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No. Uh Yeah. Yes, we can. Yes. Ok. Hi. I can't see your faces. I can only see my screen but my name is Sarah. I'm one of your orthopedic registers at Worcester. I'm on the Birmingham rotation and I have been asked to do a whistle stop tour of everything you need to know or the main high yield topics you need to know about the hip and the spine. Some of the slides that I've used are from Mister Simon Hughes, who's one of the Roh Tumor consultants. I'm sure if any of you have rotated, um, and done your PC block. You would have done two weeks at the Rh. And you may have had some of some of what I'm gonna say today. So, what are we gonna try and cover today? So we're gonna try and cover hip fractures, avascular necrosis and osteoarthritis of the hip. And then with regards to the spine, we're gonna cover mechanical back pain, spinal stenosis, metastatic cord compression and cord equina. So, starting off with osteoarthritis. So, osteoarthritis, it's a degenerative disease. It's progressive and it's due to a loss of articular cartilage of both the femoral head and the acetabulum. It is the commonest cause of disability in patients above the age of 65. And it mostly affects women more than when with regards to risk factors. So you would divide them into modifiable and non modifiable risk factors. We said obviously the, the first one is females are more likely to get it. Uh, patients who, um, there's certain genetics that are associated with osteoarthritis. If you've had a hip dysplasia or if you've had Perthes or if you've had a SUFI or DGH, then you're more likely to develop osteoarthritis. And, uh, as, as obviously, as you get older, you're more likely to get osteoarthritis with regards to modifiable risk factors. So, if you've had any history of any trauma, if you're quite active, as in, like, you're doing a lot of, uh, you're loading your joints a lot, then you're gonna more obviously gonna cause more trauma. So you're more likely to develop osteoarthritis. So there's not the ati regarding osteoarthritis is that we know that there's a loss of joint space, but that's mostly due to the fact that the chondrocytes lose their ability to restore the articular cartilage. And studies have shown that it's due to telomere erosion. So, whenever you see a patient with osteoarthritis, you're obviously gonna do a clinical assessment of everything. You're gonna take a history and you're gonna do an examination with regards to history because it's a mechanical, uh, condition, you're gonna have pain or movement it's gonna be limit, it's gonna limit their function. Um, sometimes patients report pain at night but it's usually pain and movement. They may report symptoms of instability, stiffness. Um, they may have a history of trauma. You would want to ascertain how far they can walk and if they're using any aids and if they have any supports at home and if they've had any treatment done for the osteoarthritis, does anyone know any treatment that you could have, could have done prior to surgery? How would you manage someone with osteoarthritis? Any suggestions? I can't see your faces, which is part of the problem. Um, um, if anyone wants to just type it in the chat because I don't think you guys can turn on mics with the settings. We've got, let me see if I can read it out for you, if anything on the. So don't worry about that anyone. No. Ok. So the first one, anyone, no. Ok. So regular analgesia, paracetamol, ibuprofen, physiotherapy, weight control or weight loss is usually the first thing that you would offer if they, if they don't, if they don't improve with that, you can then consider steroid injections. Usually steroid injections are both diagnostic as well as them being therapeutic. So, if a patient has a positive response to steroid, it tells you the pain is most likely due to osteoarthritis rather than anything else. Once they've had a steroid injection and they've had a positive response, you can then discuss different options with them. Whe whe whether they would like to have any more invasive treatment. Yeah. Uh um, so then moving on to examination, you're gonna, obviously with anything orthopedics, you always examine the joint above and below. So you're gonna examine with the hip, you're gonna examine the spine and you're gonna examine the knee because they, that may affect the clinical presentation. You're gonna look for fixed flexion deformities. You're gonna look at their gait. You're gonna look at the, obviously the body habitus and their leg length. You're gonna see if they have any bony tenderness and then you're gonna assess their movement. Most patients have pain on internal rotation and they would have limited external rotation. They would have li limited flexion or a fixed flexion, er, a fixed flexion deformity and then in terms of special tests, so you're gonna lift their legs up, but you're gonna do a straight leg raise and see if they have any pain. If it's positive, it's most likely due to a spinal condition rather than a hip condition. But you need to make sure that it's not because of the fixed flexion deformity that they have limitation in terms of pain, then moving on. So you're gonna do a investigations. So, obviously, um, for anything orthopedics, you need to get x rays. So the first thing you're gonna do is you're gonna get ap and lateral views of the, of the joint, particularly the hip and you're gonna look at the loss. So there's a, I know it's written down but the cardinal things you look at when you're looking at a, um, an X ray, you're looking at reduced joint space or articula, uh or loss of a uh articular cartilage, osteophytes, subchondral cysts and sclerosis. Does anyone know the difference between uh those findings and the findings you will find uh in rheumatoid arthritis? Yes. No, we haven't had any responses so far. Ok. So with osteoarthritis, we said we have lots of joint space, osteophytes and the cysts and sclerosis with rheumatoid arthritis, you're going to get margin on erosion and you're going to get juxta articular demonization of the bone. So the bones are going to look a bit more osteopenic compared to what they will look like in osteoarthritis. Sorry. Um So in terms of blood, so why would you do a set of blood tests? So you're gonna do a set of blood test to optimize that patient. So you're gonna do an HBA one C because we know that diabetes increases your likelihood of having issues with wound healing and also increases your risk of infection. You're going to make sure that the patients aren't anemic because we know that they're worse off when they have had when they're anemic pre op. You're gonna need to make sure that there's no other condition that has led to this. Yeah. So it's not an infective process process or an inflammatory process that have led to these symptoms. Yeah. Then as we said earlier, you're gonna be looking at your management. So weight loss exercise, analgesia, you're gonna see if, if any walking aid helps. But obviously that's not a long term treatment. Then you're gonna consider steroid injection. Then if all of that fails, you can then consider surgery. And the aim of surgery is to have a stable fixation and to restore the alignment and the length is so the alignment, the offset and the center of rotation of that hip and depending on the patient age, you would often, um, so if they're older patients, then you may consider a hip replacement in younger patients who are female. You may consider hip pres surfacing. So you can see here, can anyone tell me what things you can see on this picture that's suggestive of osteoarthritis. Come on guys, you can do this. Ok, Maria. Um Yeah. So obviously the, the loss of joint space is OK. So there's lots of joint space there. What else can you see? Um, you can also see is like the osteophytes and things around is that? So where can you see where are the osteophytes? Um, like in, I don't know how to describe it because I can't use the mouse. But um is it coming out basically, uh there's osteophytes there? Yeah. Yeah, there's osteophyte. OK. Anything else that you can see? What are these Luces here? Uh is that subchondral cysts. Yeah, there's cysts there and this whiteness here, this is the sclerosis. Yeah. So this, if you were to see it and you can see also here there's a flattening of the femoral head. So, if you were to see this, what other condition would you think of? Uh, like avian? Yes, exactly. Avascular necrosis of the femoral head. Yeah. So that is an important, uh, differential diagnosis. Um, when you're, when you're considering AVN the reason being um is that you need to differentiate them is because the pathophysiology and how it occurs is different and therefore the treatment is different. Yeah, cool. So moving on to something that you are going to see almost on a daily basis if you are working in an orthopedic department or if you're working in an ed department, which is hip fractures, neck or feur fractures. So it is extremely common. It affects about 75,000 patients a year in the UK. The reason why it's really important is that it has a 7 to 10% 30 day mortality and a 30% mortality within a year. So that's extremely high. If you were to compare it to most cancers, I don't think most cancers have a similar mortality rate. So the most important thing when you're taking a history from these patients is to establish the mechanism of injury. So there's two concepts that you need to be able to differentiate from. The first one is it a mecha. Is it a medical fall or is it an accidental fall? There's no such thing as a mechanical fall because all falls are mechanical. If someone has a fracture in the absence of any trauma, what does that make you think of? Just kind of more frailty fractures or like osteoporosis? If someone hasn't fallen over and then had a fracture, what do you worry about or has a very minimal, like has an insignificant traumatic injury? What does that make you worry about? Um potentially like bone mets, pathological fractures? Ok. So if there is no history or no actual history of trauma. So like the other a few months ago, I saw a patient who was going up the stairs and heard a crack. Is that normal to develop a fracture with that? Hi with that history? No, no. So you need to think of pathological factors in the event of a trauma, whether big or small you then need to establish. Is it a medical fall or is it an accidental fall? Ok. So what are things make you think about medical falls? What is a medical fall? Uh What would you classify as a medical for? Is it fools that are caused by like trauma or by underlying disease? Potentially? Yes. So if someone has a syncopal episode and they collapse, someone has chest pain and they collapse, someone has a pneumonia and they collapse. Yep, someone has had, has a heart block and they collapse. Yep. Someone who's had a stroke and they collapse. Those are very different beasts compared to, oh, I was walking and I tripped on a cable. Yeah, because the, that mortality is obviously gonna go up if someone's had a recent mi, their mortality goes up to 50% in the, in like the 1st 10 days or so. If they've had a recent m I, compared to, if someone's just tripped and fallen over. Yeah, then the most important thing and this is what people don't really understand until or uh appreciate until they start working is orthopods are obsessed with social history. OK. How functional you are as a patient determines everything. So how do you, how do you, how do you, how do you look after yourself? Do you have any carers? How many times a day do these carers come in? What do they do for you? Do you have any sticks? Are you able to go upstairs? And why do you think all of that in that information is relevant and important? Uh I guess that would determine the type of like method that you use to fix the fracture. Whether that's what exactly it, not, not necessarily the method, but what treatment options you would offer a patient. So if someone is bedbound and is asymptomatic and they have a neck, a feur fracture, would you, would you rush to get them into theater? No, no. If someone is very active they're very independent and they've fallen over. Would you rush to get them into theater? Yes. Yes. Ok. Even, even it's, the social history is so important that it has influenced nice guidance. So nice guidance is based on, well, not there's a big portion of the nice guidance which is based on your social history. Yeah. So you need to make sure that you're taking a social history. Other aspects of your history is your past medical history. So, if anyone has a history of cancer, you need to make sure where that, this is not a pathological fracture. Yeah. So you're gonna get full length fuse of the femur. If you see any lytic lesions or any sclerotic lesions, you're gonna need to get further investigations. Yeah. Then when you examine the patient, you need to make sure that this is an isolated in injury. Yeah. So many of these patients, when they come in, when they've broken their hip, they've often sustained a head injury. If someone's had a head injury and they're on anticoagulants, what investigations do you need to do? Um, things like CT head. Yes, exactly. You're gonna need to make sure that there's no bleeds. Yeah. If someone's had a, uh, had a neck injury when they've fallen or they had a hyperextension injury to their neck, you're gonna need to make sure that they don't have ac spine fracture because of the, then they're gonna need to be colored or they're gonna need to have definitive fixation for that. And what would that affect if someone's had a cervical spine fracture? In, in terms of what, like in terms of how would you, how would you treat them differently if someone's had a cervical spine fracture? Uh, well, that means that they're less able to kind of be moved into positions that, uh, so would it be more think simple stuff if you, if you've broken your neck, can you move your neck? No. Ok. So how is that gonna affect surgery? Because you, it's not gonna affect, it's not gonna affect your approach because you're operating on the hip. But what will it affect? Um, I guess you like fitness for surgery and like mobility afterwards and your anesthetic? Are you going to be able to intubate this patient? No. Ok. Are you gonna be there? There's so many things that come into play. Yeah. If they have lumbar spine fractures, you're not gonna be able to, um, you're not gonna be able to roll them. Yeah. There, there's so many things. So that's why whenever you're seeing these patients, you need to make sure that you manage them as for ATLS principles. Yeah. So I see a BCD approach. Once you've excluded it, you've made sure that it's an isolated injury, you then focus on the limb itself, you examine the pulses, you examine the skin, you examine the neovascular status and then you address it as if it's an isolated injury. Yeah. Then you're going to, obviously we've talked about c spine immobilization and then your A MT or your four at, how is the patient confused? Are they not confused? What is that gonna affect? Someone's confused? Can they consent? No. No. Yeah. So that, that's important. So, if they can't consent, what do you need? Who do you need to speak to, uh, the kind of power of attorney or kind of external? Yeah. So the next of kin or their lasting power of attorney if they have one? Ok. These patients have a high mortality. Yeah, we've just said they have an average mortality of 7 to 10% in the first month. So you're gonna need to have these detailed conversations about respect forms and DNA CPR and you need to have, you need to make sure that the family are involved and are aware that this is a life limiting condition. Yeah. So then when you examine it, when you're investigating these patients, you're gonna look in terms of what are the causes of the fall and what are the results of the fall? Yeah. So if you think there's ac ac spine injury, you're gonna need to get a CT neck or a CT trauma or a CT head. If you, if you, if you think it's a medical fall, you need to make sure that you've done bloods. If they've been on the floor for more than a few hours, they're gonna need to get a CK because they're gonna, they're gonna have a long lie, which means that they have rhabdomyolysis if they have rhabdomyolysis that are at increased risk of having an AK. Yep. So, despite what people think orthopods, they are, they need to know medicine. Yeah, we need to know medicine. We need to know how to manage these patients properly because these are a vast majority of our patients. Yeah. You need to make sure that they've not had any heart blocks or they're in sinus rhythm or if they're in af that they're on treatment for that and if they are on treatment for that, that it's stopped for, it's stopped for surgery. You need to have an X ray to see if there's any rib fractures, but also from an anesthetic perspective, if you're worried about heart failure. Yeah, then obviously the X ray is looking at the fracture itself. Long views if you're worried about cancer and then a group and screen, that's because they're going for surgery. So now we're gonna talk about different types of hip fractures. Ok. So does anyone know the two different types of hip fractures? And why are they important? I've written them down here. But what does that mean? What does extra capsular and intracapsular mean? And where does the capsule attach? Come on. We, we have spines left and we have a half an hour. So we need to come on guys, anyone, it doesn't have to be correct. Just give it a go. Just put in the chat. Any ideas? OK. So has anyone written anything down? No, not so far. No. OK. So your capsule attaches in the front in your intertrochanteric line, which is from your greater trochanter, your lesser trochanter and your intertrochanteric crest from behind, which is slightly more proximal posteriorly compared to the in intertrochanteric line. The reason why that's important is the vast majority of the blood supply to the femoral head is comes through the capsule and it comes through a retrograde fraction. There's two main vessels which are your lateral and your medial c circumflex artery which come off your femoral artery and they form lots of anastomosis within the capsule and supply the femoral head. So what that tells you is that the blood supply is coming from the capsule up towards the femoral head. So if you have an intracapsular neck, a femur fracture, what does that tell you about the blood supply to the femoral head? Is it compromised or not? If it's coming through it? Anyone guys? 5050. Ok. Has anyone said anything? No. Well. Ok. So with intracapsular feur fractures, the blood supply to the femoral head is compromised. So that means fixing it, it's not gonna heal properly or if it does heal, it's it, it's a high risk of going into nonunion or a high risk of going into avascular necrosis. So, for elderly patients, if we can't fix it. What are we gonna do? Replace it? Yeah, we're gonna replace it. Ok. For extra capsule like a femur fractures, we know the blood supply to the femoral head is not compromised or unlikely to be compromised. So you can then fix it either using an intramedullary device which is a nail or an extramedullary device, which is from the outside, which is a DHS. Ok. So I'll just quickly show you hip fractures. Yep. So there's your greater counter, there's your last a counter, there's your neck and there's your head. So, subcapital transcervical, which is through it through in the neck or basal cervical, which is at the bottom of the neck. These are all considered intra cap neck of femur fractures, intertrochanteric. So it's between the two trochanters there. That's extracapsular pertrochanteric. It's at the bottom, but still through the trochanters. And then you have your sub truck which is five centimeters distal from the lesser tranter. Yeah. So then you have different classification system. There's lots of different classification system. There's a AO classification. And then I think for your purposes, you just need to know the Gardens classification, which is for intracapsular echo feur fractures and it's really simple. So the first one, it's an incomplete fracture. The second one, it's a, there we go, it's a complete fracture. It's gone all the way through, but it's not moved, type three. It is a complete fracture and it's slightly displaced and a type four is a complete fracture and it's completely displaced. Yeah. So if you see a type one and the patient's asymptomatic, you can try your non operative treatment for this patient, but there is a possibility that it may displace. So you will watch it like a hawk. But if there is a, if a patient is symptomatic and they're not able to wait there, even if it's not, if they're non, even if they, it's non displaced, you may still want to replace it in an elderly patient. Ok. So now in terms of management, so you're gonna be on call, you're gonna be looking after these patients. So you need to make sure that you're following the right management and the right guidelines when you're managing these patients. So there's nice guidance on managing neck feur fractures, which was published, I think in January 2023 there's both guidelines which are published in 2020 you have the best practice tariff. So the best practice tariff is a financial incentive that every single trust in the UK gets for complying with um uh with complying with the guidance and for each patient that they comply with their guidance, they get, I think 1300 lbs extra. So what does that say? So basically, to receive this financial incentive, you need to make sure that these patients are going to surgery from the time of arrival to the emergency department to the time to theater within 36 hours. They need to be seen by an Ortho geriatrician within the 1st 72 hours of admission. They need to have day one or need to have, need to be seen by the physiotherapist within tw. Uh, between, yeah, between, uh, in the 1st 48 hours, they need to have a, uh, a bone health assessment. They need to be seen by a nutritionist. They need to have a delirium assessment, um when they first come in and uh they need to and they need to be admitted under both an orthopedic and an orthogeriatric team. Yeah. So if you, if you, if you ever are on the board, you will alway and you're looking after Neco feur patients, you will also always say that there's an orthopedic and an Ortho geriatric um consultant, both looking after these patients because of this best practice tariff. He said the nice guidance. It talks about it. It looks into every single aspect of the uh of managing these patients. It talks about different treatment options. In summary, if someone is oat and they've had an intraclass, a femur fracture, depending on their activity status and how healthy they are and how fit they are, it will affect what you would do. Yep. So if they're active immobilized with a stick, and you think from looking at this patient that they will live more than two years and they will survive the anesthetic and they don't have any significant medical comorbidities. That would be a contraindication, you would offer them a total hip replacement. But if they're frail and they have poor morbidity, you would offer them a hemiarthroplasty. Yeah, for extra caption and a feur fractures. The nice guidance generally suggests that you should do a DHS, which is an extramedullary device. Um In the exception, if they have a subtrochanteric or a reverse a leak fracture where you would do a uh an IM nail. So I'll, I'll explain to you what a reverse ab blaque fracture is. So, can you see my mouse? Yeah, we can. Yeah. Yeah. OK. So a most fractures or a normal fracture is going in this direction. OK. So if when you're putting the DHS, the plate is going here and the screw is going there. So it's perpendicular to the fracture line. So it will cause compression. OK. In an e reverse oblique fracture instead of going in this direction, the fracture is going in that direction. So it's going in the same line as your screw because your screw is going in that way and your fracture is going in that way. Does that make sense? So you won't be able to get compression at that site. So it will fail. So for that reason, you will use a nail instead. Does that make sense? Yeah. Yeah. Yes. Yeah. Yeah, it does. Yeah. OK. It does. OK. So then obviously in terms of prognosis. So we said these patients have a high mortality. There is something called a Nottingham hip score, which is extremely useful when you're speaking to patients and their relatives. And it basically gives you a 30 year uh a th uh a 30 day mortality. So depending on these parameters, how old the patient is, whether they're male or female, what their admission at is how, where they live and uh what their HP is and whether they have any medical history, it will give you a percentage. So when you're speaking to patients and their relatives, you can say, ok, so we think given the information that we have that your mortality in the next 30 days is 22%. So for that reason, we want to have a conversation with you about what would happen in the event that your heart would stop and then you would have this whole ceiling of care uh discussion you would have in terms of you're actively involving patients and their relative in their, in their care. So it's really important that you do this. Ok. So this is a quick case. Um So can anyone tell me what they see any answers in the chat guys? So I'll give you a hint. It's a hip fracture and it's a neck of feur fracture. What kind of fracture do you think it is on the left hand side? Oh, it's either intercapsular or extracapsular. Come on guys. 5050 intracapsular or extracapsular. Oh, I can he needs a pen. I didn't know that. Ok. So we can, we can do an entire teaching session on what you're looking at when you're looking at a pelvic X ray. Yeah. But generally speaking, it's five things. Three rings, four lines. So your first ring is your Pelvic Inlet and then you ou your foramen. OK. Your lines are your isopal line. Yeah. Is your Ingle nine your accurate lines, sentences line which is disrupted here on the left hand side which tells you there's a proximal femoral fracture. OK? And then your five things that you're looking at your joint, you're looking at your acetabulum, which the Ileo ilio iliopectineal and your ileo line will tell you about your columns and then you're looking at the proximal femur. OK. So we said she's line is disrupted on the left. There's the lesser truck, there's the great a greater tranter, the fracture is proximal to it. So it's within the capsule. So it's an intracapsular and a feur fracture. If you're not sure you're looking at the lateral. So if you look at the lateral, you follow the shaft, that's the neck, the neck is attached to the shaft and the head is on its own. So it's an intracapsular neck, a femur fracture compared to extracapsular neck of femur. What you'll see is the head will be attached to the neck and then the shaft would be separate. OK. So this is an 82 year old lady she is, she mobilizes with a frame and she's fallen over. What, what are the things that you want to know quickly from the things we've just said? Ok. Uh So you're gonna take a history, you're gonna establish if it's a medical fall, an accidental fall, you're gonna manage the patient as per ATL S. You're gonna make sure that it's an isolated injury. You've optimized the patient. Orthogeriatrics have seen them. You've done a delirium assessment, you've given them a fib block, you've made sure they're comfortable. She's 86 or 82 she mobilizes with a frame. She has an intracapsular like a femur fracture. Are you going to be doing a total hip replacement or a hemi arthroplasty? Come on guys. Ok. You're gonna be doing a hemi arthroplasty. Why? Because that's what the guidance shows and the studies have shown that total hips and hemiarthroplasties are quite similar in terms of functional outcomes in elderly patients, especially for trauma. Yeah. So this is the next case so quickly. What do you see anyone? So there's a fracture line there. OK. And you can see here the neck is not attached to the shaft, it's attached to the head. So it's an extra catch a femur fracture and it's an intertrochanteric fracture. So you're gonna do a DHS for this patient. So now moving on to a AVN. So, osteonecrosis if you're reading any American textbook. So it basically occurs when you have reduced blood flow to the femoral head, any bone that has a retrograde blood supply is at risk of having AVN. So the femoral head, the talus, the scaphoid or at risk of having AVN. Why? Because the blood supply is retrograde. Ok. AVN accounts for um and account for uh 10% of all total hip replacement and it affects patients usually from the age of 20 to 50. They don't really understand how it happens, but they think it's because you get a blood clot which then compromises the blood supply or it could be due to trauma which then damages the blood supply. Ok. Most cases it's bilateral, but it could be unilateral and it could affect more than one joint. So it could affect the ankle, the wrist or the or the other hip. It's really, really important that you diagnose it early. Why? Because you can then preserve the head because what we said earlier with AVN, you get flattening of the femoral head. If you have flattening of the femoral head, you're gonna need to get a hip replaced. Yeah. So when you see patients with VNS, so we said it's gonna affect men more than women and it's gonna affect young patients 20 to 50 it, it, it's usually a gradual onset and it's often aggregated by movement and they often have a painful range of movement. Ok. So there's certain risk factors that account for AVN. So if you have things like sickle cell or if you have, uh, if you have alcohol abuse or renal failure or diabetes or an organ transplant or if you have any hematological condition that increases your likelihood of having clots, you're at risk of getting AVN. Ok. So the most important investigation that you're gonna do is an MRI scan and on the MRI scan, you're gonna look for a double blind sign where you're gonna see two rings. The first ring is gonna show you granulation and the second ring is going to show you sclerosis. And there's, I think there's a picture here. So I don't know whether you can see it or not, but the inner ring is the yellow one and the outer ring is the black one. And you can see here that there's two lines here which are suggestive of AVN. Yeah. So that's pathic of AVN. There's lots of different classification system. You don't really need to know the classification system, but it's based on radiological findings. X rays and MRI zero is no, there's nothing on the MRI or X ray and five is that there has growths flattening of the head and your treatment depends on whether the patient is symptomatic and what are the radiological features. Ok. So if the patient is experiencing a lot of pain and they have a flattened femoral head, you're obviously going to be more aggressive with treatment compared to if someone has no flattening of the head and is managing well without any aids. Yeah. So with regards to medical treatment, you can do uh you can, there's, there's been evidence behind bisphosphonates or any osteoclast inhibitors. They have shown to be beneficial, particularly in the absence of any uh collapse of the femoral head is uh if, if medical treatment is not suitable, you can then consider either doing head preserving surgery or arthroplasty. So head preserving surgery would involve putting drill or, or drilling holes in the femoral head. And that the aim or the idea is to increase the blood flow within that bone. And then that would then increase uh the well will increase the blood flow and the blood supply to the femoral head. And then if that doesn't work, then you obviously have the option of doing a joint replacement. Why don't we just offer these patients joint replacements at like 40 or 50? What's the problem with doing that? How long does the hip last? Any guesses? So, a hip usually lasts about 20 years. That's the max, that's the, the longest or maybe 25 years is the longest the day to suggest. So if you're in your forties and then you've had a hip replacement, then you're, that will take you up to 65. That means you're gonna need to have a revision. If you have a revision at 65 then you're probably gonna need to have another revision at 80 or 75. The more surgery you have the best bones, the less bone stock you have. So, the worse the fixation, the worse the function, the worse the mobility and the more likely the risks are of having complications. So, you try and avoid doing hip or joint replacements in general in patients, less than 60 or at least 65. Yeah. And that's why they don't operate on 50 year olds. They sometimes do if they're crippled and they're disabled with pain. But that's not, that's not usually the main, the, the main group of patients that they operate on. Ok. So we're gonna move on to the hip uh, onto the back. But does anyone have any questions about the knee? Uh about the hip? There are no questions at the moment but um if any crop up, I'll let you know. Ok, perfect. So moving on to back. So back pain is really, really common. 90% of patients will experience back pain at some point in their life. Ok. Um, it's been reported that affect 75% of the population and mechanical back pain or lower back pain has been defined by the American Association of Family Physicians as uh pain that arises is intrinsically from the spine, the chest or the surroundings. It's the leading cause of disability and it could be due to a range of conditions, orthopedic and non orthopedic related conditions. Yeah. So with regards to orthopedic conditions, you can have muscle strain, ligament strain, you can have osteoarthritis, you can have, you can have disc disease. You can have spondylis, you can have narrowing in your spinal uh cord or or spinal canal, sorry. And that can cause spinal stenosis. So whenever you see a patient with back pain, you need to take a history and you need to examine these patients, key things you need to ask about is the pre presence of radicular pain or leg pain. That's particularly important because back pain in isolation may not warrant treatment. Ok. It may just need whether a steroid injection or whether they may need to be seen by the pain specialist. Rarely do spinal surgeons operate on patients with back pain in the absence of leg pain because leg pain suggests radicular pain which is nerve pain. So reducing the pressure on the nerve will lead to any any alleviation of symptoms, but it won't help your back pain. Ok. You need to ask about any neurological deficit, any numbness, any shooting pain, any weakness, any history of bladder or bowel dysfunction, or any sexual dysfunction, any history of any trauma. And interestingly in the American textbooks, they talk about the uh the presence of mental and psychiatric conditions because they significantly affect uh your perception of pain and also may contribute to non organic causes of back pain. When you see these patients, you're going to need to do an examination on an Asia chart. Has a new uh I'm hoping that you've all seen the Asia chart and you know what it looks like. Yes. No. Yeah, I think most of us would have perfect. OK. So the Asia chart basically is a chart that talks that that is something that you would fill out whenever you see a patient with back pain. And it's based on your dermatomes and your myotomes. Yeah. And you just need to tick the boxes. So one for so the sensor is divided into 01 and two and then your power is obviously your MRC scale for assessment of power. So one for sensation is altered, zero is absent and two is normal and you're doing it for light touch and you're doing it for pinprick, for motor, you have 0 to 55 is full power. Four is almost full power and against resistance, but not as mu not, not with full resistance. Three is uh against gravity but not against resistance. Two is not against gravity. Uh One, I think it uh it's, it's not, yeah, not and then one is flickering and zero is no movement whatsoever. Yeah. And then imaging. So you're going to do basic imaging. So if you think the patient has osteoarthritis or facet joint arthroscopy, you're gonna get ap and lateral views and oblique views. Um And then obviously the MRI scan is the mainstay investigations you're getting if you have a patient with back pain. So key things you need to establish in your history is the red flags. So extremes of age is varying. Patient, young patients with, with back pain is worrying if they've had a history of cancer. It's worrying pain at night, night sweats if they have any bladder or bowel dysfunction, if they have thoracic back pain, if they have a visible deformity. So the, the shape of their back looks a bit abnormal, then you need to, you need to worry if they have had recent weight loss or change in appetite. These are things that you need to worry about when you're looking after patients with back pain. Ok. So this is something that I found really confusing when I was at med school is what? Because you always hear these phrases and words, but you don't really know what they mean. So, spondylolysis is basically means degenerative changes in the back. Spondylosis is a stress fracture of the piculus, which is essentially a sheet of bone, which is between your facet joints. So between your superior and your inferior facet of each vertebra, there's a, there's a sheet of bone and that's called your ps enic. And sometimes that can break when it's a stress fracture. When that happens, it can sometimes cause the disc uh that can cause the vertebra to slip forward. And if that does happen, then it's known as spondylolithesis. So, spondylosis is degenerative back pain, spondylolysis is a stress fracture and spondylosis is when one vertebra slips in front of the other. Ok. Cool. So, stenosis. So that's one of the commonest things that you're gonna see. Oh, I have back pain and I have a bit of radicular pain. And it's basically when you have a reduced dimension of the central and the lateral lumbar uh spinal canal and it could be due to lots of different things. You can have bones so you can have osteo, it could be, it could be due to bones that are causing it to narrow or the facet joints. They can be hypertrophied, osteophytes and lysis, which is where you have union between the two. Then you can have ligamentum Flaum, which is one of the, the structures supporting the back and it can become thickened and it can sometimes cause narrowing and obviously discs, they can protrude uh and they can then therefore cause narrowing. What patients report. They typically report if sciatic pain, a pain shooting from their back through their buttocks into their legs. Yeah. Um they may report neurological symptoms in terms of weakness. They may report numbness and they may obviously report signs and symptoms of cordia quina, which are rare claudication. So, claudication basically means leg pain, but it could be due to a vascular cause or it could be due to a neurogenic cause. Yeah. So vascular claudication is usually due to peripheral vascular disease. Ok. So patients will say I walk a certain distance and I have pain, they will have signs of hyperemia. They will have, they will have maybe have absent pulses, maybe have an a, a cold foot or a relatively cold foot. Compared to a patient with neurogenic claudication. Patients with neurogenic claudication, usually they say when they bend forward, their pain is alleviated. And can anyone guess why? That's the case when you bend forward, what happens to this face? Does it increase or decrease? It increases? So the space gets bigger. So the pressure on the nerves gets less. And that's why when you're sitting, if you just, if, whilst you're sitting now you can feel this compared to when you're standing up, the space between the vertebral bodies is less. Yeah. And the curvature of your spine is more when you're sitting. So it means that there's more space. Ok? And then you're gonna examine the patient using an Asia chart and you're gonna make sure that you identify and see if there's any dermato or myoma distribution to their symptoms. Oh, sorry, I went, I'm going back. So you can see here. So this is an MRI scan. So this is a sagittal and this is an axial view. And you can see here there is a protrusion of the disc and it's causing narrowing of the, of the, of the spinal canal. Yep, on this side, you can see here there's some narrowing on this side and it's due to. So there's your spinus process. So it's probably due to a facet arthroscopy there that's causing the narrowing and that's your spinal uh well, the, the coral or your spinal canal. Yeah. So back pain or due to stenosis, it usually settles within the first six weeks and we know that surgery is no more effective uh than conservative treatment. Long term if you do have adequate relief. So non operative treatment would include physio, weight loss. Yeah, acupuncture, uh smoking, cessation, analgesia and obviously CBD and then surgery depending on the cause. If it's mostly due to a disc, then doing a microdiscectomy, which it means taking part of the disc out, which is causing the compression is often your treatment of choice. So we have two more topics left. Are you happy for me to continue or do you want to stop? Cos we're at seven o'clock now. Yeah, we can continue. Thank you. Yeah, perfect. Ok. So metastatic cord compression. So, metastatic cord compression is what that and cord equina are two of the most important emergencies that you need to be aware of. Um So it's common, it affects 5 to 40% of patients with cancer, often affecting in the thoracic spine, then the lumbar spine and then the cervical and sacral spine. Common primaries that metastasize to the back are your breast, lung, prostate thyroid renal melanoma and colorectal. Most of these meds are osteolytic, but breast and prostate are osteoblastic. So they form bones again, like anything that's important and it has a massive burden. There's guidance on it. So the nice guidance was updated in September 23 and it has guidance on every single aspect and how you manage these patients. It obviously focuses on having an MDT approach. So who or which individuals do you think are important to be involved in managing a patient with metastatic cord compression? Who would you want to be involved anyone? No. So you want your oncologist? Yeah, ideally, you would want a GP to be involved. You want the spinal surgeons to be involved. You want the individual who's providing the radiotherapy, which is often the oncologist to be involved, you would want the physiotherapist to be involved, the nutritionist to be involved. Yeah. So you need a whole team of people looking after these patients. It gives you advice on to when to refer and what are your different treatment options? The aims of treatment is to alleviate pain, to achieve stability, to re mana manage the tumor site and optimize the the quality of life and the Yeah, and obviously to preserve neurological function for these patients. So in terms of general management, so if you see these patients in A&E um they're often admitted under the medical team and then you would seek support from the spinal services. You may, you may consider giving dexamethasone or a steroid of some sort. If the patient has a hematological malignancy, you obviously want to liaise with hematology. Sometimes bisphosphonate works in terms of managing patients, specifically, those who have a uh a me uh have a myeloma, breast cancer or prostate cancer, bisphosphonates work really well. Um If there's evidence of instability, you may consider to immobilize these patients. Yep, you can either put them in a collar or put them in fat blood rest or put them in at LSO brace. As we said, we want to involve the oncologist. So they may consider doing chemotherapy, immunotherapy or hormone therapy or radiotherapy, which is the mainstay treatment for metastatic cord compression with regards to surgical management. And this is when you're seeking support from the spinal surfaces, it's there is three, there's two main indications as to why you would want to operate on a patient. So in the evidence of mechanical stability, so I've asked several spinal surgeons how you can establish whether the spine is unstable and it's very difficult to ascertain it comes with clinical experience and just clinical acro. But the key feature is that will tell you that their spine is unstable is one if you have a deformity. So if you have a visible deformity or if you have a deformity on weight bearing as in when the patient stands up, and the spine's not able to tolerate physiological load, and therefore they develop a deformity that tells you that the this is unstable if a patient has ir retractable pain and this is really difficult because different patients have different pain thresholds. But if a patient is in agony, then that will tell you that it's probably unstable and in the presence of a neurological compromise. So if they have neurology, that is, that goes in line with the radiological features that you're seeing, then that tells you that this is an unstable spine that requires stabilization. And obviously, neurological compromise. If they have, as we said before, if they have any neurological symptoms, then that would warrant them to have surgery depending on what you have. And whether in, in the presence of instability, in the presence of instability, you may do a decompression plus minus stabilization. So a decompression is basically getting rid of that tumor or debulking that tumor. So that you are allowing those nerves space to breathe. Stabilization is you're putting pedicle screws and you're putting rods to stabilize that spine because that spine is essentially crumbling into pieces. Yeah, if someone has widespread disease, so has disease at the lumbar spine, thoracic spine. Um cervical spine, would you offer them surgery or do you think they would? So that patient would be amiable to surgery? It's a yes, no, no one's answering but no, no. So they would not be amenable to surgery. So that's why it's really important that you have a prognosis from the oncologist and you have a full imaging of the spine uh before before deciding what you want to do in terms of managing these patients. Ok. The last thing we're gonna talk about is Corda Quina Syndrome. So, Corda Quina syndrome is really really important. The reason why it's really important. It's because it's time critical. But also there's a huge amount of litigation around Cordo Quina because it has a massive burden on the patients if it is misdiagnosed or if it's missed. So it is a clinical diagnosis and it's a constellation of symptoms resulting uh symptoms and sign that result from the compression of the cord equina. And it usually presents with lower back pain, The presence of leg pain, often bilateral and uh essentially dysfunction to the bladder and bowel. Um It can be divided depending on the extent of the neurological deficit into incomplete or complete corna or it could be subdivided into cor equina. So su or suspected, which is they have radiculopathy, but they don't have bladder and bowel symptoms. So these are the early stages of quina or it could be quina incomplete, which means they have bilateral leg symptoms. They don't have complete urinary continence or retention, but they have urinary symptoms or bowel symptoms. So things like frequency in the absence of a uti or they have uh yeah, increased frequency from a bowel perspective in the absence of an infective course. Yeah. Or it could be cardioquin retention is where the patient has an instate bladder and they've gone into retention. Ok. So, these subcategories are really important because it tells you when you should intervene surgically. Yeah. Um So if they have coral retention, so you're obviously going to need to intervene, inter intervene sooner uh than you would with a qui suspected. Yeah, but it's, it's just as, as a framework for you to know what you need to do. Usually after 72 hours, any loss of neurological function is not restored. So that's why it's time critical that you make sure that you diagnose this condition, this condition quite early on. Yeah. So there's lots of different causes but it's essentially, it's a compressive, it's a, it's a compressive condition. So you have something that's compressing on the cord equina. It could be a due to a disc which is the commonest cause. It could be of trauma, it could be a fracture, it could be stenosis, it could be a cancer. You can have ankylosing spondylitis, which would mean that you're having uh your spine is basically fused. You can have Paget's disease, which is making your spine stiff. You can have spondylisthesis. So one disc, one vertebral body is slipped in front of the other and that's why it's causing compression. Yeah, the pathophysiology behind uh Cordia equina syndrome is they've described it as either due to mechanical compression. So that results in reduced blood supply and then that results in a reduced CSF diffusion or it's also been described as intraneural compartment syndrome. So essentially what happens is is that you have increased pressure within the venous system that leads to edema and hyperperfusion. So that means that the arterial flow into the spinal cord is reduced, which means that it leads to ischemia. Uh again, like anything important, there's guidelines on how you need to manage it. So uh last year updated how you manage coa and there's this lovely pathway which tells you what you're meant to do whenever you see a patient with back pain and how you're meant to manage. And you can see here that it goes through, you're triaging them. If you, if you suspect they have symptoms of Coria equina, you then need to refer to the secondary hospital. Uh the second. Well, yeah, secondary uh secondary care where further investigations need to happen, key things that you need to know when you're, when you're looking after these patients, that you need to do a bladder scan on these patients and you need to make sure that they are emptying their bladder. Um So you do a pre and post void bladder scan. The other thing is is that the most recent guidance has now suggested that you do not need to do apr examination. And that's quite controversial because historically, the teaching has been, you do apr examination, you examine for anal tone and you also examine for sudden anesthesia, but now you are going on the subjective assessment of the patient. So if a patient tells you, I have numbness in my back passage, that is enough and warrants an MRI scan. Ok. Uh The guidance also suggests that these MRI scans should happen within four hours and then you need to refer to the spinal service accordingly. Uh And then based on that, they can then decide whether these patients need surgery. There's also bas guidelines. So bas is the British Association of Spinal Surgeons and it gives a detailed account of what needs to be done uh for these patients, uh which is the same as what g but it's also another set of guidelines that you need to be aware of and that is the end of my talk. So um there's quite a lot of resources around. Um I don't think you need to know or you don't need to know that ao uh that or you don't need to read the AO S book, but this is a really good orthopedic book that will help you prep for the fis. Uh And that is the end of my talk. Does anyone have any questions or anything that you would like me to go through again? Um Yeah, there don't seem to be any questions at the moment, but um thank you so much, Sarah for a great talk. Um That was really useful actually, I know quite a lot. Um and I hope everyone else enjoyed it too. So uh we've just sent out the feedback forms to everyone. So um yeah, I think some people might have shot off. Um But we'll send them out to everyone and they should be sent to your medical accounts and to your emails So if you guys fill that out then you'll get your certificates. Um but otherwise yeah, thank you very much, Sarah. No worries. Take care. Thank you. Bye.