phase are going to need a revision, and those are in the remit of the the bottle plastic surgeon, if you ask me. The other thing is, has the implant failed? Acutely. So if you look at the image on the right, that's a rheumatoid lady with a well functioning knee replacement the day before she fell over. The problem is now because the bone quality is so poor her implant has failed because there is now no longer any bone attached to the metal implant. And so fixing the bones. And even if you got the bones to heal, you're not going to save the implant. So you need to be thinking of revising the implant rather than fixing the fracture. And if you ask me, um, I think this goes on as we get ready. Yeah, so into prosthetic fractures. That's question, too. Is there something above the the knee or below the knee? I guess there's gonna alter the the operation you're going to do for them. So So you need to answer that because that is going to alter what the options available to. Is there enough distal bone? That's always the question, isn't it? So you look at egg trays and you're trying to work out whether you can fix it or not. Um and you have to make that decision now. Lots of people seem to be seating these, which I think is it can be useful to try and give you a little bit more information. Um, but ultimately and like, this is where you know, come back to your question. Actually, these are the cases where that you may have to change inter operative Lee. So if you set out with a few that you've got enough bone there to fix, get into it and that and that has happened to me, you get in with an idea, you're going to fix something and you literally pull out the femoral component with about three millimeters of bone on the back. Because often these things are so much more osteoporotic that you've really encountered. And that's why your approach is important. Because if you start going in laterally and then find you've got no bone to fix, you'd wish you'd gone through a midline approach and you had a Plan B, and I'll talk you a little bit through that later on. Um, so Matav for seal combination is kind of what's coming to the fore over the last 56 years. I guess, um, and I like to call it. I had to talk about the direction of travel because I think things are different. You know, when you look at these, the two X rays I've put up for you, you get another one on the left. You can see that it's a fairly oblique fracture with the whole distal block heading laterally. And I put it to you that actually, if you if you therefore put a plate on the lateral side of that injury and you're buttressing that bone back on, you'll restore the medial column, and you may well get away with it. That's worth thinking about. The extra on the right is different, because on the right hand side, it's going immediately. If you go into that laterally, put your lateral plate on. You're trying to pull the medial column back on, and and the implants aren't designed to pull. They're kind of designed to push so so metaphysical combination direction. Travel, I think, is the key really to these sort of injuries that if you've got something that that is going immediately, you've got to put something on media to bring it back. It's the same. Same principle with all franch is just that we've got a knee replacement. Right. Um it's slightly flippant to sort of say something about the heart, but I don't mean that flippantly. What I mean is that no matter what I tell you, no matter what, what decisions you make in your trauma meeting about fractures? Um, you then at the end of your trauma meeting, gonna wardrobe and you see these people and everything might change when you look at the end of the bed and you suddenly realize that that actually this elderly, frail person might just might not withstand what you're planning. So So that isn't a flippant common it is all about You know what is realistic and and the best for this person. Um, I vividly recall putting bilateral nails up a lady. Um, in fact, I've broken one of the images later who who was wheelchair bound and fall out of the wheelchair and had bilateral paraprosthetic fraction of other knee replaces. Um, and we nailed them both. We didn't get great reductions, but we gave her a quick operation and we got her back into a wheelchair. and that's very different to a 60 year old. He's got a paraprosthetic fracture who still wants to, you know, walk up mountains and stuff. So So that's what I mean about the last bit. You know, things might change when you when you get the history and all right, I'm going to take this in reverse order because these ones are the simple ones. So Sue type three. We said we're fractures within the confines of an implant where pretty much the femoral component has become loose because of the fracture, not because of a failing implant. And I say these are easy because Because some of these are really, really are unreconstructed, so they're not fixable. When you've got a literally a centimeter of bone stuck behind the femoral component, you're not going to get enough. Hold on that to to do anything about. So so these. These are the cases where we still go for distal femoral replacements. Get the patient up the next date bending, then the and walking. Um, but, you know, it's a big, but I am desperately desperately trying not to do this nowadays because of the problems I've seen over the years with them. But sometimes you have to sometimes another option. Okay, we'll go back. So that was three. We can dismiss them to type one. So these are the fractures that are a proximal to the implants. Uh, they're often a simple pattern. I forgot to say this, but when you look at native distal femoral fractures, uh, my experience is they are often more complex fractures, um, peri prosthetic fractures above the confines. The impact are often simple. The spiral injuries, uh, and you don't You often don't see the metaphysical combination that you do with the, uh, the non period prosthetics. Um, but as I said you before, this is all about making things simple. So I think so. Type one simple fracture pattern. You've got to restore these anatomically because that's your best chance of getting them up and about quickly. And this is the decision making. So if you're confident you can reduce that fracture. Um, and the reason why this changes is because these are the only types of fractures I do, as you can see top right with someone lying on the side a bit like a hip replacement. Uh, and I do these through a lateral institutions because I think, actually, if you um if you put the leg in that position the minute you've got them in that position, you can reduce the fracture easily. You can put cables around if you want to, and you can almost let go once the first or second cable on and your plate just drops on. And it makes life really, really quite simple. So So those are the type ones. Um, this is a similar thing, so there's a butterfly frame in office, but I think you'll all agree that's a simple fracture pack. If that was a fibula, you've been licking your lips saying, Right, let's get a plate on and easy. So the same thing. So lateral position. Um, I have started to use cables people used to talk about and being a sort of work of the devil over the years. Um, but if you get some cables around, restore it, you can see we've restored medial and lateral columns, um, lateral plate just to stabilize. Um, you can get up and walk on that on on day one. So those are the easy ones. The problem comes with these and we've I've shown you bit. So this is the lady on the left hand side who fell out a wheelchair. So, uh, so introductory nailing versus, uh, dual plating. Um, and those are the questions you've got to answer. And I'll again I'll try and talk you through over there. So, um, let's have a look. So here you go. Uh, let's have a poll. Let's do the pole. So here's a lady who has a Communist ID peri prosthetic friendship, and above the femoral component, she is going. As you say, direction of travel is going immediately. Uh, she's gone into hyperextension. Isn't she as well. So let's have a poll. Who wants to do an intimate gallery nail? Same as last time. Uh, who wants to a lateral plate? Who wants to do a dual plate? And who wants to do a nail plate? Um, is that so? I got nail plate, lateral plate, dual plate. What was just good now, or somebody else or other? Yeah. Okay. If anyone puts other, they'll have to justify their decision. All right. Okay. There you go. Okay. I'll give you another minute. Test responses. 21. Okay, so we're getting a picture, Are we? So? So my thing says nail and plate. 50% lateral plate, 12% dual plate, 25% nail for other eight. I'm curious to know the other. I'm missing. So he he wrote. Gosh, is that fair? Does someone want to shout out the other? Anyone has any? Consider. I just a replacement for this lady. Sorry. You can consider this or family replacement. Yeah, you could do. Yeah, you're right. That's the other. I'm glad there's someone. Yes, you could. You could replace the whole thing. Um, I've tried to put you off that if I can be actually right, and it's and actually this probably is one that you You probably would want the equipment available to you, wouldn't you? Just in case, I think there is. If you look at the lateral view, there is more than enough bone there to fix. Um, but you're right. As I've already said to you, Never quite that. So you'll get that. So we've got So the 50% you want to put nail plates in, Um, so that's that's an interesting thing. And that's that's I'm going to mention that a little bit later on. Um, the question is, so this is a genesis to crucial retaining implant. And this goes back to two. Something you mentioned briefed. And I was going to mention again the minute about knowing your implant. The question is, can you nail through a genesis to implant? The answer is, you can, um, with our Smith and nephew Nailed it is is difficult. And the problem is that the flange at the front of the femoral component comes down very low. So if you're gonna put a nail through, you have to start with a very, very posterior entry point. And the problem then is you tip the knee into extension a bit like you can see on the lateral. Now you'll end up with something that I'll show you that in a minute. So So I'm not keen on, so I'm very keen on nailing these things. But I'm not real keen on nailing Genesis to implants because I generally don't think you can do it or you can do it. But you can't do it properly, and you end up with an implant. That's, uh, that's not aligned properly, and I kind of think that's important So I think I take your point that this needs more than just a lateral plate. I think you can argue with me. So what do we do that we did this? So this has a dual plate, and I'm going to say again because I want really want to take home message. To be approach is really, um So how do we do it? We can see I put the POSTOP film on because it's still what the clips on. So this is a midline incision. Uh, it's a lateral para patella in decision. So we get access, easy access to the distance of the femur. Uh, we can put a medial plate in through a lateral parapatellar because if you go a little bit higher, you can just swing the whole vastus around and see, and you can see you get pretty long plates down onto the medial side and you can see on the extreme left the clips of where we've done an incision to get up to the top of the plane. Um, so that's what I do for implants where I can't get nails through. Um, But I'll tell you what. There is. There are new nails coming out as well. I'm aware of that. The strike, and I'll produce a nail with a bit more Bend on it. And I have no experience that I'm going to go and have a look at it at some point, um, maybe Maybe that's that's the future. Um, but I think you've got to do more than one thing. So there you go. So that's your plating. Um, this has become a thing over the past few years. I'm just gonna time to 10 o'clock. Am I? Am I gonna overrun it? Uh, look, how much do you want to? You want me to come to a crashing end? Uh, next speaker. He's actually on the line. I think we're okay just to carry on for unless I carry on. Unless, uh, if that's all right, I'll try and wind up with climate. Um, Okay, so So this is where some evidence came through over the past few years. Fracture's significant media combination should undergo retro ticket nailing or dual in Palm Plantation. I think we've all got that. So you've got to do two things. Um, this is close. Smith's paper. That was about a year ago, which is worth reading, actually. But what it What it basically says is that if you fix these fractures, they do just as well as difficult from an arthroplasty. But you got to fix them properly. They look back at their failures and basically shows that all the failures weren't fixed with dual plating or a nail plate system and so failed almost predictably. So I think that's where we've learned where we're going. This is the point I was trying to make about the last thing. So whatever you're doing, you must know what you're what you're implies doing and what you're able to do. So that includes your nailing system. What angle is your is your retrograde now, uh, the the images in the middle? Who on earth knows what that knee replacement is? If anyone can tell me whether you can get a nail through that I'd like to know because you can't tell from those X rays. Um, and then the extreme right is a gente ps knee, which I put two you can't put a nail through. Um, so you've got to know what you're dealing with before you start out. Uh, this is a great paper from Steve Mitchell. Who was? It was a s h o of mine years and years ago. Um, who basically says you can now virtually anything. Um, but it's difficult. And you damage things if you do that. So So you've got to be a little bit careful. And the image of the bottom is exactly what I'm talking about. So, yes, you can get a nail through Genesis to implant, but look, you are gonna hyper extend it. Now the question Is that a problem or not? I don't know. I think you can do it better without having to do that. Um, there's evidence if you want evidence. The evidence is that, actually nails have a slightly higher complication rate. Depending on which paper you read, you can read. Um, you can read. You can make any operation fit, can't you? That's the problem with the literature. Whichever paper you read tend to show you what you want to say. So, um so really, I don't think it matters what matters, and I'm going to say it again because this is what I want you to remember is how you approach this. So all of these operations, uh, would done, uh, through a midline incision. So So you. If you want to start with a nail, you can start the nail. It's an easy midline approach if your nail doesn't, or if you can't get your nail in because you suddenly find you've got an implant. Um, that that that won't allow entry. You can extend your incision up and you can do all plate it. If you're going in with a midline incision to dual plate something and you suddenly find that there's not enough bone on the back of your femoral component, you can put your de fr in because you're in the right place to do that. So so I would absolutely advocate this midline incision lateral para patellar. As I said to you before, the only time that I wouldn't do that is in simple fractures where you can put a lateral plate on because you've got a medial column. Uh, and you can make that right two minutes very protective. Affect. This is easy. There's a classification I won't go into. Uh, the answer is, um, if your implant has failed, we've seen this X ray before and you can't fix that bone because the implant is loose and you need to do something else. So failed Implant equals revision, surgery. It's not the ream of a trauma surgeon. Um, you can treat any fraction nonoperatively. I rarely do, but, you know, sometimes you can get away with it. This was an elderly, frail person that we put in plaster on it. He'll, um, probably more through luck than judgment, to be honest, but tibial paraprosthetic, tibial fractures and the plates until proven otherwise. Um, so there's no there's no learning here. You know, you you've got limited options unless you're going to take the whole thing out and revised it, which I really wouldn't recommend in the present. A fracture. So there's enough bone approximately put a plate on. If you've got a mid shaft fracture, put a plate on. If you've got a distal fracture, put a plate on. There you go. That was easy and the only again take out. So my final thoughts are where we're heading. So here you go distal femoral replacements and that then fall over and break below it and the one the one take home or learning point from this is Remember, these implants come in multiple multi complaint components. So a revision of this is not the same as a normal revision again, you can't see my mouth. But but what I'm trying to say here is that you can uncouple these implants so they're linked by a hinge at the back. So this is a lady who fell after a D F R. Rather than trying to plate a bone that's got virtually no bone left, you can uncouple the tibia, take the tip your out and just get a bigger tip. So the femoral side you don't need to change it all makes the whole thing an awful lot easier. Uh, the future. Here you go. You can always think about this over the next few days. So here you go. Here's a distal femoral replacement. Uh, that's fractured the tip. What are we going to do about that? Because these are going to come in through the door. I've just shown you the tibial side of things. You know, there's a big push from Basque at the moment to do more and more units, but with you knees come problems. Uh, what are we going to do with distal femoral fractures around the unique apartments and the replacement. If you go to London or other places, there's now a vogue for multiple union compartment replacement. This is a lady who had a, uh, on the extreme right telephone, real replacement and a lateral uni, uh, with Media Low, A bizarrely, um, but has a fracture through the lateral femoral condo and into in an inter complex split. Um, what we're going to do with that, that's that poses a whole different problem. But again, this is what's being done, and these things are going to increase through your sort of, uh, consultant career. I thought I'd end with this because because I was asked to talk about native native distal femoral fractures and paraprosthetic fractures. And I thought, This encapsulates the entire thing, doesn't it? Right? So here's a guy who had a thermal antiviral nail done for trauma about 10 years ago in Orange, uh, regrettably decided to get back on his motorbike and 10 years later gets hit off his most bike, and he came in with a peri prosthetic distal femoral fracture. Not one we see very often, Um, but here you go so bent nail, horrible injury. Um, but the principles are the same. You know, Uh, if this no matter how young or old he is, what we wanna do, we want to fix it. We want to get him up out of bed the next day. So the only problem with this is you got to take the metal, work out his ways of doing that, uh, and you've got to fix him. So how what do we do? Well, we did that so exactly like, I was gonna have a poll, but we run out of time, so take the metal. Look out. We have to cut the nail to get it out. But we're back to the what? We've learned what I've learned over 20 years, which is actually all menting, uh, fact fracture fixation with horribly unstable injuries. Uh, in the old days, he would have probably got a retrograde nail, but But we've moved on. Uh, so he got a nail plate lateral para patellar incision just to let you all know, um, so we can get the nail in easily, and you've got direct access to the lateral size, and I think that's me. So There you go. That's just something. There you go. Sorry, I overran very slightly, but, uh, that's fantastic. Thanks so much, Mr All Good. And I just got one question from Iggy in the audience. He's just said with regards to retrograde nails through knee replacements. If can you do it with PS knees and if so, do you take the poly out nail and then put Poly back in, Uh, good question. I don't do it. I never I've never nailed a ps knee. So So the reason for that is that we have a huge volume of genesis to needs. I don't think. And I may even prove wrong. You can nail through a PS knee that's a gen to PS knee. Um, there will be PS sneezing. You get nails through, and there are There are articles written telling you all the implants that you can put a nail through. But my view is, if I if I'm facing the paraprosthetic fracture around PS knee, they won't get mad. Sorry, I did, uh, just just gonna add Aussie or fully consult. So I think one way around that is doing a, uh, anti grade now or yeah, the element. Uh, W nail. So I did that last week. I did an open approach. The distal femur reduced it put a mantra media anterolateral plate. And then because it was a P s knee and there was a good enough distal a bone stock, Um, I didn't manage to get a salary nail, so I guess that's 11 way around it. I thought, Yeah, pretty much where you're Frank choices, isn't it? Yeah. And if you got enough distal bone, Yeah, that's one way around it. I wouldn't I wouldn't just nail it that, you know, you're absolutely right. You got to do something else, haven't you? Because you won't have enough control on the distal block to put an antegrade nail into that. That's fantastic. Is there any more questions from the audience? You're welcome to either put something in the chat or just speak up quickly. Um, but otherwise, I think that's everything. Thank you so much, Mr Good. I really appreciate that. I'm going to stop the recording if I can, and, uh, yeah, thank you very much. We'll probably just take a quick five minute toilet break just and for our next speaker. is to get the slides up, if that's okay, and yeah, Thanks again. Good bye. Bye. Cheers. Um, so if we just take five minutes quickly. So we've got Mister a Weed and homes. Oh, is one of our both. Both, I believe, uh, east of England. Trainees. We're going to talk about knee dislocations. I'm going to do a double team. Uh, so if homes are you on the line, are you able to try and put your start? Uh, and then we'll just come back in five minutes if, uh, people want to pop away.