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Orthopaedic Appliances - Part 1
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Orthopaedic Appliances - Part 1
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Language: EN.
Segment:0 .
Another important aspect of the curriculum that are mentioned there, and we are expected to up to four level 4 of it. OK so without further ado, this is the scenario that we will start with. I hope that everyone can see that. So Abdullah, this is a 60-year-old gentleman, as you can see a open wound with infected open reduction targets of the right proximal tibia.
He needs removal of metal work. It can right. You've done the procedure and you find that there's a significant bone defect in there. How do you how do you feel about the effect? OK, I have to assess the defect appropriately through the X-ray and since there is an infection, so I cannot use the patient's own bone graft because it'll just fail. So I have to fill it with something that has calcium and allow me to deliver some antibiotics.
The options I can think of is either stimulant or serum G because they allow me to deliver antibiotics and they fill the gap and they can turn into bone. OK, so you've managed to fill the gap in your bone substitute with antibiotics, but you also discover that you can't close the skin. You've managed to get good soft tissue coverage, but you can't get the skin to close. What do you do in this scenario?
I mean, you can cover it with some skin graft. However, my skin grafting techniques are not the best. Alternatively, I can use a holding measure in the form of a VAC pump and refer the patient to the plastic team as soon as possible. Excellent So if you do manage to get the skin graft on and sorry, the plastic surgeons did manage to get a skin graft on a couple of days later. But at nine months we presented with no progression to union yet, and he doesn't want any further procedures.
What options do you have now? I have to exclude the presence of infection as a cause of this nonunion. Now if this was excluded, then discussing with the patient that causes for him not to have to want surgery, I assume that he had plenty of surgery. And if he's fed up with that, we can try something like pulsed ultrasound waves like estrogen. See whether that could encourage the bone to heal.
And I will have that with the discussion with the patient. OK and naturally, of course, before you even consider doing the surgery, you would have normally talked about having plastic available to you, but you were put in a scenario where you didn't have well done. Thank you very much. Very little detail in what he gave to me. But today he's going to give you all a huge amount of detail.
Thank you. Please go ahead. Thank you, Sean. So the first part of the talk, as you've noted, is about the bone substitute and bone graft. Now this is to a compliment to the lecture given by our colleague about bone back in July. However, I decided to complement that by talking about different aspects of it at the most recent evidence about specifically bone grafts and bone substitutes.
So what do we mean by bone grafts and substitutes? It's any material that you can use to help the bone heal through its properties. It is supposed to give a mechanical support to the bone at the same time as biological stimulation to allow the healing. And that works in different methods. However, in practice, the common indications for it is to provide structural stability.
For example, you've taken a big tumor leaving a big gap, and if you leave it like that, the bone can collapse. So you want something to fill that gap and hope that it will turn into a bone in the future. The other thing is you have done a fusion and the bone quality in that area is poor, or there is a big gap that if you compress the bone, the patient will be shorter. So you want to fill that gap with something that will again turn into bone later in trauma, either because you've got an acute bone loss or chronic nonunion and you want to fill that gap with something.
So these are the scenarios that can come in the exam where you will mention the word bone graft. What is the ideal bone substitute? And I'm talking here about substitutes in general, anything that can fill the gap. It should be close to your inductive posterior in conductive and osteogenic, and I will be talking about these in a minute. You have to these have to have no immunological rejection risk or at least you know, the least possible risk.
It has to have a very low risk of transmitting infection or ideally no risk of infection. It should achieve incorporation by gradual substitution, which means that slowly the bone will take over and fill the whole gap completely and the material should resolve. You should be able to mold it into the defect regardless. Regardless of the defects shape, it should allow for sterilization and tolerate temperatures.
It should be available readily at a reasonable cost, and it should be biomechanically similar to the surrounding tissues. Now, if you think of these, there is no ideal bone substitute available, the best that can come close to that would be the patient's own bone borrowed from somewhere else. So how can we classify these and this is the definitions that I was talking about the conductive, which means it has a three dimensional shape allowing the bone to grow into osteoinductive means that it has the proteins that allow the bone to grow.
Osteogenic means that it contains cells that allow the bone to grow. A material can be one or all of these three. According to the source, where we can get these from. We have autographed allograft, xenograft. And bone substitute artificial materials, so autograft is the gold standard because this is the closest you can get to achieving all the previously mentioned points because it is sterile.
There are no immunity issues. There is no infection, infective issues. It incorporates rapidly and it has proteins. It has the three dimensional shape and it has the cells. So in an ideal world, this is what you should be using. The downside is you have to harvest it from somewhere else, which means you are leaving that area vulnerable to complications. In addition, it is limited supply.
You can take as many without causing major problems to the other source. Hence, you can use it for small gaps only. But when the gap is big enough, unfortunately you have to rely on something else. Talking about allograft, which is grafts taken from other humans and then processed in a way to reduce the risk of infection and immunological response, they can be fresh, fresh, frozen, freeze dried or dBm.
So the fresh is when you take it immediately from the other person and then just clean it and try and reduce the infection. Fresh frozen preserves the BNP the freeze dried does not reserve the BNP, which is the protein mostly linked to encouraging the bone to heal. And then we will talk about the dBm separately. Xenograft are not available in practice very much, which is from other species, and then we can talk about bone substitutes, which which are artificial materials that represents some aspects of the bone and allow the bone to grow into that area that can be having the calcium component or other compounds or polymers or a mixture of the above.
In general, these are the benefits and risks of each in comparison to each other. Let this slide will be in the YouTube, so I will not dwell on it, you can look at it later on from the YouTube channel, but I've talked about the important one, which is the autographed. Now, what are the risks of bone grafts in general? You have donor risk morbidity, you have disease transmission, which we've alluded to, which cannot be zero percent, but we are talking about very, very few numbers nowadays.
We are talking about one in 100,000 or one in a 10,000 and then immune sensitization. You can put the bone graft as an inlet graft, which is just using it to fill the gap, the cavity or strut graft, which gives structural support. So you are using cortical in the second and cancel us, usually in the first. How does it incorporate you notice that I am talking very quickly about these aspects because as I mentioned, these are covered nicely by Ajith.
So again, if you look at the picture here, you start with a bone graft at number one. Then slowly there will be some inflammation, which will attract the blood vessels and the immune cells. And slowly, that would lay a new calcium through heaping substitution. And on the x-ray, it looks like increased density. And then slowly that will remodel. And the original material of the bone graft, which is the cancerous bone, has completely disappeared.
The cortical bone, the story is slightly different. The first two stages are the same, however, don't have a creeping substitution and most of the action happens at the surface. And the core of the material of the bone graft remains for years and sometimes never disappears. OK, so the autographed news, the most common used one is the iliac crest, and it is the commonest it has a complication rate between two to 36% The interior has more risks.
The risks are bleeding the injury to surrounding nerves. It can lead to a hernia if someone is very aggressive and damaging the insertion of the muscles. Infection fracture, scar anchors, Mrs. and chronic pain. And that is to do with the position of it. And as it is very close to where the belt is, the fibula and the ribs are the most common source of vascularized autographs and can be used as a strut grafts. Now, what I wanted to talk about is this new technique.
This is called remember, get a respirator, it is borrowed from when we used to ream the inside of the bone. Someone thought of, OK, what if I put a filter at the end of that? And all the debris from that reaming, which is bone marrow plus bone plus blood, plus all these juicy things, if I filter it and put it back into the cavity. And actually, there is an increase in the healing because it is concentrated, it is the patient's own material and there is no immunological reaction to it.
And you can mix it with other aspects like bone substitutes to increase its bulk. The downside of that is it is an additional procedure. So imagine yourself trying to fill a gap, a gap in the spine. And then having to drilled and ream the tibia or the femur to get that it's an additional procedure with its own risks. So probably what is a halfway between is when you are aiming for the nail of tibia, just try and keep the rims and reintroduce them again into the area of the gap.
Or you can use that for severe cases where there is significant nonunion or union nearby. OK allograft, they come as more civilized, which is broken down into small pieces, us cortical counsellor's cortical ostrich control, whole ball hole bone segments like the femoral head, which you can get and you cut the way you want it, or DBM, which is de mineralized bone matrix.
What is dbm? There is a standard process for making the DBM, and it is made up or brought up by your wrist. So these are the stages. First of all, you break it down into small, the bone into small particles, then you dimensionalize them in each seal for three hours. Then you clear the seal with sterile water and alcohol that leaves all the proteins and maintain the shape of the bone.
OK, so it acts as osteoinductive because it contains all the proteins that are needed. However, the bone material, the calcium is almost gone, so it does not have the strength to hold the mechanical stresses. On its own, it is not enough to increase the bone healing. However, if you combine it with other substitutes, especially calcium products, then it increases its effective efficacy.
The common question is bond banks on how to set up a bond bank. And again, it is being answered by a joke. I will just quickly run through that. The first step is to donor selecting, and that process means that you have to send them for it. You have to ask to explain the situation to them, and you have to get a pool of patients who are willing to donate that their bones after death or, you know, after procedures after death.
Usually, sorry, then you have to screen the patients clinically and with blood testing, and then you sample, you harvest the sample and then you prepare the graph. And that is by physical debridement, mechanical cleansing, then alcohol smoking to reduce the bacterial load and then antibiotics working again to reduce the bacterial load gamma radiation to reduce the sensitivity or sensitization. Sorry and the last bit is to dimensionalize it like DBM, then you have to consider the storage and the lifespan of it, and it depends on the temperature, you are leaving it between.
The lower the temperature, the more expensive it is, but the longer it lasts and then methods of distributing it. So when you store it, it can be fresh, fresh, frozen or freeze dried, as we mentioned earlier. And what you can request as an NHS doctor, you can request a fresh frozen femoral head, which the benefit of that is it comes in an entirety and you cut it to the shape you want.
And it's commonly used for cutting wedges for either acetabular surgery or for a high tibial osteotomy hour. It can come as cancellous cubes, which you can put in a bigger voids or cancel struts. Now, let's talk about bone substitutes again, these can be divided depending on what you are replacing. So if you are replacing cells, then you can use injecting of mesenchymal stem cells, which has been tried.
However, it is expensive and I think currently I don't. I'm not aware of any hospital where this is a common practice. You can replace stimulating proteins like BMP 7 and BMP two, or you can inject platelet rich plasma PRP and some places do inject that it is an easy procedure to do. Basically, you take the patient's own blood and then you put it in a sedimentation machine that will just spin very at high speed.
And that would separate the plasma from the red cells, and you can inject the plasma back again into the patient themselves. Again, I'm not aware of any trust where this is a common practice. I work with the limb reconstruction team. We have the facility to do that, but I haven't seen it done frequently. The last thing, which is the more common one to be asked about, is replacing minerals with the ability to add antibiotics.
These can be calcium phosphate, try calcium phosphate, calcium carbonate hydroxide, appetite, sulfate, silicone based polymers or a mixture of the above. Quickly, let's talk about them, so calcium sulfate is the most commonly used one. It comes as pellets or powder. The common one is stimulant. It allows you to add antibiotics to that. It is fastest at resorption between six to eight weeks, and it has a high risk compared to all the others of having a serious drainage.
It is sterile. It is just the byproducts of breaking down of the calcium sulfate by the body's tissue. The calcium carbonate is not commonly in use. I did convert in the body to calcium phosphate. The calcium phosphate can be in two shapes either try calcium phosphate or the cement. They try calcium phosphate converts into hydroxyapatite. It results in about 3 of 13 to 20 weeks.
It has faster absorption than hydroxyapatite. And it has a similar strength once it is solidified in similar strength to the Kessler spawn itself. It comes as injection. And then you leave it in, you leave it outside the body. It's like the cement you usually use and then when you inject it into the body, it goes solid. The second shape is calcium phosphate cement, which is a combination of more than one calcium product, and the idea is to benefit from the different rates of absorption.
So you have something that absorbs very quickly and then something that takes long. The issue with that is the ideal substitute will have to absorb as the bone is growing. So there will be no area, no time where there is a void. The problem with the first products, the first three products is they tend to get absorbed before the bone has fully integrated into that gap and filling it, so there will be some void.
However, the cement, the design behind it is some of it will get absorbed, leaving a space for the bone to grow, while the rest of it is still there, holding the gap and filling it and preventing structural weakness. The new technique that I wanted to mention is the CPC in 3D printing. And this is a clever technique where in certain areas you you can apply it again. I think in the UK you can do that and it's available, but I think it's available only in some centers.
And you have to apply for a permission to for the funding for it. Basically, you do a CT scan into the area, you decide how much is the gap, what is the shape of it, and then you send it to a company that prints a three dimensional structure to fill exactly that gap and that the material they are using is a combination of hydroxyapatite and B to try calcium phosphate.
And that combination is the cement, as we mentioned earlier. As I said, it has the benefit is no. One filling exactly the same shape at the same gap. Number two, this three dimensional structure allows the body to allows the bone to grow there faster and in a bigger rate, and at the same time, it lasts as long as it is needed for the bone to do that.
Let's talk about hydroxy appetite, which you can get alone, but again, it's not common, you know, you don't see it. The reason is it takes very, very, very long time to be resolved by the body and it is very brittle, so it's not used for its mechanical structures. The biphasic product is the one we talked about, and the one commonly used in practice is the sediment that I am aware of, and G stands for gentamicin, so it allows you to add some antibiotics to it.
A new materials like bioactive glass are silica based, and they contain calcium oxide and phosphate. And when you put it in the body, they form a layer around them, which is like a jelly. And that area protects the area the material and allows the bone to grow into it. And then slowly, some of that gets resolved. It is expensive and in practice, not many surgeons like it because they have this glassy feel when, when, when you, you know, they leave these glossy granules in the wound that.
Patients may not like poly, garlic, sorry, but poly, glycolic acid and poly lactic acid again have a still conductive properties. You can put them in three dimensional shape again, to encourage that. But I haven't come across them and I believe they would be expensive. The evidence you can quote is a calcium phosphate allow for bone defect, filling early rehabilitation and prevention of particular substance.
Let's talk about substituting proteins. Let's talk about BNP bond more photogenic protein is a natural material that exists in the body, which and increases at the time of fractures induced by osteoblasts. The FDA in America and the UK have approved the BMP two for open tibial fracture, a selective clinical indication and BMP with iliac, non-union and traumatic bone defects.
They are not used alone. Some people believe that the amount we are putting in the wound in the fracture is so small that regardless of how much you put it, is so small compared to the body's physiology that you need something else. It works, but it's not. It doesn't work alone, so you have to have something else as well.
Um, this is coming from a bovine usually they are coming from this is the material available in the market in the UK and it comes from bovine origin. So what is the available evidence? I leave this for you to read. So basically the bottom line is allograft, the present first choice for most reconstructive solutions. However, in revision total hip replacement, you don't have the femoral head.
So they are saying that in general, fresh frozen bone is firmly recommended for structural graft, freeze dried and/or radiated bone maybe use, Alternatively for impacting grafting. So this is from effort in Europe. There is another evidence about the role of bone grafts for foot and ankle surgery. Same thing and in spinal surgery. That's from the UK.
And again, they are saying that they have good evidence of working in the combination of BNP and bone grafts. Blast evidence is this review, which looked at the use of recombinant BMP two in lumbar fusion, and they found that it does increase the rate of union. This is from 2020. Before we continue, does anyone have a question about the above?
Or shall I continue? Sorry, do you mind if I do ask Abdullah because. Yes, because the next topic is quite different. Yes so actually, if Mahmoud has asked, how does dBm act as Austria conductive? And also, how does dBm powder provide structural support? I didn't say that it does provide structural support, I said provides the proteins, as you can see here, mainly because inductive material you go.
So there is a difference between strut and structural. I would be very wary about mixing up those two when we say usually when we say structural, we do mean it's micro structural, not actual taking weight and things like that, which is different to a strut given strut support. But yes, you're right, you didn't say dBm is structural support said maybe possibly act as conductive materials, but the general allograft, because yes, it still maintains the three dimensional shape.
And that's the three dimensional shape of the bone. And the bone likes that, and it actually stimulates the engine neurogenesis and stimulates the osteoblasts. There is new evidence that one of the stimulation of osteoblasts to differentiate is actually the three dimensional shape of the structure around them. And that's why if you look the new, the new materials, they are all 3D printed to allow this to happen to stimulate the osteoblasts through this 3D shape.
So that's how it can be conductive. It's the three dimensional shape. But the main thing is just your inductive. Now, as you mentioned one, it is different than the structural as in allowing to take compression. So the DBM, you should not rely on it to fill a gap where the bone the patient will be walking upon and expect them to hold. What you usually do is the typical, you know, use for that is, for example, if you have a tibial plateau fracture, so you put a raft of screws on top, you have a big gap.
How do you fill it? You can use dBm to fill that gap because it incorporates bone faster than any other material, and you can combine it with serum and g. For example, if you are doubtful about infection and that combination gives calcium hydroxide appetite, gives the proteins and gives the three dimensional shape. But you are not resisting pressure compression, I meant. Yes OK, thank you.
I think that's quite clearly explained. I hope you guys are happy with that. Thank you. No problem. We continue. Or do you have any questions? If anyone's getting questions about bone grafting and substitute bone graft, please to speak up now. OK, fine, so let's talk about the vac bump, which the technical term is negative pressure wound therapy.
How does it work? No one knows. How does it work exactly. However, there are theories about and observations about why it may work, and it is to do with two phenomenon, which is macro strain and micro strain. So macro strain is what you can see with your own eyes, which is it draws the wound edges together. It just distributes the negative pressure across the wound itself, and it may remove some of the extra dates from the wound.
It does remove the extra dates and that can result in reducing the infection. However, this has not been proven. The infection bit the micro strain, however, is probably where most people feel that it works, which is the encouraging the most wound healing by promoting granulation tissue and engineer new angiogenesis. It increases the cellular proliferation and migration into the wound, and that and that by itself can speed up the healing.
And it can reduce the edema. And again, this is not 100% proven. The studies suggest that it increases the number of fibroblastic migration by 3 folds, and they reduce the cell death by 2 to 2.4 fold. So there is some cellular result of the vacuum pump. When do we use them, we can use them either in acute or chronic conditions in acute conditions can be used in traumatic wound with deep, extensive skin defects as the one, you know, described before surgical excision.
When you finish the surgery and you find that there is a big defect when there is a skin adhesions and you want to fill the gap with something without stitching and putting the rest of the skin under pressure. And when using skin grafts in chronic wounds like ulcers, it speeds up the development of granulation tissue and shortens the healing time. We cannot we use it, if you think of it, you are applying negative pressure around the tissues.
So if you have tissues that are vulnerable, then you should apply it malignancy again because you are spreading the infect the tumor when you have. Um, not explored fistula. Then you should not allow apply it. And when you have a scar because the scar will prevent the negative pressure from working, so you are just wasting time, you use it. You have to consider using it.
Sorry, you have to think hard before using it. When you have weakened the blood supply or vessels because it may explode and cause bleeding when delicate structures are exposed, when there is active bleeding currently. So try and stop the bleeding before that. If you have fistula that where they're coming from, patients requiring certain treatments like hyperbaric oxygen or they are going to an MRI.
This this is you. They are not saying you should not. They are saying you should consider and additional precautions when you have spinal cord injury or infected wounds. The important message is it is not a replacement for proper debridement. I've seen surgeons do a bad job at dividing the wound and then say, well, the rest of it will be done by the vac, which is not true.
You do a proper debridement and then you encourage the granulation through the vac. It is not treatment for infection. It is not treatment for crap surgery. How do you apply it? You use a sterile reticulated polyurethane sponge. There are different color of that. You use a silicone interface to stop it from adhering to the wound.
So when you take it off, you are not taking all the granulation tissue and it doesn't cause pain. You have three types of foam that you can apply. Black is the standard one stimulate granulation tissue for large wounds. White it has a smaller cells that protect fragile tissues, and the great which has silver, which you can use if there is infected infection.
Then you apply an adhesive plastic sheet to seal the whole thing, including the pump tube, and you can set it at any pressure you want. But the common pressure is 125 sorry, minus 125 mercury. You put it at a setting of either continuous or intermittent, the continuous you use initially. And the reason for that is you want to allow the seal to complete itself.
And then after that, once the whole sealing has happened, days later, you can change into estimated suction, which is 5 on to off minutes that allows more granulation tissue to fall if you are putting a skin graft. You have to put it at continuous. The dressing itself is changed. 48 to 72 hours at least, I mean maximum, so you can change it more frequently and the like infected wounds and the canister itself has to be changed at least once weekly.
What are the complications it cause, it causes pain, bleeding, and some patients don't like the noise that they produce and the cost is the main thing. If you compare it to the complications of wounds in difficult operations or difficult settings, then these complications are nothing to to, you know, to be compared with. The foam can cause irritation and can break down the skin.
As we mentioned, it should not be put directly into the skin, you have to have a separation layer between the two. If you see the back story, the tissue viability nurses, when they apply it, they spend even, you know, they spend double the time that we do to apply that and we apply that frequently. But they have their own technique where they add a bit of cream around the edges to protect the skin edges and then some jelly petroleum petroleum jelly again around the edges to protect them.
Yeah, but as a surgeon, these are what you need to know about. What is the evidence for that? The Cochran did some review in 2018, and what they are saying is there is no clear difference in healing rates in participants with open fracture wounds treated with vacuum pump compared to those receiving standard care, which is interesting. And there is moderate evidence that it is not cost effective, in addition or treating pressure ulcers again, they say we were not able to draw any conclusion.
And that was in 2015. Interestingly though, if you look at the nice guidelines, which is what you should quote in the exam, they say that for diabetic foot problems like ulcers, you are it the negative pressure treatment provides. There is good evidence that it works, provided that you discuss it with the mdc-t foot Kessler foot care service and sign agrees with that as well. Sign in Scotland.
There is a new portable vac pump designed for the patient to be able to take home and look after himself. It's called the PICO. It works exactly the same principle. And for whatever reason, nice feels that it is a good thing to apply, even for normal wounds. So this is something you can quote in the exam. So the peker, which is the portable, portable version of the same, is supported by nice.
And if you look at the NICE guidelines for complex fracture, they say, consider negative pressure wound therapy after the immediate, definitive soft tissue cover has not been performed. OK that's I will end the pump. Any questions about that? And no questions from our audience.
I have a question about PICO PICO is quite expensive. Are we sure that there is a similar cost? I think it's not as expensive as you think, to be honest, if you can pair it with the vac pump. It is much, much cheaper patients like it. I miss people for a standard incision. Absolutely it is very expensive. Yeah, but I have to admit I have a confession that I did not manage to get through the whole recommendation for this.
If you look, I've crammed a lot of guidelines into this. So this particular guidelines, I did not manage to go through the fine details of it to see how much they estimated the cost of it. Exactly however, it's available there and you've got the number there and we can look at it later. Having said that in our trust, as I said, I work in a limb reconstruction. This is something we have used very, very frequently.
And in fact, patients who have diabetes patients where we feel that, for example, the soft tissue is. Going to be compromised, we use that liberally. And so you don't use that as your primary, sorry, I just. No, no, that was the impression I had when you were speaking for you. All right, so when you look here, what they've raised, It is evidence supports the case of adopting PICO negative pressure wound dressing for closed surgical incision in the NHS, which is interesting.
As I agree with you, it doesn't make a lot of sense compared if you compare the price of it compared to the normal dressing. OK but I think, you know, people, people take that with their own, you know, they use their minds, they use their brains, OK. One of our arguments is Imran, do you have something to say? Yeah, it's just to add on the people dressing, actually. I mean, I work in a unit where we manage complex ones, from revision surgery, from sarcomere surgeries, bone tumors.
And actually, we use a lot of people. But it's not as a primary kind of device, sometimes for partially open wounds or for revision wounds that are still oozing. So in the first 24, 48 hours, we found that it's actually very good to use a pickle and then we can step down. One of the one becomes dry. So I think it's a very useful thing and it's very portable.
Like I mentioned, it's easy for the patient to manage. They can go back home with community intervention from the nurses. So I think it's a good one, but I'm not sure about the how expensive it is compared to the proper I. I think for our audience and for the forks at the moment, I wouldn't recommend same people as your primary wound for standards. Yes OK, I agree.
Thank you. Sorry, guys. I just wanted to establish that the yes, that is what you meant. OK, excellent. The last bit is the bone healing stimulant stimulation. What I mean by that is methods to encourage to nudge the bone into healing. You can use systemic enhancement, distant skeletal injury and electromagnetic fields.
Let's talk about each one of them. So systemic enhancement is when you give the patient something parenterally or orally that is supposed to go into the bone fracture area and encourage it or not get to healing. People have tried using IGF vitamin D prostaglandins. None of them has proven, you know, working enough to justify using it in routinely. So we don't do that.
However, I've heard it many times. People say give vitamin c, you know, give vitamin D just in case the patient is deficient. I wouldn't mention it in the exam as a recommendation for the patient, but I'm aware that it there is something called systemic enhancement. The next one, which is interesting, is distant skeletal injury studies, and this is well known for some time.
But it doesn't come into practice, into daily practice in every unit, in units dealing with limb reconstruction or children. They use this principle if you injure the bone somewhere along the line, it causes angiogenesis around it, in the bone itself, along the bone and then surrounding tissues. And in fact, if you think bulk disease, one of the treatment of convoke disease is distal radial, you know, not osteotomy, but, you know, just cutting the bone there.
And they didn't know how it worked. And then it proved that what did happen, what happens at a cellular level is just injuring the bone itself or doing. Codecademy produces a lot of proteins that encourage new vessels to form at the same time as osteoblasts to progress and mature, and that encourages the healing of the distant area of that bone.
And this is a well known phenomena. So I've seen some surgeons who would do codecademy khatami near a nonunion to encourage it to heal. And you know, this is. Don't mention this in the exam, but some believe that even the Pinzon Elizabeth has some effect in that, and that one of the benefits of laser or the frame's is actually, does this don't mention this in the exam?
This is just a theory. Let's talk about electromagnetic fields. This stems from the fact that they have noted that there are two phenomenons, there is electrical charges around the bone and the tissues in the bone. In addition, the hydroxyapatite crystal itself has what we call a photoelectric current, which means if you compress it on a certain shape, on a certain direction, it produces a little bit of electricity.
And if you apply electricity to it, it changes its shape. This is used in the ultrasound, as for basic science, and some people believe that applying a massage around the healing can sell. Carlos actually uses the photoelectric character of that to encourage the bone to heal. And again, that's another theory why the elixir of fine wires work because they allow a little bit of this compressive movement across the fracture, which encourages the bone to heal.
And they have noted that a few, as you can see in this diagram, I hope it is showing from the pictures that there will be a negative charge and a positive charge based on the compressive forces on the bone itself. So it's negative on the tensile and the compression. It's positive. So people have tried to use this phenomena to encourage the bone to heal by either applying mechanical forces or electrical forces or ultrasound forces.
Let's talk about the ultrasound one. So we have the low intensity pulse ultrasound, which is called lipase. This is trying to use the characters of ultrasound by steam by stimulating a certain area of the wound of the fracture. To try and use the photoelectric character of the hydroxide hydroapatite and the collagen to encourage the healing.
There is conflicting evidence about it. Some say that it does work. Some say it does not. And people who believe that it does work, if that it increases the fluid flow, it increases the circulation, redistributes the nutrients and increases the oxygen and signal signaling molecules. Others don't believe that they say that this does not transfer into actual healing tissue.
So let's look at the evidence. So the NICE guidelines looked at this in 2018 and found that. It has no major safety concerns, however, current evidence does not show efficacy that is for fresh fractures. That's 2018. Then they looked at for fracture at high risk of nonunion and the same thing, the current evidence is very limited quantify and quality in quantity and quality.
So they don't recommend it. And what about non-union? They again repeat the same thing. The current evidence inadequate. But when it comes to oxygen, which is ultrasound low, low voltage, low-low wave ultrasound. The nice says. Supported by clinical evidence, high rates of fracture healing, and it saves person 1407 per patient bed with current management through avoiding of surgery, and that's what the established nonunion.
However, the evidence for delayed union is not as robust. To be honest, I don't know how they come up with that conclusion. However, in the exam, you mention the nice guidelines, and if you are going to say the ultrasound, don't say the ultrasound. Just say X again, because that is by name in the NICE guidelines. And for me, it is like this where everyone looks at the data.
Each one sees something different. Anyway, that's it for today. I hope that was useful. Um, I know that it is a lot of information, please, you know, refer back to this lecture later in YouTube. And if you have any questions now, you can ask and later you can put it on the telegraph. Thank you. Fantastic thank you very much it.
That was a very detailed and informative talk about three very important subjects that do come up quite regularly in the exam in different forms. So just in answer, I had a look as well whilst you're talking about the pico dressing. So there is another separate paper, which I have from nice, which I put on to the chart for people to have a look at and just to confirm it is yes, it is recommended in primary surgical wounds closed, but in patients at high risk of infections and as an equally long risk, what constitutes high risk of infections or developing its aroma?
So predominantly oncological surgery, particularly breast reconstruction. So it's quite a few randomized controlled trials available that sort of show reduction in infections. So subsequently, whilst it's a little bit more pricey at 140 pounds £220, actually it's cheaper than having to take a patient back to theater to reclose a breast wound. OK, one question I think from all of us is what's different between lipids and oxygen. Other than obviously oxygen is a brand name.
I spent all yesterday trying to answer this question myself, and I couldn't answer it. So looked at the literature from the oxygen itself, looked at the website, looked at the nice guidelines, I could not find the difference. I'm sure there is otherwise, you know, nice in its glory wouldn't separate the two. But I fail to find it and I'm sorry if someone can find the difference, please enlighten me.
And I'm not saying that jokingly. I am serious. I honestly don't know. But my there are different types of low, low, low grades, low, low intensity pulsed ultrasound. One is continuous. You put it on the patient under the test or with the dressing, and they walk away with the machine attached to them, and the other one is done by physiotherapists, where they spend half an hour an hour doing a directed pulse.
Pulses oxygen, I think, is the one done by physiotherapist, but I'm not 100% sure failure of any program. There are many definitions of non-union. One of them is to say if there is no sign of progress of healing at all. So you have to take an X-ray six months down the line and is exactly the same as it was six months ago, then it is unlikely that with the coming three months that it will unite.
It doesn't happen like that. So Yeah. Minor things in terms of once you start observing something, it can change the outcome. As with any experiments, so you have to be very careful when you go down this route. Yes so as for the guys that are out there, you can see that we're not convinced one way or the other with the information that we have in the exam.
Don't come down hard or anti these therapies because you don't know what the exam on the other side. Just make sure that you say you're aware of these therapies and these are things that you would consider after discussion with the MDT. OK OK. A couple of things, so the way I would the reason for this presentation is number one so that you can know how do these topics come in the real exam question, how the discussion can lead to mentioning these number two so that you are aware of the conflicting evidence about some of these.
So I would anticipate that if you are discussing these details, you are talking about the level eight. So the score eight, you finished everything and the examiner just wants to chat to you about the latest evidence about pico or about the bump or anything like that. And if you reach that, it means you've passed and they just want to see how much evidence you know about these topics and how do you think about them?
And you know, how do you think outside the box? OK just going back to this question, which I have seen, I find it confusing to understand that the powder will give structural support. The powder will not give structural support. You mix it with the fluid and that becomes solid. Like the cement, the cement can give structural support, doesn't it? But the way it does is you mix it and then it can give some structural support.
It's not the liquid that provides the structural support. So it comes as powder. You mix it with a fluid, you keep it to become solid and then you inject it or you put it in the bone. So it does give a little bit of structure, but as we discussed earlier, it's not enough for the patient to walk on. It is just enough to hold that small area of bone from collapsing on its own weight.
If you know what I mean, you are relying on the raft of screws to hold the whole bone. You are, you know, you are stopping the blood from going there for the clots, from going there, the bacteria from getting there, by having that, that solid thing. Does that make any sense? Or am I talking gibberish? No, I understand.
I think it's something we have to. We have to appreciate that we talk about macroscopic and microscopic. So it's a microscopic structure. We think of the scaffolding, but not the big chunks of coral of coral in the bad old days. But this is of the microscopic what the anatomical sort of the molecular structural stability that you mean a point of pride.
But the key thing, though, is I want to make sure you understand what also inductive osteogenic and in inducing are. So as long as you understand those key things, you are safe. This is what we want to make sure that you understand. Absolutely Imran, you wanted to say something. Yeah, thank you. A very exhaustive lecture. I know it's still on the topic of ultrasound exogenous lipase, so I've seen a few.
I don't know what evidence you've seen so far on the indication of ultrasound therapy, especially for things like plantar fasciitis. I know that that's a different thing. That's a different thing. OK that's a different talk. I was going to talk about it, but no one at the con quoted me. Number two.
In fact, that was my fourth topic. But I strictly kept this to the bone healing. OK, so we're talking about only ultrasound for bone healing. Thank you. That was my fourth one, but I'm afraid time didn't allow me to deliver that. Well, we can present it another day. Well, I'm waiting for someone else to volunteer that as well. I think I've brought people to death with my talks, people.
This is a difficult topic. It's a topic, which you've done really well. And it's an important topic because if you're reaching the discussion about whether you can also then proceed to talk about the ancillary side of wound management and non-union using innovative options, it just demonstrates you are where you've worked in the center that does these things. OK it is quite an important topic, which often is missing from a lot of candidates.
Right OK. If no one has a question, we can proceed to the next spot. We can stop the recording, I think. OK just before we go again, thank you very much, Abdullah, for a fantastic talk. And again, I'd just like to reiterate what I said at the beginning. There are still a few places left on the river course coming to Saturday and also as aptly advertised on swan's bookcase.
The concise notes textbook is available from your online retailers.
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Another important aspect of the curriculum that are mentioned there, and we are expected to up to four level 4 of it. OK so without further ado, this is the scenario that we will start with. I hope that everyone can see that. So Abdullah, this is a 60-year-old gentleman, as you can see a open wound with infected open reduction targets of the right proximal tibia.
He needs removal of metal work. It can right. You've done the procedure and you find that there's a significant bone defect in there. How do you how do you feel about the effect? OK, I have to assess the defect appropriately through the X-ray and since there is an infection, so I cannot use the patient's own bone graft because it'll just fail. So I have to fill it with something that has calcium and allow me to deliver some antibiotics.
The options I can think of is either stimulant or serum G because they allow me to deliver antibiotics and they fill the gap and they can turn into bone. OK, so you've managed to fill the gap in your bone substitute with antibiotics, but you also discover that you can't close the skin. You've managed to get good soft tissue coverage, but you can't get the skin to close. What do you do in this scenario?
I mean, you can cover it with some skin graft. However, my skin grafting techniques are not the best. Alternatively, I can use a holding measure in the form of a VAC pump and refer the patient to the plastic team as soon as possible. Excellent So if you do manage to get the skin graft on and sorry, the plastic surgeons did manage to get a skin graft on a couple of days later. But at nine months we presented with no progression to union yet, and he doesn't want any further procedures.
What options do you have now? I have to exclude the presence of infection as a cause of this nonunion. Now if this was excluded, then discussing with the patient that causes for him not to have to want surgery, I assume that he had plenty of surgery. And if he's fed up with that, we can try something like pulsed ultrasound waves like estrogen. See whether that could encourage the bone to heal.
And I will have that with the discussion with the patient. OK and naturally, of course, before you even consider doing the surgery, you would have normally talked about having plastic available to you, but you were put in a scenario where you didn't have well done. Thank you very much. Very little detail in what he gave to me. But today he's going to give you all a huge amount of detail.
Thank you. Please go ahead. Thank you, Sean. So the first part of the talk, as you've noted, is about the bone substitute and bone graft. Now this is to a compliment to the lecture given by our colleague about bone back in July. However, I decided to complement that by talking about different aspects of it at the most recent evidence about specifically bone grafts and bone substitutes.
So what do we mean by bone grafts and substitutes? It's any material that you can use to help the bone heal through its properties. It is supposed to give a mechanical support to the bone at the same time as biological stimulation to allow the healing. And that works in different methods. However, in practice, the common indications for it is to provide structural stability.
For example, you've taken a big tumor leaving a big gap, and if you leave it like that, the bone can collapse. So you want something to fill that gap and hope that it will turn into a bone in the future. The other thing is you have done a fusion and the bone quality in that area is poor, or there is a big gap that if you compress the bone, the patient will be shorter. So you want to fill that gap with something that will again turn into bone later in trauma, either because you've got an acute bone loss or chronic nonunion and you want to fill that gap with something.
So these are the scenarios that can come in the exam where you will mention the word bone graft. What is the ideal bone substitute? And I'm talking here about substitutes in general, anything that can fill the gap. It should be close to your inductive posterior in conductive and osteogenic, and I will be talking about these in a minute. You have to these have to have no immunological rejection risk or at least you know, the least possible risk.
It has to have a very low risk of transmitting infection or ideally no risk of infection. It should achieve incorporation by gradual substitution, which means that slowly the bone will take over and fill the whole gap completely and the material should resolve. You should be able to mold it into the defect regardless. Regardless of the defects shape, it should allow for sterilization and tolerate temperatures.
It should be available readily at a reasonable cost, and it should be biomechanically similar to the surrounding tissues. Now, if you think of these, there is no ideal bone substitute available, the best that can come close to that would be the patient's own bone borrowed from somewhere else. So how can we classify these and this is the definitions that I was talking about the conductive, which means it has a three dimensional shape allowing the bone to grow into osteoinductive means that it has the proteins that allow the bone to grow.
Osteogenic means that it contains cells that allow the bone to grow. A material can be one or all of these three. According to the source, where we can get these from. We have autographed allograft, xenograft. And bone substitute artificial materials, so autograft is the gold standard because this is the closest you can get to achieving all the previously mentioned points because it is sterile.
There are no immunity issues. There is no infection, infective issues. It incorporates rapidly and it has proteins. It has the three dimensional shape and it has the cells. So in an ideal world, this is what you should be using. The downside is you have to harvest it from somewhere else, which means you are leaving that area vulnerable to complications. In addition, it is limited supply.
You can take as many without causing major problems to the other source. Hence, you can use it for small gaps only. But when the gap is big enough, unfortunately you have to rely on something else. Talking about allograft, which is grafts taken from other humans and then processed in a way to reduce the risk of infection and immunological response, they can be fresh, fresh, frozen, freeze dried or dBm.
So the fresh is when you take it immediately from the other person and then just clean it and try and reduce the infection. Fresh frozen preserves the BNP the freeze dried does not reserve the BNP, which is the protein mostly linked to encouraging the bone to heal. And then we will talk about the dBm separately. Xenograft are not available in practice very much, which is from other species, and then we can talk about bone substitutes, which which are artificial materials that represents some aspects of the bone and allow the bone to grow into that area that can be having the calcium component or other compounds or polymers or a mixture of the above.
In general, these are the benefits and risks of each in comparison to each other. Let this slide will be in the YouTube, so I will not dwell on it, you can look at it later on from the YouTube channel, but I've talked about the important one, which is the autographed. Now, what are the risks of bone grafts in general? You have donor risk morbidity, you have disease transmission, which we've alluded to, which cannot be zero percent, but we are talking about very, very few numbers nowadays.
We are talking about one in 100,000 or one in a 10,000 and then immune sensitization. You can put the bone graft as an inlet graft, which is just using it to fill the gap, the cavity or strut graft, which gives structural support. So you are using cortical in the second and cancel us, usually in the first. How does it incorporate you notice that I am talking very quickly about these aspects because as I mentioned, these are covered nicely by Ajith.
So again, if you look at the picture here, you start with a bone graft at number one. Then slowly there will be some inflammation, which will attract the blood vessels and the immune cells. And slowly, that would lay a new calcium through heaping substitution. And on the x-ray, it looks like increased density. And then slowly that will remodel. And the original material of the bone graft, which is the cancerous bone, has completely disappeared.
The cortical bone, the story is slightly different. The first two stages are the same, however, don't have a creeping substitution and most of the action happens at the surface. And the core of the material of the bone graft remains for years and sometimes never disappears. OK, so the autographed news, the most common used one is the iliac crest, and it is the commonest it has a complication rate between two to 36% The interior has more risks.
The risks are bleeding the injury to surrounding nerves. It can lead to a hernia if someone is very aggressive and damaging the insertion of the muscles. Infection fracture, scar anchors, Mrs. and chronic pain. And that is to do with the position of it. And as it is very close to where the belt is, the fibula and the ribs are the most common source of vascularized autographs and can be used as a strut grafts. Now, what I wanted to talk about is this new technique.
This is called remember, get a respirator, it is borrowed from when we used to ream the inside of the bone. Someone thought of, OK, what if I put a filter at the end of that? And all the debris from that reaming, which is bone marrow plus bone plus blood, plus all these juicy things, if I filter it and put it back into the cavity. And actually, there is an increase in the healing because it is concentrated, it is the patient's own material and there is no immunological reaction to it.
And you can mix it with other aspects like bone substitutes to increase its bulk. The downside of that is it is an additional procedure. So imagine yourself trying to fill a gap, a gap in the spine. And then having to drilled and ream the tibia or the femur to get that it's an additional procedure with its own risks. So probably what is a halfway between is when you are aiming for the nail of tibia, just try and keep the rims and reintroduce them again into the area of the gap.
Or you can use that for severe cases where there is significant nonunion or union nearby. OK allograft, they come as more civilized, which is broken down into small pieces, us cortical counsellor's cortical ostrich control, whole ball hole bone segments like the femoral head, which you can get and you cut the way you want it, or DBM, which is de mineralized bone matrix.
What is dbm? There is a standard process for making the DBM, and it is made up or brought up by your wrist. So these are the stages. First of all, you break it down into small, the bone into small particles, then you dimensionalize them in each seal for three hours. Then you clear the seal with sterile water and alcohol that leaves all the proteins and maintain the shape of the bone.
OK, so it acts as osteoinductive because it contains all the proteins that are needed. However, the bone material, the calcium is almost gone, so it does not have the strength to hold the mechanical stresses. On its own, it is not enough to increase the bone healing. However, if you combine it with other substitutes, especially calcium products, then it increases its effective efficacy.
The common question is bond banks on how to set up a bond bank. And again, it is being answered by a joke. I will just quickly run through that. The first step is to donor selecting, and that process means that you have to send them for it. You have to ask to explain the situation to them, and you have to get a pool of patients who are willing to donate that their bones after death or, you know, after procedures after death.
Usually, sorry, then you have to screen the patients clinically and with blood testing, and then you sample, you harvest the sample and then you prepare the graph. And that is by physical debridement, mechanical cleansing, then alcohol smoking to reduce the bacterial load and then antibiotics working again to reduce the bacterial load gamma radiation to reduce the sensitivity or sensitization. Sorry and the last bit is to dimensionalize it like DBM, then you have to consider the storage and the lifespan of it, and it depends on the temperature, you are leaving it between.
The lower the temperature, the more expensive it is, but the longer it lasts and then methods of distributing it. So when you store it, it can be fresh, fresh, frozen or freeze dried, as we mentioned earlier. And what you can request as an NHS doctor, you can request a fresh frozen femoral head, which the benefit of that is it comes in an entirety and you cut it to the shape you want.
And it's commonly used for cutting wedges for either acetabular surgery or for a high tibial osteotomy hour. It can come as cancellous cubes, which you can put in a bigger voids or cancel struts. Now, let's talk about bone substitutes again, these can be divided depending on what you are replacing. So if you are replacing cells, then you can use injecting of mesenchymal stem cells, which has been tried.
However, it is expensive and I think currently I don't. I'm not aware of any hospital where this is a common practice. You can replace stimulating proteins like BMP 7 and BMP two, or you can inject platelet rich plasma PRP and some places do inject that it is an easy procedure to do. Basically, you take the patient's own blood and then you put it in a sedimentation machine that will just spin very at high speed.
And that would separate the plasma from the red cells, and you can inject the plasma back again into the patient themselves. Again, I'm not aware of any trust where this is a common practice. I work with the limb reconstruction team. We have the facility to do that, but I haven't seen it done frequently. The last thing, which is the more common one to be asked about, is replacing minerals with the ability to add antibiotics.
These can be calcium phosphate, try calcium phosphate, calcium carbonate hydroxide, appetite, sulfate, silicone based polymers or a mixture of the above. Quickly, let's talk about them, so calcium sulfate is the most commonly used one. It comes as pellets or powder. The common one is stimulant. It allows you to add antibiotics to that. It is fastest at resorption between six to eight weeks, and it has a high risk compared to all the others of having a serious drainage.
It is sterile. It is just the byproducts of breaking down of the calcium sulfate by the body's tissue. The calcium carbonate is not commonly in use. I did convert in the body to calcium phosphate. The calcium phosphate can be in two shapes either try calcium phosphate or the cement. They try calcium phosphate converts into hydroxyapatite. It results in about 3 of 13 to 20 weeks.
It has faster absorption than hydroxyapatite. And it has a similar strength once it is solidified in similar strength to the Kessler spawn itself. It comes as injection. And then you leave it in, you leave it outside the body. It's like the cement you usually use and then when you inject it into the body, it goes solid. The second shape is calcium phosphate cement, which is a combination of more than one calcium product, and the idea is to benefit from the different rates of absorption.
So you have something that absorbs very quickly and then something that takes long. The issue with that is the ideal substitute will have to absorb as the bone is growing. So there will be no area, no time where there is a void. The problem with the first products, the first three products is they tend to get absorbed before the bone has fully integrated into that gap and filling it, so there will be some void.
However, the cement, the design behind it is some of it will get absorbed, leaving a space for the bone to grow, while the rest of it is still there, holding the gap and filling it and preventing structural weakness. The new technique that I wanted to mention is the CPC in 3D printing. And this is a clever technique where in certain areas you you can apply it again. I think in the UK you can do that and it's available, but I think it's available only in some centers.
And you have to apply for a permission to for the funding for it. Basically, you do a CT scan into the area, you decide how much is the gap, what is the shape of it, and then you send it to a company that prints a three dimensional structure to fill exactly that gap and that the material they are using is a combination of hydroxyapatite and B to try calcium phosphate.
And that combination is the cement, as we mentioned earlier. As I said, it has the benefit is no. One filling exactly the same shape at the same gap. Number two, this three dimensional structure allows the body to allows the bone to grow there faster and in a bigger rate, and at the same time, it lasts as long as it is needed for the bone to do that.
Let's talk about hydroxy appetite, which you can get alone, but again, it's not common, you know, you don't see it. The reason is it takes very, very, very long time to be resolved by the body and it is very brittle, so it's not used for its mechanical structures. The biphasic product is the one we talked about, and the one commonly used in practice is the sediment that I am aware of, and G stands for gentamicin, so it allows you to add some antibiotics to it.
A new materials like bioactive glass are silica based, and they contain calcium oxide and phosphate. And when you put it in the body, they form a layer around them, which is like a jelly. And that area protects the area the material and allows the bone to grow into it. And then slowly, some of that gets resolved. It is expensive and in practice, not many surgeons like it because they have this glassy feel when, when, when you, you know, they leave these glossy granules in the wound that.
Patients may not like poly, garlic, sorry, but poly, glycolic acid and poly lactic acid again have a still conductive properties. You can put them in three dimensional shape again, to encourage that. But I haven't come across them and I believe they would be expensive. The evidence you can quote is a calcium phosphate allow for bone defect, filling early rehabilitation and prevention of particular substance.
Let's talk about substituting proteins. Let's talk about BNP bond more photogenic protein is a natural material that exists in the body, which and increases at the time of fractures induced by osteoblasts. The FDA in America and the UK have approved the BMP two for open tibial fracture, a selective clinical indication and BMP with iliac, non-union and traumatic bone defects.
They are not used alone. Some people believe that the amount we are putting in the wound in the fracture is so small that regardless of how much you put it, is so small compared to the body's physiology that you need something else. It works, but it's not. It doesn't work alone, so you have to have something else as well.
Um, this is coming from a bovine usually they are coming from this is the material available in the market in the UK and it comes from bovine origin. So what is the available evidence? I leave this for you to read. So basically the bottom line is allograft, the present first choice for most reconstructive solutions. However, in revision total hip replacement, you don't have the femoral head.
So they are saying that in general, fresh frozen bone is firmly recommended for structural graft, freeze dried and/or radiated bone maybe use, Alternatively for impacting grafting. So this is from effort in Europe. There is another evidence about the role of bone grafts for foot and ankle surgery. Same thing and in spinal surgery. That's from the UK.
And again, they are saying that they have good evidence of working in the combination of BNP and bone grafts. Blast evidence is this review, which looked at the use of recombinant BMP two in lumbar fusion, and they found that it does increase the rate of union. This is from 2020. Before we continue, does anyone have a question about the above?
Or shall I continue? Sorry, do you mind if I do ask Abdullah because. Yes, because the next topic is quite different. Yes so actually, if Mahmoud has asked, how does dBm act as Austria conductive? And also, how does dBm powder provide structural support? I didn't say that it does provide structural support, I said provides the proteins, as you can see here, mainly because inductive material you go.
So there is a difference between strut and structural. I would be very wary about mixing up those two when we say usually when we say structural, we do mean it's micro structural, not actual taking weight and things like that, which is different to a strut given strut support. But yes, you're right, you didn't say dBm is structural support said maybe possibly act as conductive materials, but the general allograft, because yes, it still maintains the three dimensional shape.
And that's the three dimensional shape of the bone. And the bone likes that, and it actually stimulates the engine neurogenesis and stimulates the osteoblasts. There is new evidence that one of the stimulation of osteoblasts to differentiate is actually the three dimensional shape of the structure around them. And that's why if you look the new, the new materials, they are all 3D printed to allow this to happen to stimulate the osteoblasts through this 3D shape.
So that's how it can be conductive. It's the three dimensional shape. But the main thing is just your inductive. Now, as you mentioned one, it is different than the structural as in allowing to take compression. So the DBM, you should not rely on it to fill a gap where the bone the patient will be walking upon and expect them to hold. What you usually do is the typical, you know, use for that is, for example, if you have a tibial plateau fracture, so you put a raft of screws on top, you have a big gap.
How do you fill it? You can use dBm to fill that gap because it incorporates bone faster than any other material, and you can combine it with serum and g. For example, if you are doubtful about infection and that combination gives calcium hydroxide appetite, gives the proteins and gives the three dimensional shape. But you are not resisting pressure compression, I meant. Yes OK, thank you.
I think that's quite clearly explained. I hope you guys are happy with that. Thank you. No problem. We continue. Or do you have any questions? If anyone's getting questions about bone grafting and substitute bone graft, please to speak up now. OK, fine, so let's talk about the vac bump, which the technical term is negative pressure wound therapy.
How does it work? No one knows. How does it work exactly. However, there are theories about and observations about why it may work, and it is to do with two phenomenon, which is macro strain and micro strain. So macro strain is what you can see with your own eyes, which is it draws the wound edges together. It just distributes the negative pressure across the wound itself, and it may remove some of the extra dates from the wound.
It does remove the extra dates and that can result in reducing the infection. However, this has not been proven. The infection bit the micro strain, however, is probably where most people feel that it works, which is the encouraging the most wound healing by promoting granulation tissue and engineer new angiogenesis. It increases the cellular proliferation and migration into the wound, and that and that by itself can speed up the healing.
And it can reduce the edema. And again, this is not 100% proven. The studies suggest that it increases the number of fibroblastic migration by 3 folds, and they reduce the cell death by 2 to 2.4 fold. So there is some cellular result of the vacuum pump. When do we use them, we can use them either in acute or chronic conditions in acute conditions can be used in traumatic wound with deep, extensive skin defects as the one, you know, described before surgical excision.
When you finish the surgery and you find that there is a big defect when there is a skin adhesions and you want to fill the gap with something without stitching and putting the rest of the skin under pressure. And when using skin grafts in chronic wounds like ulcers, it speeds up the development of granulation tissue and shortens the healing time. We cannot we use it, if you think of it, you are applying negative pressure around the tissues.
So if you have tissues that are vulnerable, then you should apply it malignancy again because you are spreading the infect the tumor when you have. Um, not explored fistula. Then you should not allow apply it. And when you have a scar because the scar will prevent the negative pressure from working, so you are just wasting time, you use it. You have to consider using it.
Sorry, you have to think hard before using it. When you have weakened the blood supply or vessels because it may explode and cause bleeding when delicate structures are exposed, when there is active bleeding currently. So try and stop the bleeding before that. If you have fistula that where they're coming from, patients requiring certain treatments like hyperbaric oxygen or they are going to an MRI.
This this is you. They are not saying you should not. They are saying you should consider and additional precautions when you have spinal cord injury or infected wounds. The important message is it is not a replacement for proper debridement. I've seen surgeons do a bad job at dividing the wound and then say, well, the rest of it will be done by the vac, which is not true.
You do a proper debridement and then you encourage the granulation through the vac. It is not treatment for infection. It is not treatment for crap surgery. How do you apply it? You use a sterile reticulated polyurethane sponge. There are different color of that. You use a silicone interface to stop it from adhering to the wound.
So when you take it off, you are not taking all the granulation tissue and it doesn't cause pain. You have three types of foam that you can apply. Black is the standard one stimulate granulation tissue for large wounds. White it has a smaller cells that protect fragile tissues, and the great which has silver, which you can use if there is infected infection.
Then you apply an adhesive plastic sheet to seal the whole thing, including the pump tube, and you can set it at any pressure you want. But the common pressure is 125 sorry, minus 125 mercury. You put it at a setting of either continuous or intermittent, the continuous you use initially. And the reason for that is you want to allow the seal to complete itself.
And then after that, once the whole sealing has happened, days later, you can change into estimated suction, which is 5 on to off minutes that allows more granulation tissue to fall if you are putting a skin graft. You have to put it at continuous. The dressing itself is changed. 48 to 72 hours at least, I mean maximum, so you can change it more frequently and the like infected wounds and the canister itself has to be changed at least once weekly.
What are the complications it cause, it causes pain, bleeding, and some patients don't like the noise that they produce and the cost is the main thing. If you compare it to the complications of wounds in difficult operations or difficult settings, then these complications are nothing to to, you know, to be compared with. The foam can cause irritation and can break down the skin.
As we mentioned, it should not be put directly into the skin, you have to have a separation layer between the two. If you see the back story, the tissue viability nurses, when they apply it, they spend even, you know, they spend double the time that we do to apply that and we apply that frequently. But they have their own technique where they add a bit of cream around the edges to protect the skin edges and then some jelly petroleum petroleum jelly again around the edges to protect them.
Yeah, but as a surgeon, these are what you need to know about. What is the evidence for that? The Cochran did some review in 2018, and what they are saying is there is no clear difference in healing rates in participants with open fracture wounds treated with vacuum pump compared to those receiving standard care, which is interesting. And there is moderate evidence that it is not cost effective, in addition or treating pressure ulcers again, they say we were not able to draw any conclusion.
And that was in 2015. Interestingly though, if you look at the nice guidelines, which is what you should quote in the exam, they say that for diabetic foot problems like ulcers, you are it the negative pressure treatment provides. There is good evidence that it works, provided that you discuss it with the mdc-t foot Kessler foot care service and sign agrees with that as well. Sign in Scotland.
There is a new portable vac pump designed for the patient to be able to take home and look after himself. It's called the PICO. It works exactly the same principle. And for whatever reason, nice feels that it is a good thing to apply, even for normal wounds. So this is something you can quote in the exam. So the peker, which is the portable, portable version of the same, is supported by nice.
And if you look at the NICE guidelines for complex fracture, they say, consider negative pressure wound therapy after the immediate, definitive soft tissue cover has not been performed. OK that's I will end the pump. Any questions about that? And no questions from our audience.
I have a question about PICO PICO is quite expensive. Are we sure that there is a similar cost? I think it's not as expensive as you think, to be honest, if you can pair it with the vac pump. It is much, much cheaper patients like it. I miss people for a standard incision. Absolutely it is very expensive. Yeah, but I have to admit I have a confession that I did not manage to get through the whole recommendation for this.
If you look, I've crammed a lot of guidelines into this. So this particular guidelines, I did not manage to go through the fine details of it to see how much they estimated the cost of it. Exactly however, it's available there and you've got the number there and we can look at it later. Having said that in our trust, as I said, I work in a limb reconstruction. This is something we have used very, very frequently.
And in fact, patients who have diabetes patients where we feel that, for example, the soft tissue is. Going to be compromised, we use that liberally. And so you don't use that as your primary, sorry, I just. No, no, that was the impression I had when you were speaking for you. All right, so when you look here, what they've raised, It is evidence supports the case of adopting PICO negative pressure wound dressing for closed surgical incision in the NHS, which is interesting.
As I agree with you, it doesn't make a lot of sense compared if you compare the price of it compared to the normal dressing. OK but I think, you know, people, people take that with their own, you know, they use their minds, they use their brains, OK. One of our arguments is Imran, do you have something to say? Yeah, it's just to add on the people dressing, actually. I mean, I work in a unit where we manage complex ones, from revision surgery, from sarcomere surgeries, bone tumors.
And actually, we use a lot of people. But it's not as a primary kind of device, sometimes for partially open wounds or for revision wounds that are still oozing. So in the first 24, 48 hours, we found that it's actually very good to use a pickle and then we can step down. One of the one becomes dry. So I think it's a very useful thing and it's very portable.
Like I mentioned, it's easy for the patient to manage. They can go back home with community intervention from the nurses. So I think it's a good one, but I'm not sure about the how expensive it is compared to the proper I. I think for our audience and for the forks at the moment, I wouldn't recommend same people as your primary wound for standards. Yes OK, I agree.
Thank you. Sorry, guys. I just wanted to establish that the yes, that is what you meant. OK, excellent. The last bit is the bone healing stimulant stimulation. What I mean by that is methods to encourage to nudge the bone into healing. You can use systemic enhancement, distant skeletal injury and electromagnetic fields.
Let's talk about each one of them. So systemic enhancement is when you give the patient something parenterally or orally that is supposed to go into the bone fracture area and encourage it or not get to healing. People have tried using IGF vitamin D prostaglandins. None of them has proven, you know, working enough to justify using it in routinely. So we don't do that.
However, I've heard it many times. People say give vitamin c, you know, give vitamin D just in case the patient is deficient. I wouldn't mention it in the exam as a recommendation for the patient, but I'm aware that it there is something called systemic enhancement. The next one, which is interesting, is distant skeletal injury studies, and this is well known for some time.
But it doesn't come into practice, into daily practice in every unit, in units dealing with limb reconstruction or children. They use this principle if you injure the bone somewhere along the line, it causes angiogenesis around it, in the bone itself, along the bone and then surrounding tissues. And in fact, if you think bulk disease, one of the treatment of convoke disease is distal radial, you know, not osteotomy, but, you know, just cutting the bone there.
And they didn't know how it worked. And then it proved that what did happen, what happens at a cellular level is just injuring the bone itself or doing. Codecademy produces a lot of proteins that encourage new vessels to form at the same time as osteoblasts to progress and mature, and that encourages the healing of the distant area of that bone.
And this is a well known phenomena. So I've seen some surgeons who would do codecademy khatami near a nonunion to encourage it to heal. And you know, this is. Don't mention this in the exam, but some believe that even the Pinzon Elizabeth has some effect in that, and that one of the benefits of laser or the frame's is actually, does this don't mention this in the exam?
This is just a theory. Let's talk about electromagnetic fields. This stems from the fact that they have noted that there are two phenomenons, there is electrical charges around the bone and the tissues in the bone. In addition, the hydroxyapatite crystal itself has what we call a photoelectric current, which means if you compress it on a certain shape, on a certain direction, it produces a little bit of electricity.
And if you apply electricity to it, it changes its shape. This is used in the ultrasound, as for basic science, and some people believe that applying a massage around the healing can sell. Carlos actually uses the photoelectric character of that to encourage the bone to heal. And again, that's another theory why the elixir of fine wires work because they allow a little bit of this compressive movement across the fracture, which encourages the bone to heal.
And they have noted that a few, as you can see in this diagram, I hope it is showing from the pictures that there will be a negative charge and a positive charge based on the compressive forces on the bone itself. So it's negative on the tensile and the compression. It's positive. So people have tried to use this phenomena to encourage the bone to heal by either applying mechanical forces or electrical forces or ultrasound forces.
Let's talk about the ultrasound one. So we have the low intensity pulse ultrasound, which is called lipase. This is trying to use the characters of ultrasound by steam by stimulating a certain area of the wound of the fracture. To try and use the photoelectric character of the hydroxide hydroapatite and the collagen to encourage the healing.
There is conflicting evidence about it. Some say that it does work. Some say it does not. And people who believe that it does work, if that it increases the fluid flow, it increases the circulation, redistributes the nutrients and increases the oxygen and signal signaling molecules. Others don't believe that they say that this does not transfer into actual healing tissue.
So let's look at the evidence. So the NICE guidelines looked at this in 2018 and found that. It has no major safety concerns, however, current evidence does not show efficacy that is for fresh fractures. That's 2018. Then they looked at for fracture at high risk of nonunion and the same thing, the current evidence is very limited quantify and quality in quantity and quality.
So they don't recommend it. And what about non-union? They again repeat the same thing. The current evidence inadequate. But when it comes to oxygen, which is ultrasound low, low voltage, low-low wave ultrasound. The nice says. Supported by clinical evidence, high rates of fracture healing, and it saves person 1407 per patient bed with current management through avoiding of surgery, and that's what the established nonunion.
However, the evidence for delayed union is not as robust. To be honest, I don't know how they come up with that conclusion. However, in the exam, you mention the nice guidelines, and if you are going to say the ultrasound, don't say the ultrasound. Just say X again, because that is by name in the NICE guidelines. And for me, it is like this where everyone looks at the data.
Each one sees something different. Anyway, that's it for today. I hope that was useful. Um, I know that it is a lot of information, please, you know, refer back to this lecture later in YouTube. And if you have any questions now, you can ask and later you can put it on the telegraph. Thank you. Fantastic thank you very much it.
That was a very detailed and informative talk about three very important subjects that do come up quite regularly in the exam in different forms. So just in answer, I had a look as well whilst you're talking about the pico dressing. So there is another separate paper, which I have from nice, which I put on to the chart for people to have a look at and just to confirm it is yes, it is recommended in primary surgical wounds closed, but in patients at high risk of infections and as an equally long risk, what constitutes high risk of infections or developing its aroma?
So predominantly oncological surgery, particularly breast reconstruction. So it's quite a few randomized controlled trials available that sort of show reduction in infections. So subsequently, whilst it's a little bit more pricey at 140 pounds £220, actually it's cheaper than having to take a patient back to theater to reclose a breast wound. OK, one question I think from all of us is what's different between lipids and oxygen. Other than obviously oxygen is a brand name.
I spent all yesterday trying to answer this question myself, and I couldn't answer it. So looked at the literature from the oxygen itself, looked at the website, looked at the nice guidelines, I could not find the difference. I'm sure there is otherwise, you know, nice in its glory wouldn't separate the two. But I fail to find it and I'm sorry if someone can find the difference, please enlighten me.
And I'm not saying that jokingly. I am serious. I honestly don't know. But my there are different types of low, low, low grades, low, low intensity pulsed ultrasound. One is continuous. You put it on the patient under the test or with the dressing, and they walk away with the machine attached to them, and the other one is done by physiotherapists, where they spend half an hour an hour doing a directed pulse.
Pulses oxygen, I think, is the one done by physiotherapist, but I'm not 100% sure failure of any program. There are many definitions of non-union. One of them is to say if there is no sign of progress of healing at all. So you have to take an X-ray six months down the line and is exactly the same as it was six months ago, then it is unlikely that with the coming three months that it will unite.
It doesn't happen like that. So Yeah. Minor things in terms of once you start observing something, it can change the outcome. As with any experiments, so you have to be very careful when you go down this route. Yes so as for the guys that are out there, you can see that we're not convinced one way or the other with the information that we have in the exam.
Don't come down hard or anti these therapies because you don't know what the exam on the other side. Just make sure that you say you're aware of these therapies and these are things that you would consider after discussion with the MDT. OK OK. A couple of things, so the way I would the reason for this presentation is number one so that you can know how do these topics come in the real exam question, how the discussion can lead to mentioning these number two so that you are aware of the conflicting evidence about some of these.
So I would anticipate that if you are discussing these details, you are talking about the level eight. So the score eight, you finished everything and the examiner just wants to chat to you about the latest evidence about pico or about the bump or anything like that. And if you reach that, it means you've passed and they just want to see how much evidence you know about these topics and how do you think about them?
And you know, how do you think outside the box? OK just going back to this question, which I have seen, I find it confusing to understand that the powder will give structural support. The powder will not give structural support. You mix it with the fluid and that becomes solid. Like the cement, the cement can give structural support, doesn't it? But the way it does is you mix it and then it can give some structural support.
It's not the liquid that provides the structural support. So it comes as powder. You mix it with a fluid, you keep it to become solid and then you inject it or you put it in the bone. So it does give a little bit of structure, but as we discussed earlier, it's not enough for the patient to walk on. It is just enough to hold that small area of bone from collapsing on its own weight.
If you know what I mean, you are relying on the raft of screws to hold the whole bone. You are, you know, you are stopping the blood from going there for the clots, from going there, the bacteria from getting there, by having that, that solid thing. Does that make any sense? Or am I talking gibberish? No, I understand.
I think it's something we have to. We have to appreciate that we talk about macroscopic and microscopic. So it's a microscopic structure. We think of the scaffolding, but not the big chunks of coral of coral in the bad old days. But this is of the microscopic what the anatomical sort of the molecular structural stability that you mean a point of pride.
But the key thing, though, is I want to make sure you understand what also inductive osteogenic and in inducing are. So as long as you understand those key things, you are safe. This is what we want to make sure that you understand. Absolutely Imran, you wanted to say something. Yeah, thank you. A very exhaustive lecture. I know it's still on the topic of ultrasound exogenous lipase, so I've seen a few.
I don't know what evidence you've seen so far on the indication of ultrasound therapy, especially for things like plantar fasciitis. I know that that's a different thing. That's a different thing. OK that's a different talk. I was going to talk about it, but no one at the con quoted me. Number two.
In fact, that was my fourth topic. But I strictly kept this to the bone healing. OK, so we're talking about only ultrasound for bone healing. Thank you. That was my fourth one, but I'm afraid time didn't allow me to deliver that. Well, we can present it another day. Well, I'm waiting for someone else to volunteer that as well. I think I've brought people to death with my talks, people.
This is a difficult topic. It's a topic, which you've done really well. And it's an important topic because if you're reaching the discussion about whether you can also then proceed to talk about the ancillary side of wound management and non-union using innovative options, it just demonstrates you are where you've worked in the center that does these things. OK it is quite an important topic, which often is missing from a lot of candidates.
Right OK. If no one has a question, we can proceed to the next spot. We can stop the recording, I think. OK just before we go again, thank you very much, Abdullah, for a fantastic talk. And again, I'd just like to reiterate what I said at the beginning. There are still a few places left on the river course coming to Saturday and also as aptly advertised on swan's bookcase.
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