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Play Your Paeds Right for Postgraduate Orthopaedic Exams
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Play Your Paeds Right for Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone. Today we have a combined session between the FRC s mentor group and orthopedic research UK, as usual on Wednesday evenings.
We are going to start by the introduction and we are today. We have a very interesting Session, presented by Miss Jo darnell, who is a consultant, pediatric orthopedic surgery surgeon in Maidstone and Tunbridge Wells NHS trust, and Mr. Anish rashica, consultant, pediatric orthopedic surgeon in Norfolk and Norwich University Hospitals and NHS trust, which they are going to give you how to play your piece right in the FRC as exam.
We thought that coming up with the April exam, this will be very interesting. They are going to show you how to answer the pediatric IVUS and how to score in this table. Please feel free to write any questions you have in the chat box and we are going to answer them.
There is mq after this session and there is a vyver practice in which Mr. O'Donnell and Mr. chandrashekar will Viva candidates. Please message Hannah. If you want to partake in the vyver practice at the end, I would like to recommend the concise orthopedic notes which help me to prepare for my exam, as well as the basic science books from the UK.
Without further ado, I would like to stop sharing and please Mr. O'Donnell. If you want to start sharing and start driving each other, thank you very much. Hi, everyone. Thanks, Joe, for that. So we're going to do something slightly, a little bit different.
I suspect your other talks and I'm going to pretend to be examiner and Anish is going to be the fastest candidate, and we thought we would just go through the main core topics that you're bound to get in PEDs and hopefully show you the exact things. Well, what we would expect you as examiners to come up with. So Anish, let's. The guys, while I'm answering the questions, I want you to think about what you're going to be saying in that same time.
Adnan, we are going to be doing voiceovers for everyone else after this. So I'll just see on the chat you put, you'd like to participate. You'll get your chance meet. So, yeah, while we're doing this, you need to be thinking about what you're going to be saying. And what we're going to do is you're going to get five minutes for your vibe. I'm going to try and answer everything in 2 and 1/2 minutes for each thing to show.
It's possible, hopefully. Brilliant so this is a 14-year-old young man. He's had six months of right thigh pain. The last 48 hours has suddenly become a lot worse. And take me through your thought process. What are you thinking when looking at this? What's going on? So we've got an AP pelvis and a frog lateral radiograph. And the obvious abnormality here is a slipped from relativists.
Looking at the pictures we have, I'd be worried that this is a severe slip. I'd want to measure the Southwick angle, but it can be very tricky here. You can see on the frog lateral, you're not getting a very good frog at all. So I think it'd be safe to say that the slip angle is going to be over 50 degrees here. You told me that things got much worse in the last 24 hours.
Did you say that the symptoms were going on for a few weeks before that? Yes, the whole thing is about six months altogether, but it's 48 hours and now it's much worse. So this sounds like an acute on chronic slip. Where are we seeing him? Did he walk into the hospital? He got wheelchair down to only standing only at the moment. So I'd really like to see is if he can stand even with people holding him up.
Is he able to stand upright? No, he's in a lot of pain now. He can't, right? So this is a severe, unstable acute on chronic slip from an epiphytes, and it's a controversial area. There are different ways of managing this. Personally, I'd be looking at the two options of pinning in sochi, but my concern would be a technically very difficult procedure to try and pin that.
So the other option would be discussing it with the pediatric orthopedic surgeons to see whether they think some sort of neck shortening into a capsule or osteotomy might be a better option at this stage. The controversy is about this would include the timing. Some people would want to rest the patient on traction for a couple of weeks to make the acute slap chronic, whereas others say there's no difference and you can get on with your first available list.
And the other kind of controversy would be the approach. Some people, I think in this country, it's very common to use the anterior approach and do something like a Cuneo form of fish osteotomy. But there is a big trend moving towards the donor osteotomy through a surgical dislocation. OK good. Would you like to mention anything about his other side?
So looking at Klein's line, looking at the faces, I don't see any problems there right now. I would ask him whether there have been any issues. No, he's had no pain on that side. And the other thing is I'd want to discuss, so you did say he 14 years old. So in terms of age, I don't think that's a big risk factor for a slip. On the other side, the reported literature is about 20% to 30% for bilateral slips.
I would want to know a bit about his past medical history. So does he have any issues with renal failure? Does he have any endocrinol Kathy's good? No, no, he's not. He's a large lad and no other medical problems at all. And indeed, the family had be compliant. Um, they're from quite a low socioeconomic group. They have DNA appointments about his weight and dietitian in the past.
Right so bit touch and go. Probably OK. So yeah, that's something we'd have to take into consideration with counseling for the family. Yeah would you consider prophylactic penning of the other side, do you think? Definitely based on what you've said. Yeah do any evidence around? Well, so there's again, some people have argued that the numbers needed to treat is quite high, so you'd be pinning a lot of hips just to save a few.
There was a paper, I believe, from Dundee that showed in the British Journal of Bone and Joint Surgery that we should be pinning most of these. OK in terms of the posterior sloping angle, people do measure that. I think there's a bit of an issue with its reliability, but between 11 and 14 degrees, if there was an increase in the posterior sloping on the left side, that's another reason to consider pinning.
Yeah OK. So we've got about a minute left. You talked about the anterior approach. Would you briefly tell me about the anterior approach to that? Yeah the anterior approach to the hip is the modified Smith Peterson approach. For me, I use a bikini incision. I'd be separating sartorius from TensorFlow facilita. In this case, I would split the idea of offices.
I'd identify director's femoral tendon, divide it at both its heads, push rectus down and then I'm on to the capsule. So I'd be watching out for the lateral cutaneous nerve of the thigh and the more superficial plain. But after that, you've got the branch of the femoral artery, the second flex, but nothing else that you can really going to injure. OK what will all of us choose the anterior approach rather than doing such great dislocation?
What's the big advantage you think? I think one of the things is really that we're using the anterior approach. So often, I think the surgical dislocation, the evidence for that is still very controversial. So most units that have reported their evidence, their results outside of Bern have had high rates of avascular necrosis. Yeah, whereas the Bernese group have said it's 0.
Yeah OK, but so I think that covers skivvies and so everyone can see well, and she went straight to the diagnosis, I mean, it is obvious you're not going to see much more obvious diagnosis X-rays than that. So it's important you tell the diagnosis to show that it show. You mentioned the South angle that he knew what it was and that it was a severe one.
And then going through the fact that it is controversial and that is one of most important things. I think that we wanted to get across that this is a massively controversial subject. And you you cannot say anything to wrong in this as long as you back it up. A lot of people would pin that insight to you and then deal with the consequences. And that is not wrong in the same way that if you have worked somewhere and happy going through dumb osteotomy, that is not wrong, but you need to be able to back it up.
Mentioned about avian rates and sort of talking about the literature when we had gone through everything and gone through the risk factors. So you've got all the main points and you can see an example of that in four minutes. And said, guys, what we'd want you to take from this is slip from an epimysium. You're going to talk about the slip angle, you're going to talk about stability and chronicity and then your treatment options, which are pinning insight you a corrective osteotomy, which could be intra or extra capsular.
And really, once you talk about those things with the risk factors, that's easily passed. So hopefully that slips COVID. That really is as much as you need to in a bigger setting. Yeah, any questions on that one? A new expert here. Is it reasonable to suggest open reduction if closed reduction not possible? Oh, Luke.
Yeah, you might notice that I didn't mention clothes reduction, ok? There's this whole thing people say, oh, if there's a serendipitous reduction, when I put him on a traction table, don't do it. OK you are not going to in the exam. Just don't say you are going to say I will not attempt to closed reduction in real life. Some people argue that if it's a genuine acute slip with no chronic element to it, you could try a reduction in the first 24 hours.
I think that's controversial. What do you think, joe? Yeah do you not mention that in the exam? In reality, I've had it once and I was planning doing surgical dislocation and it just popped back in and my registrar says that click that he felt will live with him for the rest of his life. But actually, it was brilliant.
It clicked back exactly perfectly, right? But that was just luck. Do not try and reduce it and certainly don't say it in the exam that's opening up a big can of WORMS. And so we've got, I'm allowed to say, names. They're putting their age, should it? Should I mention loader classification or name it? Yeah OK. If you read Lotus paper, it was rubbish.
He was talking about close reductions on these hips, which is my quote them. I shouldn't say that we're recording this. It's a really good paper. It's revolutionized practice and understanding. But there were weaknesses in it, but you should definitely mention it. But what I'm hoping is as soon as I said stable and unstable, it became clear one of the things to clarify is you might have heard me say, can he stand upright with even two people holding onto him?
That is a stable slip, OK, if they can stand upright weight bearing on their good leg. Then it's a stable slip. There's this whole thing about they should go to walk with crutches. It's not if you've got a broken, if you've got a fractured neck of femur that is completely displaced, no one can hold you upright. OK, so that's what an unstable slip is.
Natasha, when pinning inside you with one screw, when you take screw out and evidence a lot of us. Joe, I don't know what you do. We don't take the screw out unless it's causing any issues. Leave it alone at the hip, guys. I love the hip arthroplasty surgeon who said to me, Lieberman, we can take him out if we have to do it. Yeah Darren Ebro posh party has kind of fallen out of favor.
OK, so this is the whole concept of the finger of God. So if you get in there within that 24 hours, you open up the capsule, release the blood and then use a finger just to push on that femoral neck to reduce it. It is only within the first 24 hours for an acute slip, not an acute on chronic and that really rare, really rare. And again, don't be getting into that in your exam. No so you can see we kind of just stayed in one zone.
Even things like how many threads are you going to put across to your purposes? I always find that a bit pointless because you're trying to aim at 90 degrees to your fiercest and then you get in as many as you safely can. If that's three, that's three. If it's five, that's great. Just and said Luke, thank you for mentioning the closure reductions.
That's something we wouldn't have mentioned otherwise. Cheers, Jennifer. I previously been advised that a stable slip includes being able to mobilize non weight bearing with crutches. No, this is what we were saying, actually, Jennifer. So there it was really interesting at best Cos our children's society and 90 2019 they actually did a kind of vote on that and people felt that that's what a stable slip was.
It's not. If you can stand with people holding you up, that is a stable slip. You don't have to walk. You don't need crutches. Think about your awkwardness when you're on your trauma on your uncle. They're not going anywhere with their fractured knots, are they?
This is exactly the same. If it's an acute unstable and it's wobbling around all over the place, it's painful. They don't want to move right. And then we've got a couple of other questions coming in. Mohammed Askar, do we need to know about the new devices, such as the sliding screws just mentioning that, OK, Mohammed, if you throw that in, that is absolutely fine.
What you do need to know is what size screw you're going to be using. So for a lot of us, I would use a 6.5 fully threaded. Joe, would you go single big? Yep so one day people say 4.5 and things too small. But if you're going to throw in telescopic screws, that's fine. But then you might be asked about the evidence and there is none. And yeah, you use them in younger children.
Lambros Athanasios. All right. He's asking if a delayed presentation is it better to operate ASAP or wait a couple of weeks? And that's controversial, as you'll have heard that, I said that at the beginning, the Swiss say even if it's acute unstable, they will operate whenever they can, so that could be the next day. The Stanmore said Mr. Cattrall's kind of rationale was turn that acute into a chronic, and that's what a lot of us have been doing in this country.
But there's no evidence for either. But what I can tell you is that when you look at the results for the more acute surgery from everywhere else except Switzerland, the results haven't been as good. Thank you. I think the thought is you're trying to get the information down by leaving it a bit. But actually, when you talk to the guys involved, a lot of it was just due to the fact that he couldn't get any surgical theater time, and the kids ended up just sitting on a Ward on traction until they could get in there.
Like Anish says, there's no definite proper evidence behind them. And that's the thing. A case of guys. When you're doing your pediatric vyver, we can tell if you've done a pediatric job because you talk with much less certainty. If you've been reading Miller and you've been reading banaszak, you'll talk with such certainty.
Everyone will know straightaway that you've not done any PEDs. And what you're going to hear a lot of today is and that's controversial, right? So rather than a really good question, when you pin insight you and when getting the threads in the epimysium, will it not make the head rotate? It doesn't, because most of these have a chronic element. And that's the problem.
When you when you open up these hips and you're looking at this epiphytes, it is stuck trying to actually move. It is hard. So no, it doesn't rotate around as you'd think. Peter Eggleston, do we need to know the details of the osteotomy if you're going for a gold medal? OK, otherwise that's why you'll have heard. I said, and this is what I'd say to my trainees is just go with you could go into capsular or pin insight.
You then do an extra capsular, OK. The principal is next shortening because in that chronic situation, you want to shorten the neck. So you take off the tension of the blood supply at the back so that you reduce the risk of avian shino Cauchy management and chronic sleep with mild exacerbations pinning with osteotomy. So again, people from mild and moderate have done pinning in situ and then done some sort of lesser tuberosity for the fix.
I wouldn't go down there, OK, I would. I think it would be safest to say mild and moderate slips. Just pin insight you. Full stop. Would you agree, joe? Yeah, definitely. And you're getting advice from your tertiary pediatric Center for anything moderate or severe on you. And as long as you said that, remember, the focus is for day one consultant being safe, you are not going to be doing these.
Just say, just mention it and say, you know, the principles behind it. These are blah blah blah. And then last question, I think we've got to move on after this. McKenna, you said after how long do you remove the screw after inside? You're pinning, as we were saying, we don't unless it's causing a problem.
And it's a real pain to find these screws and removing the. Having said that last question. Karim Rashid, if can release this happens, what can be done? This is not a physics level, OK? But so how can you avoid controls this theoretically by not perforating the femoral head? But it's surprising I might regret things, but it's not that common. No avian is more common.
But is your big worry this GIFE not control? And that's the situation in which. Yeah, Yeah. But in which case they're probably going for a hip replacement anyway. OK let's go for the next one. OK, so this is a 14-month-old little girl who's been brought into your clinic and she's just worried about the way she's walking.
How do you approach this? So I would start obviously by taking a full history and examination with this 14-month-old girl, I want to talk to the parents, ask whether this is their first child. I would want to know whether there were any problems during the pregnancy itself. Was this a normal delivery? Was she in a breech position?
Is there any family history of age and how has she been over those 14 months as she'd been developing normally? I'd expect all the answers to those questions to be normal, to be Yes. I would ask if she was breech and if she was, did she have hip screening? And the reason why I'd ask all these questions is can see looking at the X-ray that she's got a dislocated left hip.
This looks congenital to me. The Pacific nucleus is smaller on the left and the right. You've got an increased acetabular index on that left side, suggesting acetabular dysplasia. And this is in the fourth quadrant of tennis. OK, good. As you said, she's got a left dislocated hip and she's 14 months.
What are you going to do about it? What are you going to tell mom that your plan is so at 14 months? There are a couple of approaches that people adopt. One would be to get in there at this stage, personally. That's what I would do. The other approach would be to wait until 18 months and perform an open reduction with a sole trust. To me, that's what sort of described at this stage.
I would like to talk to them about the importance of putting the hip back. I'd explain that if we leave, as is, she will start walking and she has been walking, but she's likely to develop problems as she gets older with her back and maybe even her hip becoming arthritic if she develops a pseudo acetabulum. I'd like to perform an egawa and arts program with a view to trying to perform a closed reduction in the first instance.
If this was successful, I personally would perform an adductor and so as tenotomy and put her in a hip Spiker. I am aware that there was the biggest series of this has been from stanmore, so Sally Tennant and Debra Eastwood publish this. And actually, when they are in this quadrant, the results aren't so good. There is a high rate of even if the closed reduction was unsuccessful, then I'd be looking at doing an open reduction instead.
OK and you've talked to me before about your approach to doing an opium reduction, the anterior approach. You said a or osteotomy, what other osteotomy is? Do that can be used or is that one of choices? That would be my wine of choice? I am aware that some people perform. Ifemelu strikes me, so it does depend. You can judge this by performing a test of stability, as described by Tony catterall.
But sometimes it's the femur where you might want to put in a bit of virus and do a rotation to correct from La version. Or you address the acetabulum and what you're doing is making up that deficient anterior coverage. So that could be where this ultra osteotomy. The other ones, I'm aware of the Pemberton osteotomy and also the dagger as traditional as actually described by dagger and not the modifications, but that can if you put your wedges more anteriorly than post, you really can provide anterior coverage.
OK, what about your treatment? After that, you do the operation and then that's fine. Yeah well, see, I would normally put him in a hip spyker. So a 1 and 1/2 spyker down to the ankles in the left, to the knee on the right, and then perform some form of axial imaging to check my reduction. Usually we find a CT is just easier to obtain than MRI scan. And if that looks OK, then I'd normally bring the patient back at six weeks for a change of spyker and an iOS program.
OK all right. I think should we go into doing questions and stuff on that because I think everyone can see how you can answer questions like that. So easy. Anish obviously knows what he's talking about, but he'd gone through everything exactly how to treat a delayed presentation of a. Um, the really embarrassing if I was getting it wrong, I mean, if I miss you, I can't see the questions, so nothing's come through guys questions.
This is your chance far away. Right what are the degrees of flexion this is McKenna again. Oh no, sorry, hang on, I've missed one cawsey, masood. What would you still do in acetabular hysterectomy after a closed reduction? How do you decide acetabular versus femoral? My personal feeling for the fix is, you know, just like you're going to say, you always do an exit, a hip replacement, just say you always do a soul to osteotomy.
I think that might be the safest thing so that you don't get into this or do I do the femur? Do I do the pelvis after the age of two, you should say, I'm aware that I might need to do a femoral shortening as well as an acetabular osteotomy in terms of how we do decide there is that test of stability. So what Mr catterall described was once you've done your open reduction, if all it needs is abduction and a bit of internal rotation, you do the FEMA.
And if you need flexion, then you do a pelvic osteotomy something like assaulter McKenna. What are the degrees of flexion ER and abduction of that hip while putting feet? So remember it is it really you're using AI and just checking which position it's best in, but it will be internal rotation, not external rotation. OK, so your femoral head is pointing a you're trying to keep it in any evidence on maintaining reduction with wires.
There is a paper from Columbia, I think it was where they talked about pinning the femoral head to the acetabulum. I think you will raise eyebrows and possibly fail your pediatric station. If you mentioned that the only time I've ever put wires in is in revision ones, they are very unusual ones and certainly don't go up the neck into the acetabulum. Actually, incidentally, did put a wire in one a couple of days ago, but that we put it from the audioquest into the grocery counter in a particularly difficult one.
It's very unusual. Do not go into that. Do not do it, then. Abdullah evariste immediate closed or open reduction or wait until 18 months. That's one of the controversies. OK, so I think what would you do, joe? So I would not wait. But by the time they actually get to the operating theater with a bit of an elective waiting list, they'll be 18 months given that they're 14 months.
But what would you do if they were 12 months? Would you go in or which is very slightly different to yours? I we go in and do an open reduction at the age of 12 months. I wouldn't do a pelvic osteotomy until the age of the past 18 months closer to two, but actually a lot of the evidence shows that pelvic remodeling goes on. We don't know exactly how long, and there's lots of controversy about that.
Maybe up to the age of 4 and the bony. What you see on the bony side of it isn't actually what is often there. You're putting dye into the hip. They've got a lot of cartilaginous cover, so you don't often need to do a pelvic osteotomy. I am much more likely to do a femoral osteotomy, in which case, I would do that at the age of 12 months. So like Anish said before, there is so much controversy about all this pediatric stuff.
But as long as you say what you would do or what you have seen being done, that is fine. I think that's the thing, so yeah, I would do the same actually at 12 months if I fail a closed reduction earlier. I do an open reduction and nothing else you normally because the earlier you put the hit back, the more remodeling potential you've got in my mind.
But you could say anything really the only form of appeal because you are to me before the age of 18 months in the pelvis is so thin. It's just hard taking your graft and trying to get it. Stay there. But some people do do it. Chanel Cauchy after closed reduction in egawa speicher, would you do axilo scanning immediately? Personally, it depends on how confident I am, but yeah, I think just say yes, OK.
Would you go to a CT scan or from recovery on the way back to the ward? Mohammed ashker, would you please explain what we need to know about ask for gram for the exam? I think you need a way to talk through the approach you'd use. I'd use a medial approach putting my needle underneath the adductor tendons, squirting some joint program into the joint.
If you're looking for those blocks to reduction, OK, so you're looking for the inverted labrum, you're looking for that rose thorn sign, you're looking for the hourglass constriction. Is there an age limit for attempting clothes reduction? Not really. I think most of us think that after age 18 months and beyond, it's getting less likely. They had a couple over the age of two, but it is rarer.
And some people, I think in Southampton, the guys were saying they've stopped doing close reductions. They you still have options. Yeah akash, what's the advantage of performing an ice program before and after hip spike reduction? You need to do the ice program for closed reduction just so you can be sure that the femoral head is actually in because you can't see it's cartilaginous. And even with an open reduction, often once we repaired the capsule I like to squirt, some died back in just to really check because it's really hard.
You get a small view of this acetabulum. You know, it's not like a surgical dislocation where you might have the whole thing exposed. So that's why I think Instagram helps doing that. Catherine, all right. And so we can squirt a little bit of dye. And when we've got the spyker on, if we're particularly worried about her ankle, I'm learning as well.
Do we need to talk about examination of child in vyver? That was no meant you could. I kind of skipped that, but you could say to expect there to be a shortened leg with restricted abduction inflection someone's put. Please tell us more about ask for grant. We've done that a Jade is de golf, a CP post-super deficiency. So that's what everyone says.
But if read de guy's paper and actually it was Joe's colleague, Marcus, who put me onto this because he's a big fan of the dagger. Yeah, and the big advantage of the dagger is you don't have to put wires or anything in. It's a stable osteotomy and essentially you are breaking in the same line as a soldier, but you choose where you go through the medial cortex because this is getting way too advanced for me to comment on difference between closed reduction under sedation in the Ward.
You don't do it. I do it. Yeah, doesn't exist. So you, McKenna, you've obviously seen this somewhere where they're using ultrasound. I don't think that would be common practice, and I would stay away from talking about that. Jennifer, if given the case of a say, 10-month-old with rh, could you argue for immediate attempt at close reduction, if not comfortable medial approach or just wait until 12 months and do AI think that's down to the individual surgeon.
I would definitely go for a closed reduction in that first instance. And if that fails, then look at an open. I don't. I always advise people to stay away from the medial approach in the survivor. It's one less thing for you to learn, and you just say there's a very high rate of Abn, even as long as you follow up the kid, you'll find this an Abn.
And so it's preferred not to do it. Joe, do you ever do the media open approach? Very, very rarely. I'm much happier doing the anti approach. You can get much better visualization of the acetabulum. It's just it's just what we're more all used to. And I'd say avian rates, why not just wait a couple of months and do with a lower risk area?
I haven't talked about is public answers, and you have to know what a Pavlik Harness is, what the different straps do to get the flexion, to get the abduction. The fact, you are not going to use user over the age of six months and you need to know if you're shown an ultrasound of a hip roughly what you're looking at. I would not expect you to be able to go exactly through what, not what an ultrasound, all the tiny little bits of ultrasound.
I would expect to growth. I would expect you to know the varying degrees of it you have to do. Sorry, I say here. Harsh and then panagiotis, you said if the closed open reduction is not successful, then what? Then you try try again. The case close doesn't work. You are going to open.
If you know, if you've done an open reduction and the hip is not stable, that's when you're considering your strategies. Remember, the osteotomy aren't just to correct bony anatomy is to make the hip stable, but it does happen. And then we have to go back to theater with another plan. And I think it's happened to all of us, which do is I'm going to peak.
Yes, Yes. Someone's put here approach for open reduction. We talked about the anterior approach is the anterior approach, but remember to talk about splitting the iliac hypothesis. And a lot of people who haven't done or seen an open approach forget to talk about the idea of offices for infection. You don't need to split it. You do for surgery.
Al has asked why I prefer a medial approach for our program. His a approach as well, you always go under the adult's tender name up for lateral scapula. It's just a lot easier in babies. Yeah, I think when you're trying, there's a small space for that anterior femoral neck. And if you're trying to bounce it, it's cartilage. So it doesn't work.
So well, whereas the medial approach, there's just nothing in the way. Would you still put a public in a dislocated hip? I put it on and then ultrasound it the following week to see whether it's back in and you do your learning in Bali to try and get it in. Obviously, if it's a kind of a teratogenic one, one that is not going anywhere. No, but I would give it two weeks of trying to go in and to centralize.
Andrew Hughes, why must you wait until 18 months to perform the anterior approach? It's not. The anterior approach, actually is the soldier. And that's why you need to wait until 18 months. Medhi has from what age you consider close production. That's a really good question, actually. So Graff never put a graft for, he says in a public harness, he takes them for a closed reduction for me.
So you're seeing Mr Katter is a big influence in my life because he used to visit us at the Norfolk and Norwich, and he said, wait till five or six months and that's what we do, especially because you're doing tenotomy. It's amazing how easy it is to get lost in the medial part of a baby's thigh. Would you normally wait until five or six months, Joe, or wait until six months? Yes, because it's so far and aesthetically anesthetists are much happier to guess when that age.
Yeah James Houston why do you need to split the elective offices? So you will all tell me that you're going to go in the plane between gluteus medius and rectus ephemeris, which is the superior quality ulnar nerve in the femoral nerve. But that's the way you separate the two. OK, your abductors are attached to their outer table of the ileum.
So when you split the hypothesis and you go separate austral, you take everything off and it all can then peel off the capsule, McKenna comment. All the way around the capsule, you've got to be able to get all the way laterally and medially, and you'll see when you're joining a slap ticket. You cannot get that visualization of that capsule without squeezing your policies. So you have to do that.
Then McKenna has asked on the management of terror to logic dislocated hip. The thing is to say the public harnesses. I still give it a go, but it's less successful. Same with closed reduction. Still give it a go, but it's going be less successful. So you really you're looking more likely at open surgery with or without osteotomy. But it does depend on the cause of case.
So some people would say something like spina bifida. That's a controversial one. Some people say don't put him back, especially if it's bilateral. And others say you should try. So I think that one, you've got to just say that these are the uncertainties, rather Christian. if you see a child at six months, the hip is still dislocated.
Would you do any unasked for gram and reduce the hip and put him in a spyker? Yes later, you find it's dislocated at six weeks follow up. Would you wait to a 12 months to do an open reduction or do it straight away at 8 months? I would wait. I would wait to. Yeah mainly the risk of avian.
If you're going back in on there, you're going to increase your risk of avian by Messing around. You might as well just go back in and do it properly, and it might have matured a bit and you get a better clothes reduction, even when are 12 months and whatever you do. If you're asking the advisor if they say, look, you did a closed reduction post-op CT shows it's out. What are you going to do?
I would not say I'm going to try another clothes reduction, ok? You have to say, well, I'm assuming that I did everything well the first time. So why would it work a second time? I'm listing them for an open reduction terms of people. Ask this in the force. Yes, if you're getting on to this sort of thing, they've run out of things to ask you and you've got NIPE. Do I consent for closed and open at the same time?
Depends on the case. But yeah, maybe. How do you assess from La version during surgery? You're really looking at the hip stability, but it's really difficult. OK, so when you're trying to work out how much to rotate, everyone has their own system putting wise in the femur and stuff. It's all a little bit voodoo.
And then two last questions, OK, because we've really covered this. Is there an option of other bracing, failed public kindness or straightaway? Consider close reaction? Very good question from Prateek. Some people do try rigid bracing. Some people go straight to closed reduction. Rami, do you start treatment early in life for graft type 2 or do you repeat ultrasound at six weeks?
I would repeat ultrasound at six weeks, but what do you do, Joe, if you see a graph to age three? 2b yeah, I would repeat it. If they're at 12 weeks and they are not getting any better, then I would think about putting me in a Pavlik Harness. It's very controversial and we're actually starting hopefully an act which hopefully will be nationwide to get some questions about that. But you will not be asked that in your files yet.
All right, guys. No more questions, please. Otherwise, you won't get to hear about anything. So if I just answered the last three, how long for the public kindness? Again, controversial, I would say until the hip looks completely normal. And then just stop in an exam, say you're going to scan it every two weeks.
And when it's normal, you discontinue CT scan after closed down open reductions at two months, follow up in public Highness the hip is dislocated, so rather Christian. If it was dislocated at two weeks, you shouldn't carry on would do put your graft four in a public and if at two weeks it's not reducing might not be normal. But if it's not centering, you will discontinue the Pavlik Harness.
OK, protocol is a mobilization after closed open reduction is a hip Spiker. Is the left side common to dislocate people who think it's because of the left hip being rubbed up against mom sacrum? Really, no one knows right going to end the questions there for each other as we wait to talk about the other things. Ok?
hey, guys. So this you're on the neonatal unit and mom didn't attend any antenatal appointments at all and baby has popped out looking like this. Pediatricians are completely happy and feel that this is an isolated problem. What do you think? Right? so this is a clinical photograph of a baby's legs.
The most striking abnormality here is bilateral clubfoot, a congenital Televisa coronavirus. I'm a bit concerned looking at these limbs, looking at the size of the feet in relation to both tibia and both sides. Just it doesn't look right. There seems to be hyperplasia of the muscles at the thighs. And I'd be wondering whether this is whether there's a syndromic cause behind this rather than idiopathic clubfoot.
OK what mom's asking about what treatment you can give for the club feet or her feet or is going to look like this? No, I'd explain that actually the most clubbed feet, especially if they're idiopathic, are successfully treated by the Ponseti method, which is a sequence of plaster changes. We'll be doing that. We can start that as soon as baby is well enough.
So if there are no other problems with this baby, we could do that within the next week or so. And it's a series of plaster cast and we perform a correction in a specific sequence. So you're looking at correct soup and eating the first ray first, then you're going to correct the various. And the last thing you then bring up is correcting the Aquinas.
I'd explain that 90% of babies will need an Achilles tenotomy, which we'd usually perform in clinic under local anesthetic, usually at six weeks of plaster casting, providing everything's coming along OK. And then they'd go into the final plaster for three weeks and then boots and bars, which will be full time and then nights in that only until the age of five.
And with this, there's about a 90% success rate. OK what, why? Why don't you get club feet? Do any reasons why they think it's again, it's something that we don't really know. We know that there are various theories about this. What we do know is that the whole leg from below the knee is abnormal.
Studies have shown that certain muscle compartments, the lateral compartment and the anterior compartment are underdeveloped. About 50% of these children are also missing their docile as Peter's pulse. So we know there are genetic factors. It's more common in boys than this condition demonstrates the Carter effect. And we know that it does run in families, but it's the Carter effect that explains why it skips generations.
We know that there's an increase in Maya fibroblasts when you look at this tissue histologically. But really, we don't know why it occurs. It's not a packaging disorder. Ok? are there any other associations, anything else you'd be worried about? You said you worry about syndromes. Anything else you would routinely look up.
So one of the controversial associations is there are various papers papers published by Robin Paton that suggest that there isn't a genuine association between clubfoot. And I believe most people and most units do still scan children born with clubfoot for each. With these children, I would do a full head to toe examination. I'd also be looking for external signs of spinal deformity. And this racism to exclude conditions like spina bifida.
And yet here, I'm just still wondering whether these are featureless limbs. I'm not seeing lots of creases, and every time I see a bilateral congenital telepathic coronavirus, I'd be thinking about us for Kaposi's. Good OK, any questions that have come through? Yeah, there are a few. OK so Karim, I thought this pic of Arthur guy post, that's what I was wondering.
I do want to jump in with it because I wasn't completely sure. Is it? Arthur proposes. Yeah, I think it is ulnar claw process. Yeah Thomas, what is the Carter effect? Basically, the Carter effect is a genetic thing where a certain amount. So you have a certain amount of genetic load and you need differing amounts of genetic load to manifest the phenotype.
So in clubfoot, the theory is females can have that the same amount of genetic load but not demonstrate the condition, whereas a male will have that and demonstrate the condition, so explains why you can have conditions that are more common in one gender than in the other, but without having a relationship to the sex chromosomes. Keith ideal answer have asked about management of bilateral club presenting late in a teenager.
You are not going to get that. OK? and that's really controversial. I would. Let's not go there. Everyone knows the answers frames, but we won't talk about that. Karim, why? Yes, caves, clubfoot happens in spinal racism.
Do the honest answer of all of these things? None of us know, but it's to do with muscle imbalances. Is Ponseti caste extended above the knee? It's to provide that rotational stability. It's really important people have mucked around with all of those things and found it doesn't work. You've got to do it above the knee. Cool all of them.
Yeah oh, a couple more. Do we need to know the genetic associations? Not really. Just say it runs in families for the less astute of us. What are the hints in this photo that this guy poses? You know, it's a tricky one, and that's why it's a little bit unsure. But those legs just don't look normally that have very chubby thighs.
What we talk about is the lack of skin creases and the featureless. If you look at these, they just look tubular and shiny. And I think that's what would make you think. It's a process, a bilateral or severe club feet as well should always ring. Yeah I mean, you haven't talked about speroni score. Yeah, someone's just put that away. Out of six, you get three points for the three posterior elements.
So the empty heel posterior crease and the rigid requirements and then three points for the medial or the midfoot. So the medial crease that uncovered talar head and the medial lateral border. And so that's a way of looking at these clubbed feet right from the start to the finish, and the physios grade them at each time just to make sure that everything is going well.
And it's not until you have got rid of all of the three midfoot things that you can consider doing your Achilles tenotomy. So I wouldn't expect you to know much about the point score, but I would expect you to know that it exists, and it's a way of monitoring the progress of these clubbed feet. And McKenna has put politics in terms of the genes. If you know it through it in ages, asked about scoring jokes just answered that no man, what is the age?
An indication of gene poster and media release. There are very few indications AK Ponseti is the main one. I think the only indication would be failed Ponseti multiple times. So it's the syndromic feat. We just don't do media releases anymore. It's not done. And the only one scene is in one that is a really abnormal foot with multiple of coalitions and saying yes, yeah, it's just not.
And so normally they're about 18 months. By the time you tried the poinsettia a few times and then going in to do that tip and transfer. So depending on what you read, someone's put it to transfer question mark. Yes 25% to 30% Chanot Joe's answer to your question about peroni, so you don't need to know in detail, but just be able to name it kurram.
If clubfoot is part of our growth process, would you treat with ponseti? Yeah, there are papers on using Ponseti for syndromic clubbed feet. You do give it a go. There are various tips and tricks that the Ponseti purists know about. I'm not one of them, and the main thing, if someone asked you, is that you're going to probably be using more plaster casts.
That's the main thing. Once rates are much higher for Thomas cook speaking about a growth process, how in-depth should we know about it? I wouldn't go into matters of detail. OK, but you need to know that there's the distal type. There's a complex type and just that it can cause to rattle hip dislocations. It can cause knee extension, deformities and clubfoot.
Management of residual deformity at older age, Tamara's. I think there are various osteotomy fusions. The Taliban transfer is the main one. I think they'll ask you about. Again, that would be a rummy. What if casting failed or late presentation? Any role for gradual correction of external fixation depends on who you speak to. I think definitely so.
Joe, so as well? Yeah and I think some of our colleagues who have gone out to Africa and they are very, very pro doing Ponseti casting almost at any age and they have seen it work late teens, early 20s. So it's a quick, easy thing to do, whereas putting frames on it is horrible and it's worth doing Ponseti first. I would, Yeah.
McKenna's book please explain what exactly is a rock bottom deformity? So that's where you're basically trying to correct that awkwardness. But rather than correcting the quietness, you're doing it through the midfoot, and that's not a good thing to do. Should we mention doing X rays? Jaehyun has said so.
Actually, if you're being really good with your evidence and saying, actually, I know that John and Berg in Baltimore uses X-rays to assess whether Achilles tenotomy is required, then yes, but not just for measuring feet, not just for diagnosis. McKenna is asked about the exact difference between residual recurrent and resistant CTV, but apparently you've forgotten two more hours. Do you know anything about this five hours, joe?
Five hours? No, no. So I'm just guessing here McKenna residual means there's still a little bit of deformity when you finished recurrent means you got it better and then it's come back and resistant means you never got it better to begin with because it was probably syndromic. I've never heard of that.
So you'll have to teach us about that one critique how to diagnose dynamic superinfection clinically. When you watch them walk, they kind of lift that first ray like that. That's all it is. And if you get endorsed flex, they'll kind of do that. So it's just literally supination man. McKenna, I don't know what you've been reading, but you've got more knowledge than I have.
Do we need to know pavers or TAVR in capitals? Never heard of it for the old CTV. I'm going to take that as a no. My team would allow weight bearing if using Ponseti in an older child. Good question. I think it can be hard to control. There you go. The above New plasters.
They probably won't walk. They'll crawl around, and I think you've got to accept that that's what's going to happen. I think the only thing we haven't covered that would like to say is the boots and about the highest rate of recurrence is non-compliance. So right from the start you need to tell the parents they need to keep this kid in boots and bars, nights and nap times.
If they don't, their feet will recur. OK right, it's eight, 20. So shall we do one more and then throw it open to everyone else? Yeah OK. A seven-year-old boy. He's actually the son of one of our local gp's, wants to play for West Cam like his two twin sisters, and he's been complaining of severe left hip pain for the last few months.
He's clinically very well got no other medical problems. So this is an AP pelvis, and it shows that this 17-year-old boy. Has Perth hip tip, Shenzhen's Allen is intact, but you can see that if you look at the lateral pillar, there's over 50% loss of height, so this is a Herring. See, there are some head at risk signs I can see metaphysical cyst. I do wonder if there's some privacy or calcification.
And so I'd want to know a little bit more about this child in terms of working out what I'd be in terms of my management. OK he comes in sitting in a wheelchair, he's very reluctant to wait there on this at all. He holds the hip in about 10 degrees of abduction and does not like you moving it at all. He used to comply with physio, but not anymore. Right? it's unusual to have that degree of hip pain in this kind of condition with Perth, so it'd be a bit concerned about this.
Is he systemically? Well? yes, completely. Yeah, right? And so it sounds like this is clinically also ahead at risk. So he's got progressive loss of range of movement. It sounds like he's got an addiction contracture. And so Perth, this is really controversial. People really don't know what the ideal treatment would be. Given his gender and his age, he should have a good outcome even if we do nothing.
But based on the X-ray and especially the clinical picture that you describe, I'd be more likely to consider operative intervention. I'm aware that there is very little evidence that this would improve the outcome, but especially if he's struggling this much, I think this is the kind of child I'd consider admitting for traction and maybe going further with that.
It depends on how we can control the symptoms and getting complying with physiotherapy. OK do you know anything about the etiology of Percy's disease? There have been various theories. The biggest associations we have are with passive smoking and lower socioeconomic class. Prof Dan from all day has published a lot of work on birthdays, and one of his most recent studies in the bone and Joint Journal showed that there is definitely a link with being from a lower socioeconomic class, but they couldn't separate the effect of that from the effect of passive smoking.
I'm aware that there's also been the boss study, which has just reported its preliminary results, but this was a longitudinal study survey. It was basically a survey or a registry of all kids with this disease over 2a year period. OK and. Any questions in Perth is the ultimate treatment goal. So what do you aim to do with it?
My treatment goal would be containment. That's the main principle. We need to keep the femoral head within the acetabulum. Usually this would be with physiotherapy. I ask them to stretch the duck to muscles so that they've got good abduction and keeping that femoral head moving into the acetabulum. If that's not working, there are various other approaches that have been described.
Some people have described tenotomy of the adductor tendon and then broomstick plasters or a-frame braces. Others have talked about various or stretches of the femur. Benjamin Joseph has written up a big series on those from Moneyball. Others have talked about using the sole trust to me or a shelf, and some people put all of these things together. There is no evidence that any one of these is better than any others.
What are you going to tell the parents about this? They want them going back to football and they want the quick fix. What's the quickest way of doing it? I'd have to explain to him that there is no quick fix in this situation. Perth disease lasts about three years. You've got the various stages, you've got the initial stage where you've got sclerosis, then fragmentation, then healing and then the remodeling phase.
Altogether, that will take about three years. The pain and stiffness normally lasts for about a year and a half, and it's very variable even if we do an operation that's not going to make this well. The evidence there is controversial. Most people don't think it accelerates healing. There is some evidence from Benjamin Joseph's study group and from Sheffield children's hospital, where they use hip detractors that it can accelerate healing.
But as far as this family is concerned, I would not be making any promises. I'd also be Warning them that because you've got total epimysium involvement here, I'd be worried about proximal femoral morphology abnormality as this child gets older and that they might need further surgery at that stage as well. How about the other side? Yeah, I'd like to see a frog lateral, because sometimes it's easier to see changes on for a lateral view.
Again, it's about a 25% to 30% chance of having bilateral involvement. So be watching for that side as we go along with time to do any evidence about vitamin D use with in places? I believe there is some there, but it's controversial. So some there has been a paper, I think, from India that suggested that there is an association, but there's also been one that suggested there isn't. OK, any questions come through yet?
There are. Hold on a second. We have got to. You know, right, so guys, I have to say my first thing I always say to the trainees when you answer the question about management is, say containment. And I'm a bit disappointed that Joe had to ask me, what's the principal? Sorry about that, right?
Where are we? I'm trying to find where we were. Rami, any role for bisphosphonates in Perth disease? Again, not farke's level. People were investigating it, but the biggest problem is if you've got no blood supply to the femoral head. And you inject intravenous medicines, it won't get to the femoral head.
So people were talking about injecting it directly into the femoral head, but I don't think that got approval. Alistair, how do you if you've got if you're losing bisphosphonates in why you stop using them around the type of any fractures, you've got pertes, you've got loads of little micro fractures or it just doesn't. It's not a good idea. And there's no evidence for it. How long would you traction for?
So, Alistair, I have to be honest, I've never come across someone with such severe birthdays, and I don't know if that's what you were looking for with the traction, but I know that people out there do do it and essentially it would be until the symptoms subside. So sometimes a week or two. Some people use traction a lot. Yeah yeah, it's not something I used.
I think it's along the same principle you said of the distraction fixes. Yeah, just to let it settle down. Yeah McKenna etiology theories, the vascular theory. There are loads of theories, but none of them have been proven. So we know that there's a vascular insult. You can induce this in pigs by basically tying off the blood supply to the femoral head. But what causes that is the big issue.
What I do love is when you look at the pathology, you get more cartilage forming because cartilage withstands that ischemic environment. But and that's why you get Cox and magna, because the cartilage needs to be bigger because it doesn't withstand the shear forces. So that stuff makes sense to me, but I don't think anyone's actually explained why it happens. What grade would this be?
See? remember, you applied the Herring gradient stage of maximal fragmentation, but it's not going to get any worse than this, is it? She how to practice practically distinguish between BC and see in an X-ray. The BC was something that was kind of added later. And when you read those Herring papers, there's no clarification about what that is.
So my advice would be ignore that for the exam. Lawrence, if you have a child under the age of 6 with a Herring, see how would you manage this? I don't find Herring particularly useful, I must say, and I think a lot of us completely ignore it. My how I would treat a child with birthdays depends on whether they have wholehearted involvement, whether they're a load of head at risk signs that lateral extrusion.
That is always a really bad sign because it means that when that head is starting to remodel, they're going to impinge, they're going to have an awful shaped head. So Herring, yes, mention it. About it, but say from experience, you know that pediatric orthopedic surgeons are more worried if the whole head has become a vascular and you just need to get containment of that.
So yeah, we know that kids, no matter how old they are, if they have only a little bit, that has. Sort of become a vascular. They are generally going to do well. But if they have the whole of it, that is a vascular, they need some help and you need to get that head in the right place, even if they are really young. Yeah, I think that's the thing is the problem with the Herring with the Herring classification is that thing about applying it at peak fragmentation by which stage, you actually missed the boat for doing your surgical containment procedure.
Agnese Duthiers worth mentioning any classification other than Herring. You could mention the catterall classification, but I personally don't think you need to go into that for five years. While it is to manage per phase conservatively, how long do you follow the patients up and how often do you imaging? Good questions.
Also, what's your threshold finding to convert conservative management to surgery? I think we have to be clear her, but there is no evidence that surgery changes. Anything the boss study has in its preliminary results suggested that it's only a two year follow up. But having said all that, sometimes you just bite the bullet because you're watching and thinking, man, if I don't do anything and this ends up bad, it's my fault.
And I think it's a combination of clinical factors as well as the X-ray. So I'm a big believer in the clinical head at risk signs and the radiographic. So if I'm seeing what Joe described it progressively stiffening hip. My worry is that actually this is a hip that is slowly subluxation. And if we leave it where it is, when it does reform, it's not going to match the acetabulum.
So that's what I'm looking for. So when I follow these children, I see them every three months with an X-ray and a definite clinical examination. And if we find that they're complying with physio and still stiffening up in my world, that's when they're going to be looking at possible surgery. Yeah, kids that are losing their abduction are ones that I worry about. I have quite a low threshold for teams there, too.
Doing an EAA arthrogram because the anesthetic takes away their pain, you can see their true range of movement and putting dye into the hip I find very useful. I know that's a very pediatric pod thing to do. We love Arthur grabbing joints, but it's because you can just see so it gives you so much information. Yeah, definitely. Herring be above the age of eight. Would you operate.
So Abdullah again? Good question. A lot of people at that age are worried, and I think if you're seeing progressive sign of femoral head collapse again based on those head at risk signs the older child, I would have a lower threshold to operate. Yeah, I do. You're off the ground, but can them for an osteotomy at the same time?
And Karim has said, well, I thought as differential diagnosis and first look like telltale sign of septic arthritis. So I wasn't sure. OK, I didn't think this to me. This isn't classic septic arthritis, but based on what Joe was describing, leukemia can also have a similar appearance. I've seen a case of that with one of my colleagues dealt with, and that's why I was just a little bit paranoid.
And you know, this is an example of exam mode. When you're in exam mode, you're looking for the weird and wonderful. So even if it's really straightforward, Perth is based on the History. I think is you're trying to catch me out. If you're trying to catch me out, there's over 100 people watching, is you're going to make me look like a fool? And in exam mode, you're always looking for that wrist thing.
Chanot how practical is it to maintain non weight bearing for such long periods? You might. So we didn't talk about that. I don't keep them non weight bearing again. If you do your ground reaction force diagrams, the joint reaction forces are lower with touch weight bearing than non weight bearing. All I ask my Perth kids to do is not run around, so I do let them walk.
I don't give them trampolines and jumping on beds. Yeah, I give them usually either crutches or frame or some kind of protection, and often not to go on long walks as well and at school as well. They're generally not doing PE and running around in playtime. Can we use Herring grading for any stage other than fragmentation? Well, it's for acute Perth, as you remember. After that, you'll be using the stool classification.
But what we're saying is it should be applied at peak fragmentation, but you only know that you've hit peak fragmentation when the next X-ray shows that you are healing up. Ok? what stage would you start the treatment? So the question and it should be before peak fragmentation. And that's why we're having classification is a brilliant shares.
How would you differentiate between Abn and based on an X ray? I think some of that's going to be your history, really, because Perth is Aden, right? So if there's a history of DCH that's been treated and there is an association with Nadh and then a late Perth days ago, so no signs of Abn and then suddenly age five or six, there are signs of Perth disease, and people aren't sure if the two are related or has said how would traction or spanning fix help?
Essentially, the idea is you're reducing those joint reaction forces, you're taking the force off that soft femoral head. Haitham is put. Do you do you ask for ground before considering open reduction? We're not talking about open reduction Perth as a case. So Perth is containment, so you're either doing a femoral osteotomy to dip it in or you're doing a shelf. Eating a soda or eating both.
But we're not opening up the hip joint itself. Ali, how would you treat hinged abduction? If you get hinge abduction, you've missed the boat. That's when you've got that femoral head deformity and they need a valgus osteotomy as a salvage procedure or is what I'd say? Yeah what joint? Andrew, here's what joint preservation techniques should trainees be able to talk about discussing the fix?
None OK, that is all experimental. Well, it's not experimental, but people are doing femoral head reduction or stretching music. They're literally taking that big cocks, Magna taking a wedge of the femoral head out and putting the femoral head back together. I don't know, Joe, is anyone doing that in the UK. Andreas road pushes crazy, right? A couple of times.
I think Fabian has done it a couple of times as well, but that's certainly nothing you want to be getting into in your fast. Yes Yeah. I mean, you saw how quickly time when Anish was answering the questions, know the basics behind it. The important things that you have got to say. Don't focus on them like weird and wonderful like that.
You don't need to. I think because I've got a message here from imogen, who is kindly organizing the whole thing she's saying get a move on. All right. So, so last question, OK, how to differentiate Perth from Med and said it's to do with that difference in time. So if you're looking at things that are happening synchronously, it's more likely to be Medi.
Get an X-ray of the knees or a skeletal survey. If you really worried to pick up that face doesn't happen, you don't have it in the same stage bilaterally. Yeah, right. So now you've seen how I approached it, you're going to show me how we should, how I should have done it by answering the vyver questions that we're going to ask you.
Segment:0 .
Good evening, everyone. Today we have a combined session between the FRC s mentor group and orthopedic research UK, as usual on Wednesday evenings.
We are going to start by the introduction and we are today. We have a very interesting Session, presented by Miss Jo darnell, who is a consultant, pediatric orthopedic surgery surgeon in Maidstone and Tunbridge Wells NHS trust, and Mr. Anish rashica, consultant, pediatric orthopedic surgeon in Norfolk and Norwich University Hospitals and NHS trust, which they are going to give you how to play your piece right in the FRC as exam.
We thought that coming up with the April exam, this will be very interesting. They are going to show you how to answer the pediatric IVUS and how to score in this table. Please feel free to write any questions you have in the chat box and we are going to answer them.
There is mq after this session and there is a vyver practice in which Mr. O'Donnell and Mr. chandrashekar will Viva candidates. Please message Hannah. If you want to partake in the vyver practice at the end, I would like to recommend the concise orthopedic notes which help me to prepare for my exam, as well as the basic science books from the UK.
Without further ado, I would like to stop sharing and please Mr. O'Donnell. If you want to start sharing and start driving each other, thank you very much. Hi, everyone. Thanks, Joe, for that. So we're going to do something slightly, a little bit different.
I suspect your other talks and I'm going to pretend to be examiner and Anish is going to be the fastest candidate, and we thought we would just go through the main core topics that you're bound to get in PEDs and hopefully show you the exact things. Well, what we would expect you as examiners to come up with. So Anish, let's. The guys, while I'm answering the questions, I want you to think about what you're going to be saying in that same time.
Adnan, we are going to be doing voiceovers for everyone else after this. So I'll just see on the chat you put, you'd like to participate. You'll get your chance meet. So, yeah, while we're doing this, you need to be thinking about what you're going to be saying. And what we're going to do is you're going to get five minutes for your vibe. I'm going to try and answer everything in 2 and 1/2 minutes for each thing to show.
It's possible, hopefully. Brilliant so this is a 14-year-old young man. He's had six months of right thigh pain. The last 48 hours has suddenly become a lot worse. And take me through your thought process. What are you thinking when looking at this? What's going on? So we've got an AP pelvis and a frog lateral radiograph. And the obvious abnormality here is a slipped from relativists.
Looking at the pictures we have, I'd be worried that this is a severe slip. I'd want to measure the Southwick angle, but it can be very tricky here. You can see on the frog lateral, you're not getting a very good frog at all. So I think it'd be safe to say that the slip angle is going to be over 50 degrees here. You told me that things got much worse in the last 24 hours.
Did you say that the symptoms were going on for a few weeks before that? Yes, the whole thing is about six months altogether, but it's 48 hours and now it's much worse. So this sounds like an acute on chronic slip. Where are we seeing him? Did he walk into the hospital? He got wheelchair down to only standing only at the moment. So I'd really like to see is if he can stand even with people holding him up.
Is he able to stand upright? No, he's in a lot of pain now. He can't, right? So this is a severe, unstable acute on chronic slip from an epiphytes, and it's a controversial area. There are different ways of managing this. Personally, I'd be looking at the two options of pinning in sochi, but my concern would be a technically very difficult procedure to try and pin that.
So the other option would be discussing it with the pediatric orthopedic surgeons to see whether they think some sort of neck shortening into a capsule or osteotomy might be a better option at this stage. The controversy is about this would include the timing. Some people would want to rest the patient on traction for a couple of weeks to make the acute slap chronic, whereas others say there's no difference and you can get on with your first available list.
And the other kind of controversy would be the approach. Some people, I think in this country, it's very common to use the anterior approach and do something like a Cuneo form of fish osteotomy. But there is a big trend moving towards the donor osteotomy through a surgical dislocation. OK good. Would you like to mention anything about his other side?
So looking at Klein's line, looking at the faces, I don't see any problems there right now. I would ask him whether there have been any issues. No, he's had no pain on that side. And the other thing is I'd want to discuss, so you did say he 14 years old. So in terms of age, I don't think that's a big risk factor for a slip. On the other side, the reported literature is about 20% to 30% for bilateral slips.
I would want to know a bit about his past medical history. So does he have any issues with renal failure? Does he have any endocrinol Kathy's good? No, no, he's not. He's a large lad and no other medical problems at all. And indeed, the family had be compliant. Um, they're from quite a low socioeconomic group. They have DNA appointments about his weight and dietitian in the past.
Right so bit touch and go. Probably OK. So yeah, that's something we'd have to take into consideration with counseling for the family. Yeah would you consider prophylactic penning of the other side, do you think? Definitely based on what you've said. Yeah do any evidence around? Well, so there's again, some people have argued that the numbers needed to treat is quite high, so you'd be pinning a lot of hips just to save a few.
There was a paper, I believe, from Dundee that showed in the British Journal of Bone and Joint Surgery that we should be pinning most of these. OK in terms of the posterior sloping angle, people do measure that. I think there's a bit of an issue with its reliability, but between 11 and 14 degrees, if there was an increase in the posterior sloping on the left side, that's another reason to consider pinning.
Yeah OK. So we've got about a minute left. You talked about the anterior approach. Would you briefly tell me about the anterior approach to that? Yeah the anterior approach to the hip is the modified Smith Peterson approach. For me, I use a bikini incision. I'd be separating sartorius from TensorFlow facilita. In this case, I would split the idea of offices.
I'd identify director's femoral tendon, divide it at both its heads, push rectus down and then I'm on to the capsule. So I'd be watching out for the lateral cutaneous nerve of the thigh and the more superficial plain. But after that, you've got the branch of the femoral artery, the second flex, but nothing else that you can really going to injure. OK what will all of us choose the anterior approach rather than doing such great dislocation?
What's the big advantage you think? I think one of the things is really that we're using the anterior approach. So often, I think the surgical dislocation, the evidence for that is still very controversial. So most units that have reported their evidence, their results outside of Bern have had high rates of avascular necrosis. Yeah, whereas the Bernese group have said it's 0.
Yeah OK, but so I think that covers skivvies and so everyone can see well, and she went straight to the diagnosis, I mean, it is obvious you're not going to see much more obvious diagnosis X-rays than that. So it's important you tell the diagnosis to show that it show. You mentioned the South angle that he knew what it was and that it was a severe one.
And then going through the fact that it is controversial and that is one of most important things. I think that we wanted to get across that this is a massively controversial subject. And you you cannot say anything to wrong in this as long as you back it up. A lot of people would pin that insight to you and then deal with the consequences. And that is not wrong in the same way that if you have worked somewhere and happy going through dumb osteotomy, that is not wrong, but you need to be able to back it up.
Mentioned about avian rates and sort of talking about the literature when we had gone through everything and gone through the risk factors. So you've got all the main points and you can see an example of that in four minutes. And said, guys, what we'd want you to take from this is slip from an epimysium. You're going to talk about the slip angle, you're going to talk about stability and chronicity and then your treatment options, which are pinning insight you a corrective osteotomy, which could be intra or extra capsular.
And really, once you talk about those things with the risk factors, that's easily passed. So hopefully that slips COVID. That really is as much as you need to in a bigger setting. Yeah, any questions on that one? A new expert here. Is it reasonable to suggest open reduction if closed reduction not possible? Oh, Luke.
Yeah, you might notice that I didn't mention clothes reduction, ok? There's this whole thing people say, oh, if there's a serendipitous reduction, when I put him on a traction table, don't do it. OK you are not going to in the exam. Just don't say you are going to say I will not attempt to closed reduction in real life. Some people argue that if it's a genuine acute slip with no chronic element to it, you could try a reduction in the first 24 hours.
I think that's controversial. What do you think, joe? Yeah do you not mention that in the exam? In reality, I've had it once and I was planning doing surgical dislocation and it just popped back in and my registrar says that click that he felt will live with him for the rest of his life. But actually, it was brilliant.
It clicked back exactly perfectly, right? But that was just luck. Do not try and reduce it and certainly don't say it in the exam that's opening up a big can of WORMS. And so we've got, I'm allowed to say, names. They're putting their age, should it? Should I mention loader classification or name it? Yeah OK. If you read Lotus paper, it was rubbish.
He was talking about close reductions on these hips, which is my quote them. I shouldn't say that we're recording this. It's a really good paper. It's revolutionized practice and understanding. But there were weaknesses in it, but you should definitely mention it. But what I'm hoping is as soon as I said stable and unstable, it became clear one of the things to clarify is you might have heard me say, can he stand upright with even two people holding onto him?
That is a stable slip, OK, if they can stand upright weight bearing on their good leg. Then it's a stable slip. There's this whole thing about they should go to walk with crutches. It's not if you've got a broken, if you've got a fractured neck of femur that is completely displaced, no one can hold you upright. OK, so that's what an unstable slip is.
Natasha, when pinning inside you with one screw, when you take screw out and evidence a lot of us. Joe, I don't know what you do. We don't take the screw out unless it's causing any issues. Leave it alone at the hip, guys. I love the hip arthroplasty surgeon who said to me, Lieberman, we can take him out if we have to do it. Yeah Darren Ebro posh party has kind of fallen out of favor.
OK, so this is the whole concept of the finger of God. So if you get in there within that 24 hours, you open up the capsule, release the blood and then use a finger just to push on that femoral neck to reduce it. It is only within the first 24 hours for an acute slip, not an acute on chronic and that really rare, really rare. And again, don't be getting into that in your exam. No so you can see we kind of just stayed in one zone.
Even things like how many threads are you going to put across to your purposes? I always find that a bit pointless because you're trying to aim at 90 degrees to your fiercest and then you get in as many as you safely can. If that's three, that's three. If it's five, that's great. Just and said Luke, thank you for mentioning the closure reductions.
That's something we wouldn't have mentioned otherwise. Cheers, Jennifer. I previously been advised that a stable slip includes being able to mobilize non weight bearing with crutches. No, this is what we were saying, actually, Jennifer. So there it was really interesting at best Cos our children's society and 90 2019 they actually did a kind of vote on that and people felt that that's what a stable slip was.
It's not. If you can stand with people holding you up, that is a stable slip. You don't have to walk. You don't need crutches. Think about your awkwardness when you're on your trauma on your uncle. They're not going anywhere with their fractured knots, are they?
This is exactly the same. If it's an acute unstable and it's wobbling around all over the place, it's painful. They don't want to move right. And then we've got a couple of other questions coming in. Mohammed Askar, do we need to know about the new devices, such as the sliding screws just mentioning that, OK, Mohammed, if you throw that in, that is absolutely fine.
What you do need to know is what size screw you're going to be using. So for a lot of us, I would use a 6.5 fully threaded. Joe, would you go single big? Yep so one day people say 4.5 and things too small. But if you're going to throw in telescopic screws, that's fine. But then you might be asked about the evidence and there is none. And yeah, you use them in younger children.
Lambros Athanasios. All right. He's asking if a delayed presentation is it better to operate ASAP or wait a couple of weeks? And that's controversial, as you'll have heard that, I said that at the beginning, the Swiss say even if it's acute unstable, they will operate whenever they can, so that could be the next day. The Stanmore said Mr. Cattrall's kind of rationale was turn that acute into a chronic, and that's what a lot of us have been doing in this country.
But there's no evidence for either. But what I can tell you is that when you look at the results for the more acute surgery from everywhere else except Switzerland, the results haven't been as good. Thank you. I think the thought is you're trying to get the information down by leaving it a bit. But actually, when you talk to the guys involved, a lot of it was just due to the fact that he couldn't get any surgical theater time, and the kids ended up just sitting on a Ward on traction until they could get in there.
Like Anish says, there's no definite proper evidence behind them. And that's the thing. A case of guys. When you're doing your pediatric vyver, we can tell if you've done a pediatric job because you talk with much less certainty. If you've been reading Miller and you've been reading banaszak, you'll talk with such certainty.
Everyone will know straightaway that you've not done any PEDs. And what you're going to hear a lot of today is and that's controversial, right? So rather than a really good question, when you pin insight you and when getting the threads in the epimysium, will it not make the head rotate? It doesn't, because most of these have a chronic element. And that's the problem.
When you when you open up these hips and you're looking at this epiphytes, it is stuck trying to actually move. It is hard. So no, it doesn't rotate around as you'd think. Peter Eggleston, do we need to know the details of the osteotomy if you're going for a gold medal? OK, otherwise that's why you'll have heard. I said, and this is what I'd say to my trainees is just go with you could go into capsular or pin insight.
You then do an extra capsular, OK. The principal is next shortening because in that chronic situation, you want to shorten the neck. So you take off the tension of the blood supply at the back so that you reduce the risk of avian shino Cauchy management and chronic sleep with mild exacerbations pinning with osteotomy. So again, people from mild and moderate have done pinning in situ and then done some sort of lesser tuberosity for the fix.
I wouldn't go down there, OK, I would. I think it would be safest to say mild and moderate slips. Just pin insight you. Full stop. Would you agree, joe? Yeah, definitely. And you're getting advice from your tertiary pediatric Center for anything moderate or severe on you. And as long as you said that, remember, the focus is for day one consultant being safe, you are not going to be doing these.
Just say, just mention it and say, you know, the principles behind it. These are blah blah blah. And then last question, I think we've got to move on after this. McKenna, you said after how long do you remove the screw after inside? You're pinning, as we were saying, we don't unless it's causing a problem.
And it's a real pain to find these screws and removing the. Having said that last question. Karim Rashid, if can release this happens, what can be done? This is not a physics level, OK? But so how can you avoid controls this theoretically by not perforating the femoral head? But it's surprising I might regret things, but it's not that common. No avian is more common.
But is your big worry this GIFE not control? And that's the situation in which. Yeah, Yeah. But in which case they're probably going for a hip replacement anyway. OK let's go for the next one. OK, so this is a 14-month-old little girl who's been brought into your clinic and she's just worried about the way she's walking.
How do you approach this? So I would start obviously by taking a full history and examination with this 14-month-old girl, I want to talk to the parents, ask whether this is their first child. I would want to know whether there were any problems during the pregnancy itself. Was this a normal delivery? Was she in a breech position?
Is there any family history of age and how has she been over those 14 months as she'd been developing normally? I'd expect all the answers to those questions to be normal, to be Yes. I would ask if she was breech and if she was, did she have hip screening? And the reason why I'd ask all these questions is can see looking at the X-ray that she's got a dislocated left hip.
This looks congenital to me. The Pacific nucleus is smaller on the left and the right. You've got an increased acetabular index on that left side, suggesting acetabular dysplasia. And this is in the fourth quadrant of tennis. OK, good. As you said, she's got a left dislocated hip and she's 14 months.
What are you going to do about it? What are you going to tell mom that your plan is so at 14 months? There are a couple of approaches that people adopt. One would be to get in there at this stage, personally. That's what I would do. The other approach would be to wait until 18 months and perform an open reduction with a sole trust. To me, that's what sort of described at this stage.
I would like to talk to them about the importance of putting the hip back. I'd explain that if we leave, as is, she will start walking and she has been walking, but she's likely to develop problems as she gets older with her back and maybe even her hip becoming arthritic if she develops a pseudo acetabulum. I'd like to perform an egawa and arts program with a view to trying to perform a closed reduction in the first instance.
If this was successful, I personally would perform an adductor and so as tenotomy and put her in a hip Spiker. I am aware that there was the biggest series of this has been from stanmore, so Sally Tennant and Debra Eastwood publish this. And actually, when they are in this quadrant, the results aren't so good. There is a high rate of even if the closed reduction was unsuccessful, then I'd be looking at doing an open reduction instead.
OK and you've talked to me before about your approach to doing an opium reduction, the anterior approach. You said a or osteotomy, what other osteotomy is? Do that can be used or is that one of choices? That would be my wine of choice? I am aware that some people perform. Ifemelu strikes me, so it does depend. You can judge this by performing a test of stability, as described by Tony catterall.
But sometimes it's the femur where you might want to put in a bit of virus and do a rotation to correct from La version. Or you address the acetabulum and what you're doing is making up that deficient anterior coverage. So that could be where this ultra osteotomy. The other ones, I'm aware of the Pemberton osteotomy and also the dagger as traditional as actually described by dagger and not the modifications, but that can if you put your wedges more anteriorly than post, you really can provide anterior coverage.
OK, what about your treatment? After that, you do the operation and then that's fine. Yeah well, see, I would normally put him in a hip spyker. So a 1 and 1/2 spyker down to the ankles in the left, to the knee on the right, and then perform some form of axial imaging to check my reduction. Usually we find a CT is just easier to obtain than MRI scan. And if that looks OK, then I'd normally bring the patient back at six weeks for a change of spyker and an iOS program.
OK all right. I think should we go into doing questions and stuff on that because I think everyone can see how you can answer questions like that. So easy. Anish obviously knows what he's talking about, but he'd gone through everything exactly how to treat a delayed presentation of a. Um, the really embarrassing if I was getting it wrong, I mean, if I miss you, I can't see the questions, so nothing's come through guys questions.
This is your chance far away. Right what are the degrees of flexion this is McKenna again. Oh no, sorry, hang on, I've missed one cawsey, masood. What would you still do in acetabular hysterectomy after a closed reduction? How do you decide acetabular versus femoral? My personal feeling for the fix is, you know, just like you're going to say, you always do an exit, a hip replacement, just say you always do a soul to osteotomy.
I think that might be the safest thing so that you don't get into this or do I do the femur? Do I do the pelvis after the age of two, you should say, I'm aware that I might need to do a femoral shortening as well as an acetabular osteotomy in terms of how we do decide there is that test of stability. So what Mr catterall described was once you've done your open reduction, if all it needs is abduction and a bit of internal rotation, you do the FEMA.
And if you need flexion, then you do a pelvic osteotomy something like assaulter McKenna. What are the degrees of flexion ER and abduction of that hip while putting feet? So remember it is it really you're using AI and just checking which position it's best in, but it will be internal rotation, not external rotation. OK, so your femoral head is pointing a you're trying to keep it in any evidence on maintaining reduction with wires.
There is a paper from Columbia, I think it was where they talked about pinning the femoral head to the acetabulum. I think you will raise eyebrows and possibly fail your pediatric station. If you mentioned that the only time I've ever put wires in is in revision ones, they are very unusual ones and certainly don't go up the neck into the acetabulum. Actually, incidentally, did put a wire in one a couple of days ago, but that we put it from the audioquest into the grocery counter in a particularly difficult one.
It's very unusual. Do not go into that. Do not do it, then. Abdullah evariste immediate closed or open reduction or wait until 18 months. That's one of the controversies. OK, so I think what would you do, joe? So I would not wait. But by the time they actually get to the operating theater with a bit of an elective waiting list, they'll be 18 months given that they're 14 months.
But what would you do if they were 12 months? Would you go in or which is very slightly different to yours? I we go in and do an open reduction at the age of 12 months. I wouldn't do a pelvic osteotomy until the age of the past 18 months closer to two, but actually a lot of the evidence shows that pelvic remodeling goes on. We don't know exactly how long, and there's lots of controversy about that.
Maybe up to the age of 4 and the bony. What you see on the bony side of it isn't actually what is often there. You're putting dye into the hip. They've got a lot of cartilaginous cover, so you don't often need to do a pelvic osteotomy. I am much more likely to do a femoral osteotomy, in which case, I would do that at the age of 12 months. So like Anish said before, there is so much controversy about all this pediatric stuff.
But as long as you say what you would do or what you have seen being done, that is fine. I think that's the thing, so yeah, I would do the same actually at 12 months if I fail a closed reduction earlier. I do an open reduction and nothing else you normally because the earlier you put the hit back, the more remodeling potential you've got in my mind.
But you could say anything really the only form of appeal because you are to me before the age of 18 months in the pelvis is so thin. It's just hard taking your graft and trying to get it. Stay there. But some people do do it. Chanel Cauchy after closed reduction in egawa speicher, would you do axilo scanning immediately? Personally, it depends on how confident I am, but yeah, I think just say yes, OK.
Would you go to a CT scan or from recovery on the way back to the ward? Mohammed ashker, would you please explain what we need to know about ask for gram for the exam? I think you need a way to talk through the approach you'd use. I'd use a medial approach putting my needle underneath the adductor tendons, squirting some joint program into the joint.
If you're looking for those blocks to reduction, OK, so you're looking for the inverted labrum, you're looking for that rose thorn sign, you're looking for the hourglass constriction. Is there an age limit for attempting clothes reduction? Not really. I think most of us think that after age 18 months and beyond, it's getting less likely. They had a couple over the age of two, but it is rarer.
And some people, I think in Southampton, the guys were saying they've stopped doing close reductions. They you still have options. Yeah akash, what's the advantage of performing an ice program before and after hip spike reduction? You need to do the ice program for closed reduction just so you can be sure that the femoral head is actually in because you can't see it's cartilaginous. And even with an open reduction, often once we repaired the capsule I like to squirt, some died back in just to really check because it's really hard.
You get a small view of this acetabulum. You know, it's not like a surgical dislocation where you might have the whole thing exposed. So that's why I think Instagram helps doing that. Catherine, all right. And so we can squirt a little bit of dye. And when we've got the spyker on, if we're particularly worried about her ankle, I'm learning as well.
Do we need to talk about examination of child in vyver? That was no meant you could. I kind of skipped that, but you could say to expect there to be a shortened leg with restricted abduction inflection someone's put. Please tell us more about ask for grant. We've done that a Jade is de golf, a CP post-super deficiency. So that's what everyone says.
But if read de guy's paper and actually it was Joe's colleague, Marcus, who put me onto this because he's a big fan of the dagger. Yeah, and the big advantage of the dagger is you don't have to put wires or anything in. It's a stable osteotomy and essentially you are breaking in the same line as a soldier, but you choose where you go through the medial cortex because this is getting way too advanced for me to comment on difference between closed reduction under sedation in the Ward.
You don't do it. I do it. Yeah, doesn't exist. So you, McKenna, you've obviously seen this somewhere where they're using ultrasound. I don't think that would be common practice, and I would stay away from talking about that. Jennifer, if given the case of a say, 10-month-old with rh, could you argue for immediate attempt at close reduction, if not comfortable medial approach or just wait until 12 months and do AI think that's down to the individual surgeon.
I would definitely go for a closed reduction in that first instance. And if that fails, then look at an open. I don't. I always advise people to stay away from the medial approach in the survivor. It's one less thing for you to learn, and you just say there's a very high rate of Abn, even as long as you follow up the kid, you'll find this an Abn.
And so it's preferred not to do it. Joe, do you ever do the media open approach? Very, very rarely. I'm much happier doing the anti approach. You can get much better visualization of the acetabulum. It's just it's just what we're more all used to. And I'd say avian rates, why not just wait a couple of months and do with a lower risk area?
I haven't talked about is public answers, and you have to know what a Pavlik Harness is, what the different straps do to get the flexion, to get the abduction. The fact, you are not going to use user over the age of six months and you need to know if you're shown an ultrasound of a hip roughly what you're looking at. I would not expect you to be able to go exactly through what, not what an ultrasound, all the tiny little bits of ultrasound.
I would expect to growth. I would expect you to know the varying degrees of it you have to do. Sorry, I say here. Harsh and then panagiotis, you said if the closed open reduction is not successful, then what? Then you try try again. The case close doesn't work. You are going to open.
If you know, if you've done an open reduction and the hip is not stable, that's when you're considering your strategies. Remember, the osteotomy aren't just to correct bony anatomy is to make the hip stable, but it does happen. And then we have to go back to theater with another plan. And I think it's happened to all of us, which do is I'm going to peak.
Yes, Yes. Someone's put here approach for open reduction. We talked about the anterior approach is the anterior approach, but remember to talk about splitting the iliac hypothesis. And a lot of people who haven't done or seen an open approach forget to talk about the idea of offices for infection. You don't need to split it. You do for surgery.
Al has asked why I prefer a medial approach for our program. His a approach as well, you always go under the adult's tender name up for lateral scapula. It's just a lot easier in babies. Yeah, I think when you're trying, there's a small space for that anterior femoral neck. And if you're trying to bounce it, it's cartilage. So it doesn't work.
So well, whereas the medial approach, there's just nothing in the way. Would you still put a public in a dislocated hip? I put it on and then ultrasound it the following week to see whether it's back in and you do your learning in Bali to try and get it in. Obviously, if it's a kind of a teratogenic one, one that is not going anywhere. No, but I would give it two weeks of trying to go in and to centralize.
Andrew Hughes, why must you wait until 18 months to perform the anterior approach? It's not. The anterior approach, actually is the soldier. And that's why you need to wait until 18 months. Medhi has from what age you consider close production. That's a really good question, actually. So Graff never put a graft for, he says in a public harness, he takes them for a closed reduction for me.
So you're seeing Mr Katter is a big influence in my life because he used to visit us at the Norfolk and Norwich, and he said, wait till five or six months and that's what we do, especially because you're doing tenotomy. It's amazing how easy it is to get lost in the medial part of a baby's thigh. Would you normally wait until five or six months, Joe, or wait until six months? Yes, because it's so far and aesthetically anesthetists are much happier to guess when that age.
Yeah James Houston why do you need to split the elective offices? So you will all tell me that you're going to go in the plane between gluteus medius and rectus ephemeris, which is the superior quality ulnar nerve in the femoral nerve. But that's the way you separate the two. OK, your abductors are attached to their outer table of the ileum.
So when you split the hypothesis and you go separate austral, you take everything off and it all can then peel off the capsule, McKenna comment. All the way around the capsule, you've got to be able to get all the way laterally and medially, and you'll see when you're joining a slap ticket. You cannot get that visualization of that capsule without squeezing your policies. So you have to do that.
Then McKenna has asked on the management of terror to logic dislocated hip. The thing is to say the public harnesses. I still give it a go, but it's less successful. Same with closed reduction. Still give it a go, but it's going be less successful. So you really you're looking more likely at open surgery with or without osteotomy. But it does depend on the cause of case.
So some people would say something like spina bifida. That's a controversial one. Some people say don't put him back, especially if it's bilateral. And others say you should try. So I think that one, you've got to just say that these are the uncertainties, rather Christian. if you see a child at six months, the hip is still dislocated.
Would you do any unasked for gram and reduce the hip and put him in a spyker? Yes later, you find it's dislocated at six weeks follow up. Would you wait to a 12 months to do an open reduction or do it straight away at 8 months? I would wait. I would wait to. Yeah mainly the risk of avian.
If you're going back in on there, you're going to increase your risk of avian by Messing around. You might as well just go back in and do it properly, and it might have matured a bit and you get a better clothes reduction, even when are 12 months and whatever you do. If you're asking the advisor if they say, look, you did a closed reduction post-op CT shows it's out. What are you going to do?
I would not say I'm going to try another clothes reduction, ok? You have to say, well, I'm assuming that I did everything well the first time. So why would it work a second time? I'm listing them for an open reduction terms of people. Ask this in the force. Yes, if you're getting on to this sort of thing, they've run out of things to ask you and you've got NIPE. Do I consent for closed and open at the same time?
Depends on the case. But yeah, maybe. How do you assess from La version during surgery? You're really looking at the hip stability, but it's really difficult. OK, so when you're trying to work out how much to rotate, everyone has their own system putting wise in the femur and stuff. It's all a little bit voodoo.
And then two last questions, OK, because we've really covered this. Is there an option of other bracing, failed public kindness or straightaway? Consider close reaction? Very good question from Prateek. Some people do try rigid bracing. Some people go straight to closed reduction. Rami, do you start treatment early in life for graft type 2 or do you repeat ultrasound at six weeks?
I would repeat ultrasound at six weeks, but what do you do, Joe, if you see a graph to age three? 2b yeah, I would repeat it. If they're at 12 weeks and they are not getting any better, then I would think about putting me in a Pavlik Harness. It's very controversial and we're actually starting hopefully an act which hopefully will be nationwide to get some questions about that. But you will not be asked that in your files yet.
All right, guys. No more questions, please. Otherwise, you won't get to hear about anything. So if I just answered the last three, how long for the public kindness? Again, controversial, I would say until the hip looks completely normal. And then just stop in an exam, say you're going to scan it every two weeks.
And when it's normal, you discontinue CT scan after closed down open reductions at two months, follow up in public Highness the hip is dislocated, so rather Christian. If it was dislocated at two weeks, you shouldn't carry on would do put your graft four in a public and if at two weeks it's not reducing might not be normal. But if it's not centering, you will discontinue the Pavlik Harness.
OK, protocol is a mobilization after closed open reduction is a hip Spiker. Is the left side common to dislocate people who think it's because of the left hip being rubbed up against mom sacrum? Really, no one knows right going to end the questions there for each other as we wait to talk about the other things. Ok?
hey, guys. So this you're on the neonatal unit and mom didn't attend any antenatal appointments at all and baby has popped out looking like this. Pediatricians are completely happy and feel that this is an isolated problem. What do you think? Right? so this is a clinical photograph of a baby's legs.
The most striking abnormality here is bilateral clubfoot, a congenital Televisa coronavirus. I'm a bit concerned looking at these limbs, looking at the size of the feet in relation to both tibia and both sides. Just it doesn't look right. There seems to be hyperplasia of the muscles at the thighs. And I'd be wondering whether this is whether there's a syndromic cause behind this rather than idiopathic clubfoot.
OK what mom's asking about what treatment you can give for the club feet or her feet or is going to look like this? No, I'd explain that actually the most clubbed feet, especially if they're idiopathic, are successfully treated by the Ponseti method, which is a sequence of plaster changes. We'll be doing that. We can start that as soon as baby is well enough.
So if there are no other problems with this baby, we could do that within the next week or so. And it's a series of plaster cast and we perform a correction in a specific sequence. So you're looking at correct soup and eating the first ray first, then you're going to correct the various. And the last thing you then bring up is correcting the Aquinas.
I'd explain that 90% of babies will need an Achilles tenotomy, which we'd usually perform in clinic under local anesthetic, usually at six weeks of plaster casting, providing everything's coming along OK. And then they'd go into the final plaster for three weeks and then boots and bars, which will be full time and then nights in that only until the age of five.
And with this, there's about a 90% success rate. OK what, why? Why don't you get club feet? Do any reasons why they think it's again, it's something that we don't really know. We know that there are various theories about this. What we do know is that the whole leg from below the knee is abnormal.
Studies have shown that certain muscle compartments, the lateral compartment and the anterior compartment are underdeveloped. About 50% of these children are also missing their docile as Peter's pulse. So we know there are genetic factors. It's more common in boys than this condition demonstrates the Carter effect. And we know that it does run in families, but it's the Carter effect that explains why it skips generations.
We know that there's an increase in Maya fibroblasts when you look at this tissue histologically. But really, we don't know why it occurs. It's not a packaging disorder. Ok? are there any other associations, anything else you'd be worried about? You said you worry about syndromes. Anything else you would routinely look up.
So one of the controversial associations is there are various papers papers published by Robin Paton that suggest that there isn't a genuine association between clubfoot. And I believe most people and most units do still scan children born with clubfoot for each. With these children, I would do a full head to toe examination. I'd also be looking for external signs of spinal deformity. And this racism to exclude conditions like spina bifida.
And yet here, I'm just still wondering whether these are featureless limbs. I'm not seeing lots of creases, and every time I see a bilateral congenital telepathic coronavirus, I'd be thinking about us for Kaposi's. Good OK, any questions that have come through? Yeah, there are a few. OK so Karim, I thought this pic of Arthur guy post, that's what I was wondering.
I do want to jump in with it because I wasn't completely sure. Is it? Arthur proposes. Yeah, I think it is ulnar claw process. Yeah Thomas, what is the Carter effect? Basically, the Carter effect is a genetic thing where a certain amount. So you have a certain amount of genetic load and you need differing amounts of genetic load to manifest the phenotype.
So in clubfoot, the theory is females can have that the same amount of genetic load but not demonstrate the condition, whereas a male will have that and demonstrate the condition, so explains why you can have conditions that are more common in one gender than in the other, but without having a relationship to the sex chromosomes. Keith ideal answer have asked about management of bilateral club presenting late in a teenager.
You are not going to get that. OK? and that's really controversial. I would. Let's not go there. Everyone knows the answers frames, but we won't talk about that. Karim, why? Yes, caves, clubfoot happens in spinal racism.
Do the honest answer of all of these things? None of us know, but it's to do with muscle imbalances. Is Ponseti caste extended above the knee? It's to provide that rotational stability. It's really important people have mucked around with all of those things and found it doesn't work. You've got to do it above the knee. Cool all of them.
Yeah oh, a couple more. Do we need to know the genetic associations? Not really. Just say it runs in families for the less astute of us. What are the hints in this photo that this guy poses? You know, it's a tricky one, and that's why it's a little bit unsure. But those legs just don't look normally that have very chubby thighs.
What we talk about is the lack of skin creases and the featureless. If you look at these, they just look tubular and shiny. And I think that's what would make you think. It's a process, a bilateral or severe club feet as well should always ring. Yeah I mean, you haven't talked about speroni score. Yeah, someone's just put that away. Out of six, you get three points for the three posterior elements.
So the empty heel posterior crease and the rigid requirements and then three points for the medial or the midfoot. So the medial crease that uncovered talar head and the medial lateral border. And so that's a way of looking at these clubbed feet right from the start to the finish, and the physios grade them at each time just to make sure that everything is going well.
And it's not until you have got rid of all of the three midfoot things that you can consider doing your Achilles tenotomy. So I wouldn't expect you to know much about the point score, but I would expect you to know that it exists, and it's a way of monitoring the progress of these clubbed feet. And McKenna has put politics in terms of the genes. If you know it through it in ages, asked about scoring jokes just answered that no man, what is the age?
An indication of gene poster and media release. There are very few indications AK Ponseti is the main one. I think the only indication would be failed Ponseti multiple times. So it's the syndromic feat. We just don't do media releases anymore. It's not done. And the only one scene is in one that is a really abnormal foot with multiple of coalitions and saying yes, yeah, it's just not.
And so normally they're about 18 months. By the time you tried the poinsettia a few times and then going in to do that tip and transfer. So depending on what you read, someone's put it to transfer question mark. Yes 25% to 30% Chanot Joe's answer to your question about peroni, so you don't need to know in detail, but just be able to name it kurram.
If clubfoot is part of our growth process, would you treat with ponseti? Yeah, there are papers on using Ponseti for syndromic clubbed feet. You do give it a go. There are various tips and tricks that the Ponseti purists know about. I'm not one of them, and the main thing, if someone asked you, is that you're going to probably be using more plaster casts.
That's the main thing. Once rates are much higher for Thomas cook speaking about a growth process, how in-depth should we know about it? I wouldn't go into matters of detail. OK, but you need to know that there's the distal type. There's a complex type and just that it can cause to rattle hip dislocations. It can cause knee extension, deformities and clubfoot.
Management of residual deformity at older age, Tamara's. I think there are various osteotomy fusions. The Taliban transfer is the main one. I think they'll ask you about. Again, that would be a rummy. What if casting failed or late presentation? Any role for gradual correction of external fixation depends on who you speak to. I think definitely so.
Joe, so as well? Yeah and I think some of our colleagues who have gone out to Africa and they are very, very pro doing Ponseti casting almost at any age and they have seen it work late teens, early 20s. So it's a quick, easy thing to do, whereas putting frames on it is horrible and it's worth doing Ponseti first. I would, Yeah.
McKenna's book please explain what exactly is a rock bottom deformity? So that's where you're basically trying to correct that awkwardness. But rather than correcting the quietness, you're doing it through the midfoot, and that's not a good thing to do. Should we mention doing X rays? Jaehyun has said so.
Actually, if you're being really good with your evidence and saying, actually, I know that John and Berg in Baltimore uses X-rays to assess whether Achilles tenotomy is required, then yes, but not just for measuring feet, not just for diagnosis. McKenna is asked about the exact difference between residual recurrent and resistant CTV, but apparently you've forgotten two more hours. Do you know anything about this five hours, joe?
Five hours? No, no. So I'm just guessing here McKenna residual means there's still a little bit of deformity when you finished recurrent means you got it better and then it's come back and resistant means you never got it better to begin with because it was probably syndromic. I've never heard of that.
So you'll have to teach us about that one critique how to diagnose dynamic superinfection clinically. When you watch them walk, they kind of lift that first ray like that. That's all it is. And if you get endorsed flex, they'll kind of do that. So it's just literally supination man. McKenna, I don't know what you've been reading, but you've got more knowledge than I have.
Do we need to know pavers or TAVR in capitals? Never heard of it for the old CTV. I'm going to take that as a no. My team would allow weight bearing if using Ponseti in an older child. Good question. I think it can be hard to control. There you go. The above New plasters.
They probably won't walk. They'll crawl around, and I think you've got to accept that that's what's going to happen. I think the only thing we haven't covered that would like to say is the boots and about the highest rate of recurrence is non-compliance. So right from the start you need to tell the parents they need to keep this kid in boots and bars, nights and nap times.
If they don't, their feet will recur. OK right, it's eight, 20. So shall we do one more and then throw it open to everyone else? Yeah OK. A seven-year-old boy. He's actually the son of one of our local gp's, wants to play for West Cam like his two twin sisters, and he's been complaining of severe left hip pain for the last few months.
He's clinically very well got no other medical problems. So this is an AP pelvis, and it shows that this 17-year-old boy. Has Perth hip tip, Shenzhen's Allen is intact, but you can see that if you look at the lateral pillar, there's over 50% loss of height, so this is a Herring. See, there are some head at risk signs I can see metaphysical cyst. I do wonder if there's some privacy or calcification.
And so I'd want to know a little bit more about this child in terms of working out what I'd be in terms of my management. OK he comes in sitting in a wheelchair, he's very reluctant to wait there on this at all. He holds the hip in about 10 degrees of abduction and does not like you moving it at all. He used to comply with physio, but not anymore. Right? it's unusual to have that degree of hip pain in this kind of condition with Perth, so it'd be a bit concerned about this.
Is he systemically? Well? yes, completely. Yeah, right? And so it sounds like this is clinically also ahead at risk. So he's got progressive loss of range of movement. It sounds like he's got an addiction contracture. And so Perth, this is really controversial. People really don't know what the ideal treatment would be. Given his gender and his age, he should have a good outcome even if we do nothing.
But based on the X-ray and especially the clinical picture that you describe, I'd be more likely to consider operative intervention. I'm aware that there is very little evidence that this would improve the outcome, but especially if he's struggling this much, I think this is the kind of child I'd consider admitting for traction and maybe going further with that.
It depends on how we can control the symptoms and getting complying with physiotherapy. OK do you know anything about the etiology of Percy's disease? There have been various theories. The biggest associations we have are with passive smoking and lower socioeconomic class. Prof Dan from all day has published a lot of work on birthdays, and one of his most recent studies in the bone and Joint Journal showed that there is definitely a link with being from a lower socioeconomic class, but they couldn't separate the effect of that from the effect of passive smoking.
I'm aware that there's also been the boss study, which has just reported its preliminary results, but this was a longitudinal study survey. It was basically a survey or a registry of all kids with this disease over 2a year period. OK and. Any questions in Perth is the ultimate treatment goal. So what do you aim to do with it?
My treatment goal would be containment. That's the main principle. We need to keep the femoral head within the acetabulum. Usually this would be with physiotherapy. I ask them to stretch the duck to muscles so that they've got good abduction and keeping that femoral head moving into the acetabulum. If that's not working, there are various other approaches that have been described.
Some people have described tenotomy of the adductor tendon and then broomstick plasters or a-frame braces. Others have talked about various or stretches of the femur. Benjamin Joseph has written up a big series on those from Moneyball. Others have talked about using the sole trust to me or a shelf, and some people put all of these things together. There is no evidence that any one of these is better than any others.
What are you going to tell the parents about this? They want them going back to football and they want the quick fix. What's the quickest way of doing it? I'd have to explain to him that there is no quick fix in this situation. Perth disease lasts about three years. You've got the various stages, you've got the initial stage where you've got sclerosis, then fragmentation, then healing and then the remodeling phase.
Altogether, that will take about three years. The pain and stiffness normally lasts for about a year and a half, and it's very variable even if we do an operation that's not going to make this well. The evidence there is controversial. Most people don't think it accelerates healing. There is some evidence from Benjamin Joseph's study group and from Sheffield children's hospital, where they use hip detractors that it can accelerate healing.
But as far as this family is concerned, I would not be making any promises. I'd also be Warning them that because you've got total epimysium involvement here, I'd be worried about proximal femoral morphology abnormality as this child gets older and that they might need further surgery at that stage as well. How about the other side? Yeah, I'd like to see a frog lateral, because sometimes it's easier to see changes on for a lateral view.
Again, it's about a 25% to 30% chance of having bilateral involvement. So be watching for that side as we go along with time to do any evidence about vitamin D use with in places? I believe there is some there, but it's controversial. So some there has been a paper, I think, from India that suggested that there is an association, but there's also been one that suggested there isn't. OK, any questions come through yet?
There are. Hold on a second. We have got to. You know, right, so guys, I have to say my first thing I always say to the trainees when you answer the question about management is, say containment. And I'm a bit disappointed that Joe had to ask me, what's the principal? Sorry about that, right?
Where are we? I'm trying to find where we were. Rami, any role for bisphosphonates in Perth disease? Again, not farke's level. People were investigating it, but the biggest problem is if you've got no blood supply to the femoral head. And you inject intravenous medicines, it won't get to the femoral head.
So people were talking about injecting it directly into the femoral head, but I don't think that got approval. Alistair, how do you if you've got if you're losing bisphosphonates in why you stop using them around the type of any fractures, you've got pertes, you've got loads of little micro fractures or it just doesn't. It's not a good idea. And there's no evidence for it. How long would you traction for?
So, Alistair, I have to be honest, I've never come across someone with such severe birthdays, and I don't know if that's what you were looking for with the traction, but I know that people out there do do it and essentially it would be until the symptoms subside. So sometimes a week or two. Some people use traction a lot. Yeah yeah, it's not something I used.
I think it's along the same principle you said of the distraction fixes. Yeah, just to let it settle down. Yeah McKenna etiology theories, the vascular theory. There are loads of theories, but none of them have been proven. So we know that there's a vascular insult. You can induce this in pigs by basically tying off the blood supply to the femoral head. But what causes that is the big issue.
What I do love is when you look at the pathology, you get more cartilage forming because cartilage withstands that ischemic environment. But and that's why you get Cox and magna, because the cartilage needs to be bigger because it doesn't withstand the shear forces. So that stuff makes sense to me, but I don't think anyone's actually explained why it happens. What grade would this be?
See? remember, you applied the Herring gradient stage of maximal fragmentation, but it's not going to get any worse than this, is it? She how to practice practically distinguish between BC and see in an X-ray. The BC was something that was kind of added later. And when you read those Herring papers, there's no clarification about what that is.
So my advice would be ignore that for the exam. Lawrence, if you have a child under the age of 6 with a Herring, see how would you manage this? I don't find Herring particularly useful, I must say, and I think a lot of us completely ignore it. My how I would treat a child with birthdays depends on whether they have wholehearted involvement, whether they're a load of head at risk signs that lateral extrusion.
That is always a really bad sign because it means that when that head is starting to remodel, they're going to impinge, they're going to have an awful shaped head. So Herring, yes, mention it. About it, but say from experience, you know that pediatric orthopedic surgeons are more worried if the whole head has become a vascular and you just need to get containment of that.
So yeah, we know that kids, no matter how old they are, if they have only a little bit, that has. Sort of become a vascular. They are generally going to do well. But if they have the whole of it, that is a vascular, they need some help and you need to get that head in the right place, even if they are really young. Yeah, I think that's the thing is the problem with the Herring with the Herring classification is that thing about applying it at peak fragmentation by which stage, you actually missed the boat for doing your surgical containment procedure.
Agnese Duthiers worth mentioning any classification other than Herring. You could mention the catterall classification, but I personally don't think you need to go into that for five years. While it is to manage per phase conservatively, how long do you follow the patients up and how often do you imaging? Good questions.
Also, what's your threshold finding to convert conservative management to surgery? I think we have to be clear her, but there is no evidence that surgery changes. Anything the boss study has in its preliminary results suggested that it's only a two year follow up. But having said all that, sometimes you just bite the bullet because you're watching and thinking, man, if I don't do anything and this ends up bad, it's my fault.
And I think it's a combination of clinical factors as well as the X-ray. So I'm a big believer in the clinical head at risk signs and the radiographic. So if I'm seeing what Joe described it progressively stiffening hip. My worry is that actually this is a hip that is slowly subluxation. And if we leave it where it is, when it does reform, it's not going to match the acetabulum.
So that's what I'm looking for. So when I follow these children, I see them every three months with an X-ray and a definite clinical examination. And if we find that they're complying with physio and still stiffening up in my world, that's when they're going to be looking at possible surgery. Yeah, kids that are losing their abduction are ones that I worry about. I have quite a low threshold for teams there, too.
Doing an EAA arthrogram because the anesthetic takes away their pain, you can see their true range of movement and putting dye into the hip I find very useful. I know that's a very pediatric pod thing to do. We love Arthur grabbing joints, but it's because you can just see so it gives you so much information. Yeah, definitely. Herring be above the age of eight. Would you operate.
So Abdullah again? Good question. A lot of people at that age are worried, and I think if you're seeing progressive sign of femoral head collapse again based on those head at risk signs the older child, I would have a lower threshold to operate. Yeah, I do. You're off the ground, but can them for an osteotomy at the same time?
And Karim has said, well, I thought as differential diagnosis and first look like telltale sign of septic arthritis. So I wasn't sure. OK, I didn't think this to me. This isn't classic septic arthritis, but based on what Joe was describing, leukemia can also have a similar appearance. I've seen a case of that with one of my colleagues dealt with, and that's why I was just a little bit paranoid.
And you know, this is an example of exam mode. When you're in exam mode, you're looking for the weird and wonderful. So even if it's really straightforward, Perth is based on the History. I think is you're trying to catch me out. If you're trying to catch me out, there's over 100 people watching, is you're going to make me look like a fool? And in exam mode, you're always looking for that wrist thing.
Chanot how practical is it to maintain non weight bearing for such long periods? You might. So we didn't talk about that. I don't keep them non weight bearing again. If you do your ground reaction force diagrams, the joint reaction forces are lower with touch weight bearing than non weight bearing. All I ask my Perth kids to do is not run around, so I do let them walk.
I don't give them trampolines and jumping on beds. Yeah, I give them usually either crutches or frame or some kind of protection, and often not to go on long walks as well and at school as well. They're generally not doing PE and running around in playtime. Can we use Herring grading for any stage other than fragmentation? Well, it's for acute Perth, as you remember. After that, you'll be using the stool classification.
But what we're saying is it should be applied at peak fragmentation, but you only know that you've hit peak fragmentation when the next X-ray shows that you are healing up. Ok? what stage would you start the treatment? So the question and it should be before peak fragmentation. And that's why we're having classification is a brilliant shares.
How would you differentiate between Abn and based on an X ray? I think some of that's going to be your history, really, because Perth is Aden, right? So if there's a history of DCH that's been treated and there is an association with Nadh and then a late Perth days ago, so no signs of Abn and then suddenly age five or six, there are signs of Perth disease, and people aren't sure if the two are related or has said how would traction or spanning fix help?
Essentially, the idea is you're reducing those joint reaction forces, you're taking the force off that soft femoral head. Haitham is put. Do you do you ask for ground before considering open reduction? We're not talking about open reduction Perth as a case. So Perth is containment, so you're either doing a femoral osteotomy to dip it in or you're doing a shelf. Eating a soda or eating both.
But we're not opening up the hip joint itself. Ali, how would you treat hinged abduction? If you get hinge abduction, you've missed the boat. That's when you've got that femoral head deformity and they need a valgus osteotomy as a salvage procedure or is what I'd say? Yeah what joint? Andrew, here's what joint preservation techniques should trainees be able to talk about discussing the fix?
None OK, that is all experimental. Well, it's not experimental, but people are doing femoral head reduction or stretching music. They're literally taking that big cocks, Magna taking a wedge of the femoral head out and putting the femoral head back together. I don't know, Joe, is anyone doing that in the UK. Andreas road pushes crazy, right? A couple of times.
I think Fabian has done it a couple of times as well, but that's certainly nothing you want to be getting into in your fast. Yes Yeah. I mean, you saw how quickly time when Anish was answering the questions, know the basics behind it. The important things that you have got to say. Don't focus on them like weird and wonderful like that.
You don't need to. I think because I've got a message here from imogen, who is kindly organizing the whole thing she's saying get a move on. All right. So, so last question, OK, how to differentiate Perth from Med and said it's to do with that difference in time. So if you're looking at things that are happening synchronously, it's more likely to be Medi.
Get an X-ray of the knees or a skeletal survey. If you really worried to pick up that face doesn't happen, you don't have it in the same stage bilaterally. Yeah, right. So now you've seen how I approached it, you're going to show me how we should, how I should have done it by answering the vyver questions that we're going to ask you.
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