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but I'll try and give a. I think the key with the Vival with the exam is really to It'll come as a viable question and you have basically five minutes to to go through and gain as many marks. I think if you have a sign posted systematic approach to to your answer and you're you're you're saying the key things and the keywords and you're you're not missing out the important things. I think that way, it'll first of all avoid them asking you questions. You don't know the answer two, and it'll make sure that you know you. You score the marks and you you'll be able to guide the Viber the way you want it. Um, and I think, as with any other Viber, having key headings and then expanding on those headings is one way. Sort of. Having those headings in your mind is one way to avoid uh, being lost or missing out the important thing. So I think pretty much what similar to to homes are split. So I'll expect into Stage one and stage two. So the first stage one is initial management in e. D. As as one said, If you get this bit right? Then I think you passed the exam. Um, you know, mentioning this is a high energy mechanism. So, uh, I'll approach it with a t. L s ensuring I don't miss that. Any major head, abdominal chest injuries, uh, to use as you mentioned. And I think the key word is in neurovascular assessment is two things. When I mentioned, uh, one is, uh, a a BP i s as he said, and in summary, essentially, you do a BP, i s and everyone after you reduced it. And if the ABP I shows is less than 0.9, then you're gonna investigate further. If it's above 0.9, then you you can pretty much be rest assured that there isn't a vascular injury. And and the other key bit in this initial assessment is, uh, CPN, so we can have common point with no palsy in about 50% or more. So that's something that you want to assess initially in e. D. Um, and then splinting and Bt thromboprophylaxis. So with splinting, if it's presented to you dislocated and you have to reduce it, I'd say, Yeah, you have to put a either back slab or an expects if it's highly unstable, the back stabbers and holding it. But as I say, most of these presents, you know, more than half the patient has a dislocation. And it comes to you with the knee that feels unstable either to E. D or to your unique clinic. And I think with those ones, you could split them with a hinge new brace. Um, because if you think about it when it comes to doing the reconstructions either in ACL and PCL, you need to take the knee through a range of movement to be able to actually drill, uh, tunnels in the femur and tibia. So it's actually, uh, important to only splint if need be. Um, And if not, you want to get the knee going, um, in a safe way with a range of movement brace. So I think then. So if you've addressed you know, the initial management, you know, you've shown that you're safe. The controversy is stage two. So, you know, do you do late versus the reconstruction? What graphs do use in allographs? Um um autographs and then deciding which ligaments are actually injured. So you'd be surprised, Homes. Um, I've seen you look at the MRI scan, and it shows, you know, MCL sm CLS going p o l possible trichology bruised ACL PCL. But then when you examine them, you actually find it's giving a different story in a different picture. So the first important bit of stage two is deciding. Actually, which ligaments are oranges? Um, so we'll go through all that in detail. So, um, so let's move on to the next slide. Sorry. So So yeah, hum has been through all this and we'll go through again. The initial management of the dislocation. And exactly They said, this is the key, um, thing you want to mention, So A BP i s and C p m. So if he if they hear those two words, I'll do the A P job, and I'll check for the CPM then you know, you've scored the key marks here at the beginning. Um, okay. And so you've been so So this is the bit where I'll give you sort of a an approach which which I use, and I'll try and back it up with evidence as well. But I think if you if you do get to this stage in the exam Answer. And you You provide this approach. I think you'll you'll do, Really? You are in scoring the highest marks. So? So, As I said earlier, you get a completely different picture examining the patient versus the MRI scan. So you should never look at the MRI scan and based your reconstruction on the scan. So if they're awake and they presented to acute any clinic having had a dislocation and spontaneously reduced, you do a clinical exam. So assess, assess for like, man, look at posterior side for the PCL. MCL. You want to test? Uh, if there's an end point to the MCL in full extension, that tells you whether the p o l the posterior of leak ligamentous injury, um and then you want test valgus stress at 30 degrees and that that isolates these official MCL um, posterolateral corner? Um, there's two ways to assess that. So you have a dial test. Uh, doing it at 30 degrees will tell you whether it's a pasta lateral corner. If there's laxity an opening at 90 degrees, that's usually, uh, usually, uh, means that there may be a PCL and uh, posterolateral corner injury. Um, if you're not sure, So then there's a couple of times it's There's a validated way to confirm, um, whether or not a ligament is definitely injured and needs reconstruction. So here's an example of assessing so the lateral structures and posterolateral corner so stress testing with X rays. Um, if you have so this is comparing the left to the right knee. So So the way to know is always comparing the good versus the bad side. So if you have more than two mills of opening on various stress, compared to the Contralateral side that usually signifies at LCL in June if the difference is more than that. So if it's six millimeters, as you can see here, so there's a there's a huge difference. There's six millimeter difference opening between the picture on the right to the right knee, the injured knee and the left knee. Then that means that you're likely to have damaged both your posterolateral corner and your, uh, LCL. So most of the time, and usually what happens with needs in clinic. When you're assessing, you get a good idea of which ligaments are gone and rarely you do need to do stress testing. Um, X rays are really important. So one way to decide. So they do ask you OK, you're gonna are you going to repair or reconstruct? Uh, to keep it really simple? I would say if there's any avulsion injury which is clinically unstable, I would repair. So here you can see a PCL avulsion, which is displaced clinically. When this knee was examined, you can actually see on the X ray. There's a posterior side. Um, so in this situation, you can you can repair. And this is what it looks like. So relaxed through a posterior approach for the knee. Um, other other fractures, which you can repair so into condos, spine fractures, uh, guard is typical. So the insertion of the I t band. If that's completely of also bone, you know you can repair that rather than reconstruct a lateral side. Um, and obviously MRI is extremely useful because it helps you decide not just what ligaments are injured. If there's any meniscal displaced fragments that need to be reduced and fixed. So there's a lock. Me, um uh, etcetera So and I think the the next part of the answer. So I split. Said so. The first thing first part of the of the, um, answer is working out. So deciding which ligaments are injured. So you've done that through your, um, clinical assessment. You've done that? Maybe through a new way. Um, or through stress, X rays. The next thing is decide. Okay. So what What am I going to? Am I going to go in early or immediately think comes up briefly mentioned cases where you'd want to go meet you? Am I gonna go? I wanna go early to to reconstruct a repair, or I'm gonna go late. So obviously the immediate ones, as as mentioned already, um, in the open injuries, irreducible a vascular injury. You know that that can't wait. Usually in these immediate scenarios, you would avoid acute reconstruction or repair. Because at this early stage, you don't know really what's damaged. So, you know, had a chance to To to do an MRI. Um, once, you know, the vascular injuries been sorted, the next bit has been put on. Then you can get an MRI scan until decide what you're actually going to repair and reconstruct. Um, so these are the indications of immediate surgery when it comes to, uh, multi ligament injury or a knee dislocation. Um, so the early ones, um, now usually the but But if it's if your present with a bike Cruciate ligament injury. So ACL and PCL, um, those don't usually heal with non operative management or delay treatment. You know, you'd want to reconstruct those early. Um, the other one is a possible actual corner. Um, uh, that does that rarely heals. And, uh, the recommendation is generally to go in and repair and reconstruct the posterolateral corner. Uh, the the ideal, the golden window is 14 to 21 days. And the reason for that is, um, uh, you need that you need 14 to 21 days for the capsule to see, because if you go in and scoped me, dislocated me within 10 days, literally. The fluid is just gonna see through, and you'll be able to do anything. Um, so it allows that time for the capsule to here. Um, it gives, you know, give. It also means that, um, uh, the acute inflammation is resolved as well, and there's less insult to the knee, um, and and the healing and stiffness is sometimes less as well if you give that short window of breast before going and and operating Um, so So the ones you want to go in early because you know they're going to be bad if you just leave them and treat them not Monopoly. As I mentioned earlier, the bike cruciate ACL PCL uh, the posterolateral corner injuries. Um, now the ones you want to delay. So I'm sure some of you've done placements. Um uh, with any firm and you've noticed. Sometimes patient's are with the multi ligament injury, are placed in the braced and observed. So it's not just the patient's who are obese, uh, with multiple couple mobilities arthritis. It's also, you know, young active patient's where you you do have the option of delayed with construction. Usually the ones I would say is, uh, but the reason why we do that sometimes is because you can convert a multi ligament injury to, uh, single, do a ligament injury. So that can happen with the MCL and ACL injury or a PCL and MCL. So if we brace a cruciate and MCL injury in three months time, sometimes you find that the MCL heals, and so that that leaves you with just one leg to reconstruct, essentially making the operation easier and less invasive for the patient. Um, and the advantage of that is, if it doesn't if in three months time a cruciate and MCL injury. If that does not heal, you can reconstruct both. Uh, but the advantage of waiting three months and in this situation is you make it gets away with just reconstructing the ACL or the PCL. Um, usually, though a form the clinical assessment, you have a high grade MCL. So if the knees opening up on valgus stress both an extension and 30 degrees of flexion, that suggests that both the posterior oblique ligament and the superficial MCL is is injured. Um, and the likelihood of that healing with the brace is low. So in those situations, you you probably would want to operate early within 14 to 21 days. Um, as I think I had a slide. If you do go if you decide to operate, the ideal window is 14 to 21 days. Because evidence does show with multi ligaments. If you wait longer, Um, the results aren't as good. Um so. So essentially, when it comes to timing, I think if you get asked that question, uh, be very clear that, you know, these are the situations where I go in immediately. Um, I would go early in certain situations where I know the ligaments aren't gonna heal. So we know posterolateral corner and ligament injuries don't heal Well, so I just go and reconstruct and repair that early and the bike cruciate ligament injuries as well. Um, I've got a window of time. Um, and I would probably go a bit later with with this combination of injuries, so appreciate an MCL because the advantage of that to me is that it may end up resulting in allowing the MCL to heal and therefore leaving you with just one leg to reconstruct. Um, so I think that's the kind of conversation don't have you asked about early versus late. Um, and the other thing it does is grants. So, uh, there's lots of options, So autographs are using the patient's own graphs, you know, telethon than hamstrings, quads. The advantages that heals much better incorporates quicker, um, less risk of infection. Um, the advantage is also cost. So the allograft are are expensive, and this is one way of reducing cost. The advantage of allograph, though, is there's less operative time. So you basically cut out the stage where you have to harvest the graph. Um, and obviously there's no, uh, obviously of donor site as well. The preference are having again in the exam. If you asked. You know what? What graph? So you've got a in our multi ligament ACL and MCL, so you got to ligands to re reconstruct what would you what graphs would use? Uh, I would probably say, uh, use as many international autographs that I can use and then allographs to fill the ones that have It's God's basically So, uh, because, uh, they some some people like to go to to the other native knee and harvest graphs, but I sort of tend to think it's it's a bit better for the patient to have one need that they're recovering from and rehabbing rather than two. So, um, I, I tend to do is I use the same the hamstrings from the same knee and then the quads as well. So with the hamstrings, the advantages, you've got Brazil a sense sense. That's m e t. So sometimes, if you could quote, quote, quadruple the semi tea, you could get enough thickness to do an ACL. And that leaves you with the Brazil is as well to do a posterolateral corner. And then if you use the patient's on quadriceps tendon from the same day, you could use that for the, uh, PCL reconstruction. Um, so you could you could do quite a lot harvesting from the same thing. Um, if you need to reconstruct the medial side as well. So essentially, what's happened is I run out of graphs to use. In that case, I would, uh, request a fresh frozen after, uh, um, so So we talked about, um, deciding which ligaments I need to reconstruct. So we've said how important it is to clinically examine. Um rather than rely on the MRI scan, Um, we talked about in terms we've talked about when to operate. Um, so now and we briefly mentioned graph so now. So you can if you reach the stage, you can briefly talk about the techniques as well. So you may, if you have done a placement, uh, in a major trauma center or have worked with a surgeon who has multi ligament constructions. You may be able to talk about, um, the the operations involved, Um, and essentially, if you if you structure your answer this way that what you want for for all for all questions, You want to give the Examiner a sense that you've you've done a placement, you know, a new placement or with an ankle placement by by telling them information, which you know, is really important for the relevant surgeon operating. So So these are when it comes to multi ligaments and dislocation. So these are the key things that always run through our head. A timing, Um, what graphs do use, Um uh, deciding what ligament is injured. So they assessment a clinical assessment. So, PCL, so, uh, my preference is, uh, using, uh, initially, I was using single Bundle PCL reconstruction interference, Cruz, uh, the tibia and FEMA. There's now more evidence, and, uh, there's a vogue to move into doing, uh, double bundle reconstruction. So reconstructing both the anterolateral bundle and cost remedial bundle. Um, in these cases, you'd have to use Achilles tendon. Uh, right. Hello? Allograft and the 70 allograft as well fixing it at the femur, uh, with interference cruise. Um, with this technique you have to use, you'll have to mention that you would need a posteromedial, uh, portal as well. So you can visualize, Yeah, the the origin or or the the entry point in the tibia in a safe way. Um, a technique that's been used in the past as a large IgG, which is, uh, technically a little bit easier because you rely on X ray and the jig to, um, determine your your entry elected point in the tibia. Uh so posterolateral corner as as I mentioned, um, most authors advocate to repair, um, and Reconstruction. So repair on its own isn't enough. Um, the other advantage with posterolateral corner of going in at day 14 is you can still actually see all the injured ligaments so you can actually see the LCL there. It's surprising You know how easy it is to see these structures at the early stage. Um, you know, you can see the biceps avulsion the r t B, um, and you can incorporate all those, uh, ligaments into the repair. Um, key thing with the approach is identifying the mirror incomes I mentioned that, um, and then the there's various different techniques to reconstruct the prostatic corner. Um uh, the one the one I use at the moment is, uh, tierro technique, which is using a single, uh, semi semi tea, Um, and leaving that to essentially recreate the LCL uh, the property of the the ligaments and property s as well. I'm using a tunnel in the fibula and interference cruise in the funeral. Mhm. And I mean, even with the exam, essentially, you just want to give one or two lines about the operation just to show that you've had an idea. If you've seen it once and or twice and you know you can briefly discuss, uh, principles. Um, but I think I think even even just going back to the exam, I think it's, uh, probably the focus. If you do, progress will be on the conversation we talked about earlier, which is, you know, when to go in and which they give us. Two needs reconstruction, which need to repair. Um, the technical details. I think you won't have much time to get to go into an end of exams. I think, Um uh, medial side there's a lot of there's a difference in opinion. So as I said, I think the the approach I use is if it's lax in both full extension and 30 degrees, then that means you need to repair. Some people say, if you have a distal avulsion of the MCL, that's an indication, because essentially, you can get a Stenner lesion. Um, where the, uh, the distal aspect of the N C. L. Then lies on top of the hamstrings, and there's no way for for that to heal. Um, so that's another indication to repair the medial side or reconstruct. Um, And again, essentially, I think I think one common theme for all the reconstructions now and the Vogue is, uh, anatomical reconstruction. So, So mentioning that you know, whichever reconstruction I use on insurance, uh, anatomical reconstruction, because the evidence now is that these do the best. So when you are performing anatomical reconstruction, you need to know both the origin and insertion of of of the ligaments of concern. So your superficial MCL here originates just posterior and proximate to the media at the conduct, and it's got two insertions, so it's got a proximal insertion and another insertion six centimeters distal to to to the joint line. So with your reconstruction, whether to 70 or gracilis, you want to make sure that your pin the proximal aspects exactly where we no evidence shows, um, the origin of the superficial MCL s and you want to you want to adopt again in two places? So distal insertion of the MCL and you can use a suture anchor here as well, approximately to pin it to recreate the proximal attachment of the MCL. There, um, same thing with the posterior of league ligaments. So you can either use a gracilis or 70 and you'd ensure anatomical reconstruction where the origin would be just anterior and dis totally adopter cubicle. Um, so that's why the p o l originates, um, and inserts here. Um, so which positions to fix, um uh, PCL fix it at 90 degrees ACL. Full extension. Reverse the Lachman as well. So take the to take a lot laxity of the draft lateral side. So when you're putting the screw in to fix your graft, you got to make sure that the knees internally rotated, Um um and again with the medial side, the same thing. So it's gonna get 30 degrees of flexion. Um, except if you're reconstructing p o L. That has to be up for extension. Uh, if you have so the other point to mention that's interesting is that if you have, um, 33 or four ligament injury, they you don't have to do it all in one stage. So it is quite a big operation to do. You know, it's stressful for the surgeon and the patient reconstructing all ligaments at the same time. So it is entirely reasonable to to reconstruct to in the first city and going back and reconstructing affairs. So a common scenario is, uh, you know, by Cruciate and Posterolateral Corner, it's entirely reasonable to do to reconstruct the possible lateral corner and the PCL and then coming back at the later stage to do that, Um, and to you appreciated the ligament. And so, you know, we we have a slow, um, protect the PCL, so essentially got to order a jack brace which protects the the PCL brace. Uh, PCL reconstruction. Stiffness is really common. So you find sometimes, um, some surgeons routinely do in any way at 12 weeks because of stiffness. Um, so that's something you got to keep a close eye on. And I think, um, as I briefly mentioned that the contraindications, uh, you know, advanced age, uh, low energy. So if the high b m I low energy tend to do really badly with reconstruction, so those should be treated with a brace. Okay, So, again, this is the algorithm that I've sort of briefly presented, Um, and while probably stick with for the exam, stage one is everything that Holmes ever discussed earlier. So the thing that the things that will get you a past, the things that will make sure that you safely assessed and manage the patient and 80 I think stage two. If you get to that, I think you want to have a sensible conversation about deciding which ligaments are injured. And then again, the key thing to take home remember, the clinical assessment is more important than the MRI scan. And then having a sensible conversation about when to immediately reconstruct, went to go in at 14 days early and went to reconstruct late and then finally just deciding on graphs. And it's a surgical technique. You get to it. So any questions? Uh, we've got two questions. So, um, one I'll just ask because I think you answered it in the penultimate slide on there. Actually do question from Iggy, Do you tighten the P l C in extension or flexion? And I think on one of your slides towards the end, you said do the lateral side in 30 degrees of flexion. So the way to remember if you get confused is, uh, you want to, um, fix the ligaments, entitle them in a position where they're they're the pressure is off them basically so that you can get the most tight as possible. So if you want to offload your possible lateral corner and the lateral structures, you put the leg in valgus as well. So that's that's something I do. Uh, one of the other thing you should do as well. So I put the name valgus. So you're offloading the lateral side, Um, And fixing, uh, intensely. Basically so valgus and 30 degrees of, uh, reflection, uh, external internal rotation. That's great. Thanks. Then we've got one more question from Schumann as well. Is it contraindicated to use both and its electoral quads and bone patella tendon Bone graft in the same case, it probably is not is contraindicated because usually take a bone block from the patella. So when you take the quads, you normally take a bone block with it. So if you're taking patella tendon as well, the risk of fracture is high. So you're taking two bone blocks from the patella. The other thing is that one of the disadvantages of the quads autograph is, um they can get weakness and extension. It could take them quite a while to to regain their extension and quad stream. So if you compound that with a patella tendon granting as well, um, it may slow down the rehab, uh, by by by by a bit. So, uh, I don't think anyone does patella tendon and chords. It's a naturally So I think it's just the the 11 or the other. Brilliant. OK, that that's great. Thank you so much. I think, um, does anyone else have any other questions? Because there's no more in the chat so otherwise, I think that's, um, that's dumb. Did did anyone who's near exam want to go through a case or oh, we have one more question just come quickly is the i t be an option for a graft. Yeah, So I TB usually used to augment an ACL. So if you're if you're a CR, graft is too thin. So evidence says anything less than eight millimeters thickness, um, has a higher chance of rupture, so you can harvest some. I t bound to augment other graphs and make them thicker. But you can also use the i t band as, uh, if you're performing a l e t so a lateral ecstatic, Uh, any diseases or linear procedure so that that that's sort of a lateral ecstatically procedure to to protect an ACL reconstruction. Um, but I'm aware of Variety band being used as a primary graph. That's great. Thanks. And I don't know if anyone is, um, no one's No one's really stepped up on the chat. At least I don't know if anyone wants to be a mute themselves. If they do fancy just going through a case quickly, I think it's not recorded it, so it should be fine. I can I'll certainly stop the recording if if someone wants to go through the case, Yeah, I mean, if if no one does step up. I don't know. If does it does it? Does someone have to go through it? Or is it a case that you could just show us the images? If no one's willing? Just what I mean? A model answer. Toms. Toms. Happy Tom is not very exam. So just, uh, just bear that in mind. Mr uh, Yeah, if he's happy to go through it, that's bad. Yeah, sure. So this is probably the first. I think, the first week as a consultant, I had a multi like It is rare injury. So I mean, even in a major trauma center, you you probably see it in 2 to 3.