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She learned for five seconds. Hi, everyone. Thank you for coming. Uh, I'm Richie. I'm a 40 medic currently at the University of Leicester and I'm one of the, um, education reps on Sumpter this year. Um, today we've got Justin with us. Justin is a 40 a medic at Trinity College Cambridge. Um, Justin is interested in surgery but he's not quite sure which specialty he wants to do. Um, on the side and within medicine, Justin does enjoy doing a little bit of research outside of medicine. He enjoys playing football and going to the gym and Justin, why don't you take it away? Sure. Hi guys. So, I don't know, can people say stuff or am I expecting? I think they can see it through the chat last year. And that's unfortunately one of the limitations of this platform. So if anyone wants to contribute anything, then feel free to type in the chat, but I'll just talk about a bunch of stuff. So today's thing is about orthopedic conditions and just some of the more common ones, I guess. Um, and sort of key features about them, some of the pathology underlying them management investigations. All of that stuff. Um So firstly, we have say you're an E D and you, a patient comes in and they've got a swollen knee joint. The first thing that we have to exclude is septic arthritis because of the associated risks afterwards, it may not be septic arthritis. It could be like an infusion. It could be, you know, gout, it could be some sort of hemi arthrosis bleeding after like trauma. But we have to exclude septic arthritis because of the complications that could follow. So when the fluids accumulating the joint space, I don't know if you can see my cursor but you can, there's an increase in the intra articular pressure into articular pressure and that compresses blood vessels leading to ischemia um and necrosis, ization of the affected bones and cartilage and therefore joint destruction. So that's why we need to exclude septic arthritis as a as a primary um goal. So, septic arthritis, obviously an infection within the joint. Um and the most common cause is uh denoted by this diagram here. So these grapelike cost clusters, I don't know if anyone knows what those are. Um but that stuff stuff aureus, which is these grand positive purple grape like clusters. But then this is why taking a history is often important because another really important cause especially in sexually active young adults is Neisseria, gonorrhea, which presents with these gram negative coffee bean dip like cocky um usually as a result of disseminated infection from um the urinary tract. Um So, septic arthritis is most commonly found in the knee. Um and the most common causes hematogenous spread from a distant bacterial infection or abscess. So, given that besides the presentation here, we're going to have, you know, signs of infection like fever, lethargy, potentially sepsis or hyper like, you know, hypertension, tachycardia um in the patient systemically. Um So other things that important to take from the history, our recent surgical operations because septic arthritis is very common and important complication of joint replacement. Um So, obviously examining properly and that you would be able to feel if there's been a knee replacement if they don't tell you. Um And we'll talk about aseptic loosening a bit later on, but that's ultimately just the failure of a joint prosthesis um without any sort of mechanical cause or infection. So that's something to bear in mind. Um But ultimately, it's, it's associated with osteo isis and an inflammatory cellular infiltrate within the joint. Um So this is all that going on in the back of your mind. But obviously, when you look at the joint and it's swollen, when we have to exclude septic arthritis, the things that lead us towards that direction are things like if it's, you know, acute onset, acutely swollen, hot erythema tous read, um the fluids sort of fluctuate around it on examination, things like a reduced range of motion um in the flexion, uh and an inability to wait there, perhaps an abnormal gait. Um So you might observe like when they're walking and antalgic gate, but they're sort of like limping. Um So say this is their right leg. So if they're limping, then the stance phase will be much shorter than the right leg compared to the swing phase. And that should be quite obvious to see if you, if you look at that gate. Um an overall sort of joint stiffness when you're doing your passive movements of examination um can point in this direction. Um I said about the signs of systemic infection. So like the fever, fever, general tiredness, uh wriggles, sepsis, things like that. Um and also the Euro toe uh urinary genital symptoms that sort of make coincide, especially if it's from a Neisseria infection. Um Yeah. So other clues towards a Gona Kaku or um sort of a non staph aureus infection is if the septic arthritis is affecting multiple joints or their skin lesions or tenosynovitis that you can see it's quite obvious. Um But especially in Children, we can use criteria like conscious criteria, which are four things to assess the risk of septic arthritis. So that's if the fever is greater than 38.5, then nonweightbearing, there's an increase the s on increased white cell count. But those things are obviously ultimately just guidance. So the first line of investigation, we're gonna be um taking sign over your fluids, a joint aspiration, basically. And doing a range of tests on that. So, gram staining, which we've talked about ready crystal microscopy to exclude other causes, which I'll talk about later culturing and testing for antibiotics, sensitivities prior to giving antibiotics. Um, the fluid should be purulent and have an increased white cell count and that will pretty much give you a diagnosis. Um Some people do blood cultures as well, but to be honest, um probably wouldn't necessarily add that much if you've got the gram stain already. Um So on this right hand side, we've got an X ray of someone's hip joint. Can anyone spot where there is some evidence of septic arthritis? No worries, if not, but around sort of this region is sacred iliac joint, you can see this like diffuse edematous appearance, um and bone erosion around here and the joint effusion. So sometimes in these situations, the joints are a bit hard to aspirate and obviously your knee. Um So if these sort of emperor of antibiotics might be given just based on suspicion. Um So given that the most common causes staph aureus, which is grand positive, then we would choose antibiotics that cover those. So flu clocks are still in all the penicillins cover antibiotics, cover grand positive um infections. Well, and obviously, if it's MRSA, then we've had Vancomycin or Tiger Planning. Um Whereas in the gram negatives, we would use like third generation Keflex Boren's so like kept traction. Um So I guess it is quite important to identify what the underlying causes because if you give, you know, sort of the other antibiotics for grand positive, negative, there's not going to be any response. Um, I think the important thing is to just spot the diagnosis and then if you're unsure of certain things, such as like if there's prosthesis present and they need to, you know, go to, um, replacement surgery, um, that can just be elevated to a specialist or someone more senior. Um, but it's likely that if there's been a total joint replacement, they'll need some sort of revision surgery. Okay. So, moving on. So the next condition I wanted to talk about is gout because I think it's very common as well and it's quite easy for it to be in a Noski given that it's not that serious, I guess. Um, so gout is a crystal arthropathy, um which is caused by the deposition of monosodium urate monohydrate crystals in the sign opium. Um And then they create these to fi subcutaneous uric acid deposits that are sort of like swollen lumps um on your, on your feet or your ankles or your elbows. But most commonly around here, which is the first metatarsal Fallon, um, van Children, um, which they called podagra. Um So most presentations affect this area and the maximum intensity of pain usually occurs in around 12 hours. So the patient presents with significant joint swelling, um, pain erythema, and it's probably a good idea to look at other areas such as the, as I said, the ankle, um, wrist and the knee is, these are affected quite commonly as well. Um, in the case where it's the knee, again, we're going to be trying to exclude septic arthritis first because that will be life threatening. Whereas gap wouldn't be. And if we were able to exclude septic arthritis, then that would be one of the differentials that we've been considering. So again, in terms of investigation sign over your joint fluid aspiration, it's pretty much your key and you won't find any bacteria on culture, but you will find these negatively by a fringe int needle shaped monosodium, um urate crystals on the polarized light filters. Um It's quite complicated to explain why they're sort of they change color with like the direction they go. Um But basically they become blue when they're aligned with the direction of the polarizing light. But I guess the main thing to know is that the needle shaped um compared to pseudogout, which we'll talk about a bit later. Um Okay. So other things, yeah, if we're examining their hands as well, you can see these um soft tissue toe fires. So the uric acid deposits um in various joints in the hands. And the main one of the main. But another investigation that you would use perhaps to confirm if you, if the aspiration was a bit tenuous is an X ray. So there's quite a lot of signs for gout joint infusion here is a very common sign, um which kind of can give the diagnosis. Another key feature here is the preservation of the joint space until late late disease. So this is obviously different osteoarthritis where you lose that joint space. Um But you can see that, you know, across various joints, it looks pretty normal. Um Other things that we're looking for are sort of here, we've got punched out erosions, um which also have these, like you can see sclerotic margins um and also lytic lesions with overhanging edges. So, lytic lesions are kind of like u shaped kind of here and on the side as well. Um Again, the history can support this. So with the septic arthritis, it would make sense if you were thinking about sort of a human collagenous spread cause if they were like, you know, perhaps very sexually active. Whereas in gout, it tends to be a later, a disease of later age and the patient tends to be a male who's a beast with a high puree and high meat, high sort of oily fish diet, someone who's a perhaps a chronic drinker as well. Um But then there's also other factors um in there sort of medication history. So things that reduce uric acid secretion which forms these um swellings. So like thiazide diuretics, um CKD aspirin dehydration, all of them can increase the risk. Interestingly, um Losartan or angiotensin receptor blockers in general can lower the risk because they have a sort of a uh uricosuric uh effect where it can reduce levels of uric acid in the body. So, in patients with hypertension, that's obviously an important point. Um So treatment wise is kind of to reduce this uh information. So we start with nsaids or culture seen um if the insides are contraindicated, like in heart disease or renal impairment, impairment or peptic ulcers or things like that. Um But culture scene has the side effect of dose dependent diarrhea. So it's important to give the patient knowledge of that when you prescribe it. If both of them are contra indicated, then you can give or cortical steroids like prednisoLONE a low dose every day or steroid injections into the joint. Um If that fails, all of that fails, then tend to move on to xanthine oxidase inhibitors. So you can see in this um sort of biochemical pathway here that the ultimate last stage informing these uric acid deposits is from Sandton to uric acid by the Xanthine oxidase enzyme. So, allopurinol is the first line that inhibits this enzyme. Um and it tends to be given to all patient's after their first attack of gout and they can continue taking it sort of in subsequent um attacks of gout as well. Um But I think a really important factor to consider is the lifestyle changes. So things like reducing alcohol intake, losing weight um of avoiding foods that high in purines, there's like, you know, liver, kidney, seafood, oily, oily fish. Um and those tend to help quite a lot. I think this picture in the hands here is a result of chronic gout. So when you get these repeated episodes in different joints, you get these subcutaneous deposits um all around the hands and then that also in itself has risks of kidney stones and urethra prophy later on. So I think it's quite an important condition to nip in the bud earlier. But I would say not as life threatening as um septic arthritis. Okay. So pseudo gout is kind of similar in how it presents, but the investigative findings are completely different. So pathology wise is also crystal arthropathy, but it's caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovial as opposed to the the urate monohydrate monosodium, uh sorry monosodium urate crystals. Um and other things in the history that predisposed to pseudogout of things like having osteoarthritis already, um having sort of hyperparathyroidism or increased calcium from whatever cause. Um hemochromatosis, Wilson's disease and low phosphate, low magnesium. And these things can be checked obviously by blood test. So they can give sort of indications to um the diagnosis. But typically the presentation I guess is similar to get, you've got an older adult, they've got hot, swollen, stiff, erythema, tous, painful joint, typically, knee joint, um can affect the wrist and the shoulders as well, but primarily primarily the knee joint. So again, because we're worried about septic arthritis, we would use sign of your aspiration. But this time, the picture is a bit different. Um because again, there'll still be no bacterial growth, but you'll get these positively by a fringe int rahm bit rhomboid shaped, um calcium pyrophosphate crystals. So you can see that there are obviously very different in appearance to the needle shaped ones in gout. Um And that excludes. So here you can see the rhomboid shape that excludes the septic arthritis and kind of allows you to chill out a bit as a doctor. Um Again, if we were to conduct an X ray, a sort of um diagnostic finding for pseudo gout is this thin line of calcification through the middle of the joint, don't know if you can see that um which is known as chondrocalcinosis iss and that's diagnostic for the condition. So these linear calcifications of the mini sky um and also it does sometimes present with features of osteoarthritis as well. So, you know, the loss of the joint space, osteophytes sticking out, subconscious. Glorious is the whitening and the subchondral cyst as well. Um But that obviously isn't diagnostic. The chondrocalcinosis is what's diagnostic. So, unlike gout pseudogout often is a chronic and a symptomatic condition that kind of lasts for a while. And in lieu of that, it doesn't always require treatment, the symptoms can often resolve spontaneously. Um But if we were to treat it then a similar thing to get would be done to enter as a culture seen or steroids. And in some cases, we'll need to do um joint wash out or yeah, I was very synthesis, I guess in, in some more severe cases. Um Yep. Cool. So the next condition I wanted to talk about his compartment syndrome. So compartment syndrome basically denotes when you've got an acutely re raised pressure within a closed anatomical space. So that could be kind of anywhere really. But the main fractures that cause this are super condo to. Um so in the in the arm and also tibial shafts. So here we can see in the leg. Um so besides fractures, things like burns, crushing, penetrating injuries, a scheme of reperfusion injuries, all of those can cause compartment syndrome. Um and what happens is so an example of trauma or fracture, the excessive bleeding and adama compromises tissue profusion even further until you get necrosis. So you get swelling of the muscles, firstly, but you would get necrosis um that would cause further inflammation on a Dhiman further swelling, you're compressing all the nerves and vessels so that basically your foot becomes a scheme ick. And um you know, you can get, you know, acute limb threatening ischemia and all of those like the six P S and things like that. Um So I'm not sure if they spoke about it yesterday, but with regards to the anatomy of the leg, it's divided into Moscow compartments. So we've got an anterior compartment here, the lateral compartment and then two posterior compartments deep and superficial. And then obviously, they're associated neurovascular bundles. Um I guess we don't necessarily need to go into the, I mean, we could. Yes. So the anterior compartment is all supplied by the deep perennial nerve. Um And predominantly the functions are too dorsiflex, the ankle or extended toes as well. Um an inverter and Eva the depending on which side we're looking at. Um whereas the lateral compartment or the perennial compartment is all e version and plantar flexion um and supplied by the superficial peroneal nerve because it comes down. So the the neck of the fibula and looped downwards and then the deep and superficial. So the superficial posterior compartment is are basically carved muscles. The plantar flexion and gastrocnemius can also flex the knee and that's innovated by the tibial nerve. And the deep posterior compartments also innovated by the tibial nerve, but it's mainly toe flexion um and plantar flexion. So I think that's kind of important just because you can sort of identify which compartment is affected more when you examine the movements of the lower limb. And also when I talk about the treatment later, it kind of address is this and asked me, um which is quite important, but usually you can see this appearance in this right leg of like a would it looks like it's a would like feeling um of compartment syndrome. And the patient usually presents with a very deep burning pain that seems out of proportion um to the injury, the injury or examination findings. So kind of like um acute mesenteric ischemia, similar thing but in the abdomen, um and this, this pain can be observed especially on the movement. So it's unlikely that they'll be able to do any active movement. But even when you passively move, you know, so when you plant flex, you're gonna be stretching the anterior compartment and alternative movie dorsiflex, you're going to be stretching the posterior compartment. So, from those movements, from those passive movements, you can kind of localize where um in the leg is being affected more. Um I mentioned about those peas earlier so that parasthesia, pallor paralysis, perishing the cold, pulseless. Um those things might might be present as well. However, even if there is a present arterial pulse, so maybe posterior tibial in the medial malleolus um or the dorsalis pedis, that's just lateral to extent. How is his longest tendon? Um just because one of those may be present, it doesn't rule out this diagnosis. Um So that kind of distinguishes that from acute limb ischemia. Um So one of the ways we can assess if it's not already quite obvious that there's compartment syndrome is with this thing here, which is a needle is needle manama tree. Um So you can measure it into intra compartmentalize pressure. Um A value of over 20 millimeters of mercury is a bit abnormal, but over 40 is diagnostic of compartments, injury and other things that when you know, when they take blood because they take blood for everyone really. Um there will be evidence of rub Gemayel icis. Um my my license, sorry. Um if there's a raised creatinine canes and you can also see on your analysis um if there's raised red blood cells, there's no pathology on X ray. So that's pointless to do. Um So the immediate thing to do is to escalate orthopaedics who would in a trauma situation, remove the external dressing because you don't want to compress it more. Um and elevate leg too hot level to try and improve flow back to the heart. Um I mentioned earlier about the treatment in very like emergency situation, which is this emergency fasciotomy um which basically involves keeping the wound open until the swelling improves itself. So you can see like in the interior component, we've got necrotic tissue and the blood supply is being compressed by the edema. So they do long incisions on both sides. So one on the lateral side, one on the medial side and then that allows them to access the lateral and interior compartments and then they do another sorry. The lateral incision allows them to access the anterior lateral compartments. And then the media incision allows them to access the superficial and deep posterior compartments. So they basically cut through the fascia and sometimes even like some aspects of the super superficial parts of the muscle in order to release the pressure. Um Yeah. So the deep muscles in the lower limb, especially maybe inadequately decompressed by smaller cups. So often they have to go quite deep in order. So especially like the deep posterior compartment to, to sort of free up the pressure. Um As I said, for the um rhabdomyolysis, the myoglobinuria may occur and cause renal failure. So often these patient's need to be given aggressive IV fluids as well. Um And similarly to acute limb ischemia, if there are signs that the limb is necrotic, um you know, gangrenous ulceration, it may be required to do an amputation. But obviously, this is a really last last resort. Um I think it's important to say also that in patient's who have sort of just been exercising, especially like athletes. Um in exertion, the compartment of pressure rises um as a sort of normal physiological response. So the blood flow is normally restricted as well, but obviously, that will resolve and rest and it's not an emergency. So, compartment syndrome is when you get this picture that doesn't seem to resolve itself. Um And sometimes with regards to the peas, the pain and parasthesia can be localized to a single compartment. Um So, so sometimes these three cuts may not be necessary, maybe only you need the lateral one to access the anterior compartment. If for example, the, you know the to be a list muscles are on the front are affected. Um yeah, cool. So the next condition is another infectious condition. So, osteomyelitis, you get information of the bone and the bone marrow typically around the meta meta fossas. Um And again, most common causes staph aureus. It is great like purple clusters, but sometimes especially in those of sickle cell disease, we'll get these gram negative rods. So, um usually from salmonella and again, the cause is a human collagenous. So, bacteremia spreading in the blood from, from a primary source. Um And in adults, the most common place for Osteomyelitis is in the vertebrae. So we obviously, again, infected this care. There's a potential for the formation of an epidural abscess. Um and that can spread, the infection can spread into the vertebrae. So then you can get this Osteomyelitis. So obviously, this abscess is compressing on the spinal cord. So, depending on what level, uh you, you'll, you'll expect what the patient will present the symptoms below that level. Um In terms of sensorimotor, um there's also examples of non hematogenous spread. So sometimes like these adjacent soft tissues or, you know, direct contamination from trauma or fracture site or during an operation. So that's why if you've ever been into um Atieno surgery, they're very, very like particular about, well, I mean, all surgery is very particular about cleanliness, but especially in TNO, it's, it's the utmost importance because of the risk of things like osteomyelitis. Um So in joint replacements, especially like they can really cripple, um the prognosis and lead to a re replacement surgery, which obviously the patient wants to avoid. Um, so, besides the sort of neurological signs, the patient also presents with those classic fever pain, tenderness, erythema, swelling, um an inability or refusal to use that particular limb if it's in the leg, um or wait there and they may present in like a spine osteomyelitis with just very nonspecific symptoms of lethargy, nausea, muscle aches, back pain, um which is why it's important to have your suspicions sort of their. Um and combined with other examination findings. Um and you know, blood tests which show raised white white cell count, crp ESR um to conduct scans. So usually an MRI is best to visualize osteomyelitis. And you can see um in this vertebrae here and this, this, you've got disc enhancement and also the bone marrow enhancement compared to the other ones. Um And you can also see here, the edematous changes at the lower end of the spinal cord, x rays are less useful. Um And often don't really show any changes at all. And here there are some small changes which aren't very clear but basically periostem reaction. So the changes to the bone surface and you can see the osteo osteopenia here, which is the thinning of the cortical bone or just outright bone destruction from the infection. Um In this case, again, it's important to do bloods, uh blood cultures or sometimes bone cultures in order to establish the causative organism because that will obviously direct antibiotic usage. Um or whether there's a need to surgically debride the joint. Um But obviously, again, if it's Staph aureus, three cocks Acilin, um and sometimes they add rhythm person, refuse it a big acid. And if the Pencillin logic, then Clindamycin and then obviously the drugs for MRSA. Um yeah, I guess also it's important to know if it's associated with a joint replacement, then it will need a complete revision surgery to replace that joint. Cool. So, osteoarthritis is, um, something that I'm kind of quite interested in just because of the fact that there's not really a very concrete treatment for it apart from obviously joint replacement and things like that, which I'll talk about later. Um, and obviously we can't offer everyone with osteoarthritis, especially in this age of, um, increasing sedentary lifestyles, increasing levels of obesity. Given that osteoarthritis is a degenerative joint condition that can be worsened by things like obesity, lack of exercise or lack of bone, um, priming and younger age from weight training, things like that. Um, it seems likely that osteoarthritis cases going to keep increasing in future. Um, and obviously, we can't, I don't think we'll be able to keep up with just continually replacing everyone's hip joint basically because the NHS obviously stretched as it is. Um, so the important thing of osteoarthritis is that. As I said, it's a synovial joint wear and tear condition. It's degenerative and it's not inflammatory and usually it results from an imbalance between cartilage um being worn down and then cartilage being replaced with chondrocyte repair. Um So you get a loss of the cartilage and degeneration of the underlying bone, which makes sense that you get the loss of joint space if you're losing the cartilage. Um again, the knee is most commonly affected. So these are all these differentials that could affect the need, which I'm trying to um introduce. Um the hip is also very common and the hands as well. Um And that lends itself to a lot. So, examination findings. So as I said, risk factors for it, you can take from the history, you know, they're, they're sort of body habit, tous um their age, um the the occupation, especially if they've been doing something that, you know, like requires hard manual labor, you know, if they're a farm or things like that family history or any developmental dysplasias from young age. Um Interestingly, osteoporosis reduces the risk. So in sort of post menopausal women, that's quite important. Um I mentioned the for things that we look for for our CF ISIS already. So the loss of the joint space. Um So here you can see there's a medial joint space destruction here. Um and sometimes that can present with various deformities. So if you think about someone's leg and the medial joint space being uh obliterated. Then that can sometimes lead to a virus deformity. And also with the lateral side, at least a various deformity, it's usually doesn't really, you don't really see it, but you can appreciate that if this joint space was flattened or gone, then it, the tibia is gonna tip, sort inwards. Um Yeah, and then we've got the osteo fights as well, which I talked about sticking off and the sclerotic changes as well. Um Yeah, hopefully that makes sense what I'm trying to say with the, uh, the joint space narrowing. So medial joint space narrowing, you're going to get a various deformity because the knee joint kind of goes outwards, but your tibia tibias point inwards or the single tibia in this case where as an a lateral joint space narrowing, you get a valgus deformity because the tibia goes outwards, but the knees kind of lock together, it's very subtle. Um, but I guess it's just an interesting thing to have in mind. Um, so presentation wise, osteoarthritis has joint pain and stiffness that tends to be worsened by activity. Um, whereas an inflammatory arthritis conditions, the activity actually improves symptoms. Um, so osteoarthritis is worsened by activity but improves of rest. Um, things like rest pain, night pain, morning stiffness tend to suggest other things like inflammatory or rheumatoid arthritis. Um So those are key things to look at in the hand, especially with these changes. Also, arthritis can lead to weakened grip. So, you know, when you're testing that power in the hands, you'll notice that quite clearly. And in the knees reduced range of motion, hips as well. Um Yeah, so the hip osteoarthritis will present with reduced internal rotation. Um, sort of a groin ache after activity that's also relieved by rest. Um And the hand and knee especially because you can see them so well, the hands, we've got the Bouchard's nodes and the proximal interphalangeal joints and the heavens, nose and the dips. Um And then you've got the squaring of the thumb. So the nodes are a result of osteo fight formation and they tend to be painless. Swelling's so that's different from the gout swellings which tend to be painful. Um The squaring off, you can see kind of here looks very rigid, kind of a right angle of the thumb, carpometacarpal joint when it forms a saddle shaped joint with trapezius bone, and you get this sort of fixed abduction, deformity, a deduction um in knee osteoarthritis, especially when examining the knee feeling, you know, passive movements, extension reflection, you're going to feel the crepitus, you're going to see the swelling. And as I said, if there is a lot of joint space, then you get, you know, this malalignment, various valgus deformities. Um Yep. Okay. So often there's no need for investigations. If you know the history matches up, there's no sort of infective cause no inflammatory cause. Um But if we were to do X rays, those signs obviously very diagnostic, but importantly, the X ray signs don't always correlate with the severity of symptoms. So, I mean, I've seen patients who have all four signs like very severely, but they kind of didn't really notice anything. It was only sort of when they started walking a bit more one time that they noticed that there was a slight amount of pain and then when you get those deformities of the hip, you're going to get leg length discrepancies, which they noticed. Um Yeah, so in terms of treatment, the things that tend to start these tend to start with our education based. So weight loss, muscle strengthening, general aerobic fitness, orthotic sometimes. Um and then if it's more painful than using stepwise analgesia, so starting to proceed to mourn topical insides. Um and then, you know, elevating up to opioids, capsacin creams sometimes as well on steroids. Um There are a range of non pharmacological things that people do like tens, um shock absorbing shoes, joint supports things like that. But ultimately, the only treatment that actually cures the condition is joint replacement. Um Although they are investigating through Kozo mean, um injection treatments for sort of restorative properties, so there's a kind of a range of uh surgeries that can be done for a hip replacement. So the first thing I wanted to talk about is the hemiarthroplasty. So that spares the acetabulum. So remember the, the sort of groove in which the head of the femur sits in. But we replace the femoral head and the femoral necks in both cases, it's quite obvious here. The difference between these two images is that one of them is cemented and one of them is noncemented. And I couldn't really see the difference before. But when one of the consultants pointed out to me, I think it's more clear. So sort of around the neck of the femur, you can see what these arrows are pointing, especially this kind of this change in contour gradient that just surrounds um the, the neck of the femur. Whereas in the un cemented form there, there isn't anything like that is just basically put straight into the boat. Um So that's hemiarthroplasty, these, um and, you know, there's multiple components here as you can see. So we, we keep the acetabulum, um then we've got the cup, we've got a cup liner and then the ball and then that inserts all into the femoral stem, but then they drill into the um femur and then basically put it in. Um So that's hemiarthroplasty, the total joint replacement replaces the um acetabulum as well, basically. Um So, you know, you'll see that the orthopedic surgeons are very particular in which sized cups and cup liners and boards and things like that because obviously, if the goal is, well, if there's a leg length discrepancy because of the loss of the joint space, the goal is to try and get the legs to the same length again. So it needs to be very exact, very measured. Um Yes. So then other surgeries that they can do are things like hip resurfacing which basically spares the femoral neck. Um And you just replace the head and kind of like fix it in. Um So this metal socket fits into the end of the, the assad Tabin of the hip bone. Um And there's a kind of contentious between whether you, you cemented or unscented, uh un cemented is more common in young and active patient's, which makes sense because it would rely on biological fixation and sort of bone changes around the femoral necks around here in order for recovery to take place. Um And that preserves the femoral neck more than if you use cemented methods. Um An important thing about once we've done these joint replacements, especially when you're taking it. Uh Well, when you're about to examine the patient as well is asking them if they've had, if you, if you ask to examine the hip joint, it's important to ask them if they've had a recent joint replacement because when you come to the passive movements, you want to avoid some of them. So especially avoiding flexing the hip past 90 degrees because the normal range is sort of up to 100 and 2200 and 40 degrees as you can appreciate yourselves. Um So not crossing their legs as well. So like externally rotating, um and abducting as well because of the risk of dislocation and then they have to, you know, re operate. Um, another thing is because it's such a complex surgery. You know, we've obviously got risk of viti, so we need to give them a low molecular weight heparin for four weeks. Um, sort of give them patient education on when it might be dislocated. So most commonly you get the posterior dislocation, um And you'll hear this sort of clunk sound, internally rotated leg and an inability to wait. Best things like that are quite important to tell the patient. Um I talked about aseptic loosening a bit earlier, especially in the cases when it's not cemented. I mean, even if it is cemented, but especially in the case was when it's not cemented. Aseptic loosening is one of the most common causes of um replacement, joint replacement revision. Um You know, if there's inadequate initial fixation with the cement or over time in an unscented operation, there's a mechanical loss of fixation and this joint infection, for example, then this needs to be basically redone. Um So that's osteoarthritis. And the last condition I think talk about um, short and sweet is bunions or hallux valgus. So again, we've got bony lump over usually the first metatarsal Fallon Jill joint. So similar to gout, the pedigree of gout. Um So this bony lump creates is created by this deformity where the first metatarsal starts pointing immediately and then the hallux bones are angered laterally and that leads to inflammation, enlarged sort of the swelling here. But importantly, it develops very slowly. Um and usually things in the history such as, you know, wearing too tight shoes or pain when walking as well can point towards this diagnosis. Um I talked about varus and valgus deformity is before and it took me a while to get my head around them because they're so similar. So when we had this situation here, so when we lost the medial joint space, we had a virus deformity. So these legs are kind of showing a virus deformity and virus and valgus, we look at basically the um the like bone below the joint if that makes sense. So in the case of nioc arthritis in a various deformity, the bone below the knee joint is the tibia. And what what I mean to be a favorite or whatever, but the tibia mainly and it's going inwards, right? So various deformity has the lower bone going towards the midline. Um So the valgus, on the other hand, has it going away from the midline. So in bunions or hallux valgus, um like the clues in the name Halik. So you've got the big toe valgus away from the midnight midline, whereas the metatarsal bone is going towards the midline. So it's a virus deformity, um which kind of lends itself towards osteoarthritis. So if there is additional joint stress, like if you keep sort of walking in tight shoes, when you're, when you're creating this deformity, then that can lead to osteoarthritis. Um The deformity extent is usually accessed, assessed with a weight bearing X ray. So someone standing up and you can see clearly the deformity there. Um Conservative management, we always start conservative management force for orthopedic things. So wider shoes that are comfortable, analgesia bunion pads to protect from friction. Um But if that all fails, then surgical methods can be used. So basically using a pin to align the hallux bones and then drilling through the metatarsal so that it can be manipulated back into its normal alignment. Um And then kind of like when you have a hip fracture and you're using uh sort of internal fixation methods. Um similar sort of thing you put the pen through into the medial cuneiform bone and then eventually, what should hopefully happen is that the metatarsal bone heals and then you get the proper alignment again. So ultimately, the surgery is to realign the bones and correct the underlying deformity. Um And that's it. So I would welcome any questions um and would appreciate if you guys can fill out a very quick feedback just to let me know how to improve next time. Feel free to type questions in the chat if you have any. No worries, Nicole. Uh um What else can I talk about? Mhm I guess if no one has any questions. Um Just like an additional thing about osteoarthritis is that since so many of the risk factors are kind of lifestyle related, it's often difficult to. So we, we know there's established links between things like increased B M I and osteoarthritis. But obviously, these are usually observational and retrospective. So it's not often duck kind of solidified. Um So and so other risk factors like smoking, like drinking alcohol that we may want to assess. We're not going to be able to necessarily assess in people because you can't just make someone smoke for 50 years and see if they've got an increased risk of osteoarthritis, right. So increasingly, they're using statistical methods where you can basically use snips or the genetic variants that predispose you to smoking more or two, drinking more or to being obese or having a high B M I and using those two proxy for as if that person actually smoked. And the reason that's quite useful is because firstly, it's robust. Secondly, it's not just like an observational link, it's based off um sort of like standard errors and beta values for those snips. And also because as you know, a single, um, a snip has a corresponding gene or gene region that, that it links with. And so if you were to identify a particular snip that was increased, associated with increased risk of something and also was associated with increased risk was urethritis, then you've got this snip and you've got its underlying biochemical pathway that you can tap into. Um, and then potentially target that pathway with pharmacological, usually pharmacological because you can't really mechanically target a gene. I mean, actually could, but it tends to be pharmacological methods. Um, and then try and reduce the risk of osteoarthritis. Um, so I think that's quite an important and interesting up and coming thing they're trying to do because ultimately, as I said, the only treatment that fixes osteoarthritis completely is the joint replacement. Um, and we're not going to be able to cope if, you know, increasingly obese and sedentary populations and everyone's got a c arthritis. I think it will probably become a, not even a condition anymore. Just be like, oh, yeah, everyone kind of has osteoarthritis. Um, so, yeah, having, you know, if we were able to, um, investigate those molecular pathways and specifically create drugs that targeted those things, then thus additional, um, sort of therapeutic power besides the things like painkillers and like capsacin creams, opioid creams, things like that, which I don't really tend to give people much respite from their pain. So I guess that's just an additional thing that is interesting if you guys are interested in that sort of stuff. Um Yeah, let me see. No worries, Rebecca. Yeah. So I think so if she's still there, but I think that's gonna probably conclude today's lecture. Um, if no one's got any questions, hopefully it was useful. Um, I'm not sure if my email was anywhere but if needed, then dropped either Rishi or Florence to organizing this message and I'll get back to you. Cool. I hope everyone has a good evening and I'll see you all soon. Right. Yeah.