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Hip Replacement THR Instability for Orthopaedic Postgraduate Exams
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Hip Replacement THR Instability for Orthopaedic Postgraduate Exams
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Language: EN.
Segment:0 .
And you're allowed to also mentor a group webinar sessions to my name is one Henry I'll be moderating today. And our first presentation will be by Firas Aarnout, followed by one by Hussam knee when the first session with this session will stick to Firas, if there's some time at the end, we'll take questions. And of course, if there is even more time, we take a hot seat question if possible.
But then we look at it get a second invite to start the second session with Hassan Rouhani and everyone. Very welcome. OK, thank you everyone for joining in. I'm we will talk tonight. First topic about hip dislocation. Hip replacement dislocation is very commonly asked question and very commonly tested question in the FRC case.
Obviously, my acknowledgments are to the group, and we just want to say I'm not here to teach you anything you don't know already. I'm just here to give you a teacher a system of how to structure your answer for the exam. It is commonly frequently tested the question in the adult pathology, Viva, you are likely to be asked by a non hip surgeon.
So if you use the right terminology, you could very easily impress them and score very high. There is no one right answer as any other question is really what they're testing is that you have a safe, systematic approach. It could come into twos into two different scenarios. It could be the examiner can ask you about dislocated total hip replacement, which is the most commonly ask one, or they can tell you.
You are doing hip replacement at the end of the procedure. You find the hip is unstable. What will you do then? So one of these comments took two scenarios can come in. And you will the survivor normally starts with an X-ray like this one? The examiner will show you this and say, tell me, what do you see?
So what do you say straight away? I would like to take a history and examine the patient. Please avoid the temptation to bombard the examiner with questions at this stage. Make it brief and crisp. History, I would like to take history specifically asking about the time since the index operation.
About the number of dislocations. About the mechanism of each dislocation from first one to the current one and about the medical comorbidities. Everyone knows that you are a competent doctor who can take very good, detailed history. We don't need to go into full details asking examiners about various things. These are the main points that you need to focus your history on.
If the examiners. Things that any of this information is relevant, they would normally volunteer this information to you. So please, please avoid the temptation of saying how many dislocations, how many. What is the mechanism? Don't ask examiners questions. Just say that's what I'm looking for. Then you move promptly to examination.
They like to take history, asking about these four points. Then I would like to examine the patient. Looking at the position of the limb at the neurovascular status and the mental test scoring the patient, if the examiner thinks there's any of these points are relevant, for example, they can, they will volunteer this to you. They will tell you all the patient has sciatic nerve palsy.
But you've shown the examiner, you'll want to look for that. Don't waste any more time on this. Then you move on promptly to investigations. Very briefly say I would like to see the previous radiographs of the patient with the hip located. And also, I would like to have a lateral radiograph of the dislocated hip. So you you moved quickly, you shun the examiner very quickly and briefly, you are a safe, sensible surgeon.
You're not scoring any points yet. So the quicker you can get through this, the better. Not more, ideally not more than 30 seconds. And the examiner shouldn't have to talk much about during this period, and then you move on now to scoring. The examiner doesn't have to ask you what you're going to do. You could just volunteer that because, you know, that's what the station is about.
It's about your understanding about the management of hip instability. You could say the examiner would like to reduce the dislocation. Please don't start going into details about how you're going to reduce it. I've heard a lot of candidates, they start asking, saying, I'm going to call the anesthetist, I'm going to check the staffing status of the patient. Please don't go into all this.
No, examiner. No, you are. You know about these minor details just straight away. Say I would like to reduce under sedation or under general anesthesia with the anesthetist back up and then I would like to search for the cause. And now you starting to score points in the quicker you can get to this stage, the better for you. So management reduce and search for the cause, the cause.
There are three factors patient factors, surgical factors and implant factors, and once you get to these, the examiners will relax. And you are really here in your way to pass this station. So please get to this within the first minute or two, not in the last 30 seconds. So patience factor the easier ones and you can get them out of the way and score points for that quickly gender.
But the patience factor the gender it's known that the female to male ratio is 21. Again, for any of these factors, if you can back it up with evidence, if you find a paper to back it up, you will be obviously gaining more points. So gender, female to male ratio is 21 neurological conditions, if the patient has any neurological condition that causes soft tissue laxity and muscle weakness, it will weaken their abductor mechanism, reduce the stability, patient compliance, alcoholic patients, cognitive dysfunction, dementia.
A poor anatomy for tenotomy, either from previous multiple revisions, if it's the revision surgery or from previous infection or trauma, poor anatomy will cause compromise abductors, which also will impair the stability of the hip replacement. So these are the patient factors. You get them out of the way. They're not much to talk about them.
So you get them out the way you showing the examiner, you're actually not blaming the patient. You make it somehow clearly not blaming the patient for dislocation, but you are considering the patient factors. Then you're moving on to the surgical factors, and now here you are going to the higher level of thinking, higher order thinking, which is a paced level.
It's known that a surgeon experience is an important factor. If you can't pack, it is also reported in the MJR, and if you back it up with NJR data, you will be scoring high. The surgeon experience. Second is impingement. Infringement can be caused by fights, which have not been removed during surgery or from retained excess cement.
And this can be seen on X-ray. So if you find any of these factors evident on the X-ray that the examiners have shown you, you tell the examiner straight away, yes, I can see an austere fight there. I can see everything in there. That could be a factor, surgical factor and then prostheses alignment and soft tissue tensioning. We all know the proper processes, alignments of the cups.
20 to 30 degrees of a virgin and 35 to 45 degrees of inclination. There are studies done. If you can back it up, also, that will be useful. The cement version is 15 to 20 degrees. If there are any doubts. You could always, if you're not sure if this person is aligned properly, you can tell the examiner, I'm in doubt, I would like to have a CT scan.
Is not, you know, you're showing you are safe by requesting an appropriate further investigations, and hey, we can see how this prosthesis is retrofitted instead of being activated and what will make it prone to dislocation. So prosthesis alignment is a surgical factor because surgeons control that factor. The other factor that surgeons have control over is the soft tissue tension of the adductors complex, and that's controlled by the controlling the offset.
And there are two types of offset, acetabular and femoral offset. Most of us talk about femoral, but if you say to the examiner, there is also acetabular offset. You are showing them that you are. You fully understand with the hip offset is about. The established offset can be so ideally to improve the stability you need to increase the offset.
The acetabular offset can be decreased by over medialization of the cup, and that could be seen on the X-ray. So if you see the x-ray, the surgeon has overseen the acetabulum, you tell them that. Explain that to the examiner. Tell them I think there is a acetabular offset is reduced here. That could be a factor.
Never could commit yourself to one single factor. Just say that could be the fact that the cause because could be also the dislocation or instability could be also multifactorial. The other opposite to talk about is the federal oversight of state and the examiners like this, though straightaway ask you if you don't volunteer it yourself, they will ask you what is the role of say?
Women are upset, as you know, guys, it's a perpendicular distance, you have to say the word perpendicular, they'll be looking for that word. Nothing for nothing else. Perpendicular distance between the center of the rotation of the femoral head. To a line down the center of the femoral shaft or center of the stem of the prosthesis.
OK, guys. Sorry, if you feel I'm going a bit fast. I'm trying to slow it down, but if I'm going too fast, the session will be recorded, you can view it later on. So I said increased offset. Would increase the abductor complex moment are mainly the gluteus medius.
And it has been explained before in a presentation by Sean, how how, how. Um, the moment arm affects the force. So increasing the momentum will decrease the force that's required by the abductors if they have a longer moment on. And therefore, on the long term will reduce the stress forces on the joint. So these are the positives of increased offset, the negatives is that it puts higher stress on the stem itself.
OK and this picture here shows you an example of how offsets are different between an extended offset and the standard offset. So these are the four surgical factors just to go over them again is a surgeon experience impingement, prosthesis alignment and soft tissue tensioning.
Now moving on to the implant factors. And one of the factors is where of the lining of polyester lining. And that could also be seen on the extreme, if you see it, comment on it straight away to the examiner as an important factor. The treatment for this will be exchanging the liner, obviously, the other implant factor is the head neck ratio.
Please try to use those terms, ok? They are really the proper terms, you'll impress the examiners and they will know that what you're talking about. So the head neck ratio? Increased head neck ratio is directly proportional to increase stability of the hip. Increased head neck ratio.
Will increase the arc of movement. Which is the range of movements prior to impingement. So you want a large head neck ratio? To increase the arc of movement prior to impingement, you can see here in this picture, the top image have a smaller head neck ratio comparison to the bottom image. And you can see how the range of movements, the arc of movements in the bottom one is 120 degrees and top one is 100 degrees.
Therefore, the bottom one has to travel 120 degrees before it impinges. The top one have to travel hundreds degrees. So that demonstrates the importance of the head and neck ratio. So you want a larger head to neck ratio. To increase the arc of movement prior to impingement. Do I need to say anything more than that? The examiners will be like looking at you and being impressed.
The other important factor is the head size of the femoral component, so head neck ratio and the head size in itself in isolation is an important factor. Its size will increase. Increased head size would increase the excursion or the jump distance. Which is the distance the federal hate has to travel to dislocate.
You could see in this image how a larger femoral head has to travel a lot more to dislocate in comparison to a smaller femoral head to the head size is another implant related factor. Very important factor. OK so to recap again. We have three factors patient factor surgical factors and implant factors.
And the patient factors a gender, neurological conditions compliant patient in non-compliant, patient and poor anatomy. Surgical factors and surgeon experience impingement, prosthesis alignment and soft tissue tensioning. And the implant factor where technical issue and head size.
No, the reconstruction leather for implant related factors. Obviously, if it's patient related factor, we have to treat that patient related factor, whatever it is, if it's surgeon factor. If there is impingement we have that has to be removed, if there is a reduced offset, that has to be corrected. Most of the time surgically, obviously you could put an implant that has a higher offset or extended neck.
If it is an implant related factor. It cannot that cannot be adjusted, it has to be implant treatment, sorry. Change the implant in a way or another. So there is a. I've put up this reconstruction ladder of reconstructing a dislocated hip replacement for implant related factors. So you start with normally with the most simple measure, you could use a lip liner to change just the liner, you use the lip liner, which has the raised lip.
In the direction of the dislocation, that's very important to know whether dislocation was anterior posterior. Next measurement could be to put a device called plant, which is posterior lip augmentation device. Next step is constrained liner. And the final one is dual mobility and obviously revision hip replacement completely is the last resort.
And I doubt it very much examiners will go into any more details than this, there won't be time anyway. Even you've done the best thing by getting here. And I think any further discussion is a more robust exam fellowship standards. Not so. I think if you get to this stage, you'll be fine. So my motto for the exam always to stay, keep calm, stay organized.
Go from ABC. Examiners are testing your ability to cope with pressure, so it's part of the exam. Do you have to stay composed all the time, no matter what's put in front of you, even if you don't know the answer, try to stay some systematic and. And really, you have to show the examiners that what you're talking about.
You have to save and use the right terminology, right system, right approach. And you have the right, not just the right knowledge and the right amount of knowledge, but also the higher order thinking to use that knowledge. In your day to day practice of the patients, OK, so you have to show the examiners that what you're talking about, and that's all my presentation.
And for stability. Well done for us. Any questions, guys? It's a very, very good press. Excellent, as always. You're showing really simple, straightforward way of answering this question with a lot of knowledge in very simple sentences. If you guys just replicate that in your examination and remember, the variations in this can be along the lines of what are the things you would consider in a hip replacement on a certain type of patient or a certain type of anatomy.
And you can then again divide it into patient factors. Your surgeon factors your implant choice. Some questions that have been asked for us or Jose or any of the group I notice at our and for our chowdhury have joined us as well. So first question is, should we consider head neck ratio as a surgical factor as they are surgeon choice while wearing waiwera and loosening as implant factors? Yeah, I think that's a very good question, and when writing this presentation, I thought about it.
Ultimately, the surgeon has. For overall control of most of the factors. And even patient factors, because even the patient has a neurological condition, you could say that the surgeon could have put a constraint liner straight away anyway. However, this seems to be the most agreeable kind of classification that I found. And they seem to be putting it under the implant factor.
But yes, if you put it as a surgeon factor because the surgeon controls the prosthesis. They are using, there's nothing wrong with that. However, surgeon doesn't always have control of the head and neck ratio. There are implants, the block implants they come ready made. And if that's the only implant you have on the shelf, then you don't have much control over that. And so, for example, in the days of Charlie and other things that's stand more prostheses, there are more new block.
And some of them are not obviously over them, but some are block. You don't have a choice of ethnic ratio. It comes as comes. So that's why it decided to put it as an implant factor. Another question is how from agit medina? How do you measure combined version? Also, very good question, and that's advanced question. The combined version would use a CT scan to measure it.
I think it'll be difficult to I'm not sure of any other way to measure it, but a CT scan and a combined first version is important also. So if one component is activated. The other four, all-male aligned, let's say one company is male aligned. The other component can compensate for that. So that's the importance of combined version.
OK, but I wouldn't volunteer that information in the exam, I would if the examiners ask it, ask about it, I would say Yes. Combined version is very important and components can compensate. And the way to the state is doing a CT scan. If if you're being asked about combined version, you've even gone a very difficult direction or you're already at 7. So the other thing is, I'll just add about this complication.
It's more relative to when you do the revisions because sometimes the revisions, actually, you are right about what you can. If you have loosening in the establishment or you cannot put the car up or you have a microfracture or you have all these things or you have deformed proximal femur, or you don't have a proximal femur actually at all and you are doing femur replacement femur replacement, then come strongly into action that you have to have this 3D while you are putting use because you don't have any guide.
How are you going to put the ultrasound? Next question is difference between Lipton platt? Yeah, it's very simple, but important to note. Yeah lip implant is just the liner itself. The liner has a limp, so it's a slightly raised on one side. OK, so the lip implant is an implant that has the liner of the implant, has a small raised lip on one side normally covers about a quarter of the liner or third.
The plot is an additional device that you use to supplement the acetabular cup on the deficient part where it's dislocating. So the line the lip liner is just a normal liner, which has a lip. The plaid is extra device you add to the curve. To increase the coverage area of the cap to reduce dislocation.
Sorry, I didn't bring any images, put any images, I didn't want to complicate this. That's OK. Actually, what you put up is very good for us. I'm really impressed by it. So the next question is what is the meaning of acetabular offset definition? OK I think you covered this already. Yes just again, last question.
The stubble offset is that also the perpendicular distance? Between the floor of the acetabulum. And the center of rotation of the hip joint. Um, or to be more accurate. Between the floor of the acetabulum and center of rotation of the acetabulum itself.
And the floor of the acetabulum is marked by a line that could be asked about this in the exam, which is the a line you perpendicular distance between that line and the center of rotation is called the acetabular acetabular offset. OK we still have a little bit more time.
About 10 more minutes in total. So does anyone want to discuss any other questions or any other comments from our mentors? I'd just like to say this is a common, commonly tested question, I think you'll find a lot of people have been asked about this gift. It's a gift, really. You don't need to say more than this.
You can score really high in this question. This is one of those questions the examiner should not really talk to. The examiner should just sit back and listen to you. So if this question gets you understand, first of all, it shows your ability to deal with a complicated situation and divide it into simple, organized answers. It's also a question that delves into your knowledge of the operation and the process of selection, and they can divert off into any direction, depending on where the marks are in this question.
I think also, as always, this is a general rule, and even when I present an actually all what Russell said, it's about basic science. So you can take them there. You can start to talk about them. OK, I want to. I see here I'll be a little bit concerned about the offset. And for this, I want to first to do my templating. I want to see.
If there is any discrepancy, how they were doing before the surgery, and this will affect the implant choice. And what about the head size? Because this will affect the excursion distance. This will affect the head neck issue. And it will affect the range of motion. And when I increase these and make sure that these measurements are optimized, then I am actually optimizing also by my outcome, by decreasing the risk of the dislocation within the functional range of movement.
These are the buzz words you need. You need to talk like these buzzwords and usually once you started to talk like this. Thanks whoa. He knows what he's talking about. You know, and all this from the basic science, not that your hip surgeon, you saw many hips or you did many hips. No, no, no.
This is the basic science. So always concentrate on this while you are reading, please. And you are winning. Don't worry. Thank you. Thank you, so. That's absolutely correct to say after this session, we will log off and will log in against one will send another link.
We'll talk about Hassan next. Also, FRC is talk about pretty pathetic fractures. Another FRC is topic. And also after that will be hot seat session. Please express your interest in Hot Seat fashion, qingchuan and message with your interest and also with date of your bar to exam so he knows how to prioritize people. We will try to offer more of these sessions in the future. Just regaining it by interest from people.
And I think interest is increasing, so we will try to accommodate that demand. OK all right, everyone, thank you very much. We'll close a couple of minutes early so you can all have a little tea break. Get your tea ready. I'll send another invite in about three minutes or so. OK, thank you, everyone.
Thank you. Thank you.
Segment:0 .
And you're allowed to also mentor a group webinar sessions to my name is one Henry I'll be moderating today. And our first presentation will be by Firas Aarnout, followed by one by Hussam knee when the first session with this session will stick to Firas, if there's some time at the end, we'll take questions. And of course, if there is even more time, we take a hot seat question if possible.
But then we look at it get a second invite to start the second session with Hassan Rouhani and everyone. Very welcome. OK, thank you everyone for joining in. I'm we will talk tonight. First topic about hip dislocation. Hip replacement dislocation is very commonly asked question and very commonly tested question in the FRC case.
Obviously, my acknowledgments are to the group, and we just want to say I'm not here to teach you anything you don't know already. I'm just here to give you a teacher a system of how to structure your answer for the exam. It is commonly frequently tested the question in the adult pathology, Viva, you are likely to be asked by a non hip surgeon.
So if you use the right terminology, you could very easily impress them and score very high. There is no one right answer as any other question is really what they're testing is that you have a safe, systematic approach. It could come into twos into two different scenarios. It could be the examiner can ask you about dislocated total hip replacement, which is the most commonly ask one, or they can tell you.
You are doing hip replacement at the end of the procedure. You find the hip is unstable. What will you do then? So one of these comments took two scenarios can come in. And you will the survivor normally starts with an X-ray like this one? The examiner will show you this and say, tell me, what do you see?
So what do you say straight away? I would like to take a history and examine the patient. Please avoid the temptation to bombard the examiner with questions at this stage. Make it brief and crisp. History, I would like to take history specifically asking about the time since the index operation.
About the number of dislocations. About the mechanism of each dislocation from first one to the current one and about the medical comorbidities. Everyone knows that you are a competent doctor who can take very good, detailed history. We don't need to go into full details asking examiners about various things. These are the main points that you need to focus your history on.
If the examiners. Things that any of this information is relevant, they would normally volunteer this information to you. So please, please avoid the temptation of saying how many dislocations, how many. What is the mechanism? Don't ask examiners questions. Just say that's what I'm looking for. Then you move promptly to examination.
They like to take history, asking about these four points. Then I would like to examine the patient. Looking at the position of the limb at the neurovascular status and the mental test scoring the patient, if the examiner thinks there's any of these points are relevant, for example, they can, they will volunteer this to you. They will tell you all the patient has sciatic nerve palsy.
But you've shown the examiner, you'll want to look for that. Don't waste any more time on this. Then you move on promptly to investigations. Very briefly say I would like to see the previous radiographs of the patient with the hip located. And also, I would like to have a lateral radiograph of the dislocated hip. So you you moved quickly, you shun the examiner very quickly and briefly, you are a safe, sensible surgeon.
You're not scoring any points yet. So the quicker you can get through this, the better. Not more, ideally not more than 30 seconds. And the examiner shouldn't have to talk much about during this period, and then you move on now to scoring. The examiner doesn't have to ask you what you're going to do. You could just volunteer that because, you know, that's what the station is about.
It's about your understanding about the management of hip instability. You could say the examiner would like to reduce the dislocation. Please don't start going into details about how you're going to reduce it. I've heard a lot of candidates, they start asking, saying, I'm going to call the anesthetist, I'm going to check the staffing status of the patient. Please don't go into all this.
No, examiner. No, you are. You know about these minor details just straight away. Say I would like to reduce under sedation or under general anesthesia with the anesthetist back up and then I would like to search for the cause. And now you starting to score points in the quicker you can get to this stage, the better for you. So management reduce and search for the cause, the cause.
There are three factors patient factors, surgical factors and implant factors, and once you get to these, the examiners will relax. And you are really here in your way to pass this station. So please get to this within the first minute or two, not in the last 30 seconds. So patience factor the easier ones and you can get them out of the way and score points for that quickly gender.
But the patience factor the gender it's known that the female to male ratio is 21. Again, for any of these factors, if you can back it up with evidence, if you find a paper to back it up, you will be obviously gaining more points. So gender, female to male ratio is 21 neurological conditions, if the patient has any neurological condition that causes soft tissue laxity and muscle weakness, it will weaken their abductor mechanism, reduce the stability, patient compliance, alcoholic patients, cognitive dysfunction, dementia.
A poor anatomy for tenotomy, either from previous multiple revisions, if it's the revision surgery or from previous infection or trauma, poor anatomy will cause compromise abductors, which also will impair the stability of the hip replacement. So these are the patient factors. You get them out of the way. They're not much to talk about them.
So you get them out the way you showing the examiner, you're actually not blaming the patient. You make it somehow clearly not blaming the patient for dislocation, but you are considering the patient factors. Then you're moving on to the surgical factors, and now here you are going to the higher level of thinking, higher order thinking, which is a paced level.
It's known that a surgeon experience is an important factor. If you can't pack, it is also reported in the MJR, and if you back it up with NJR data, you will be scoring high. The surgeon experience. Second is impingement. Infringement can be caused by fights, which have not been removed during surgery or from retained excess cement.
And this can be seen on X-ray. So if you find any of these factors evident on the X-ray that the examiners have shown you, you tell the examiner straight away, yes, I can see an austere fight there. I can see everything in there. That could be a factor, surgical factor and then prostheses alignment and soft tissue tensioning. We all know the proper processes, alignments of the cups.
20 to 30 degrees of a virgin and 35 to 45 degrees of inclination. There are studies done. If you can back it up, also, that will be useful. The cement version is 15 to 20 degrees. If there are any doubts. You could always, if you're not sure if this person is aligned properly, you can tell the examiner, I'm in doubt, I would like to have a CT scan.
Is not, you know, you're showing you are safe by requesting an appropriate further investigations, and hey, we can see how this prosthesis is retrofitted instead of being activated and what will make it prone to dislocation. So prosthesis alignment is a surgical factor because surgeons control that factor. The other factor that surgeons have control over is the soft tissue tension of the adductors complex, and that's controlled by the controlling the offset.
And there are two types of offset, acetabular and femoral offset. Most of us talk about femoral, but if you say to the examiner, there is also acetabular offset. You are showing them that you are. You fully understand with the hip offset is about. The established offset can be so ideally to improve the stability you need to increase the offset.
The acetabular offset can be decreased by over medialization of the cup, and that could be seen on the X-ray. So if you see the x-ray, the surgeon has overseen the acetabulum, you tell them that. Explain that to the examiner. Tell them I think there is a acetabular offset is reduced here. That could be a factor.
Never could commit yourself to one single factor. Just say that could be the fact that the cause because could be also the dislocation or instability could be also multifactorial. The other opposite to talk about is the federal oversight of state and the examiners like this, though straightaway ask you if you don't volunteer it yourself, they will ask you what is the role of say?
Women are upset, as you know, guys, it's a perpendicular distance, you have to say the word perpendicular, they'll be looking for that word. Nothing for nothing else. Perpendicular distance between the center of the rotation of the femoral head. To a line down the center of the femoral shaft or center of the stem of the prosthesis.
OK, guys. Sorry, if you feel I'm going a bit fast. I'm trying to slow it down, but if I'm going too fast, the session will be recorded, you can view it later on. So I said increased offset. Would increase the abductor complex moment are mainly the gluteus medius.
And it has been explained before in a presentation by Sean, how how, how. Um, the moment arm affects the force. So increasing the momentum will decrease the force that's required by the abductors if they have a longer moment on. And therefore, on the long term will reduce the stress forces on the joint. So these are the positives of increased offset, the negatives is that it puts higher stress on the stem itself.
OK and this picture here shows you an example of how offsets are different between an extended offset and the standard offset. So these are the four surgical factors just to go over them again is a surgeon experience impingement, prosthesis alignment and soft tissue tensioning.
Now moving on to the implant factors. And one of the factors is where of the lining of polyester lining. And that could also be seen on the extreme, if you see it, comment on it straight away to the examiner as an important factor. The treatment for this will be exchanging the liner, obviously, the other implant factor is the head neck ratio.
Please try to use those terms, ok? They are really the proper terms, you'll impress the examiners and they will know that what you're talking about. So the head neck ratio? Increased head neck ratio is directly proportional to increase stability of the hip. Increased head neck ratio.
Will increase the arc of movement. Which is the range of movements prior to impingement. So you want a large head neck ratio? To increase the arc of movement prior to impingement, you can see here in this picture, the top image have a smaller head neck ratio comparison to the bottom image. And you can see how the range of movements, the arc of movements in the bottom one is 120 degrees and top one is 100 degrees.
Therefore, the bottom one has to travel 120 degrees before it impinges. The top one have to travel hundreds degrees. So that demonstrates the importance of the head and neck ratio. So you want a larger head to neck ratio. To increase the arc of movement prior to impingement. Do I need to say anything more than that? The examiners will be like looking at you and being impressed.
The other important factor is the head size of the femoral component, so head neck ratio and the head size in itself in isolation is an important factor. Its size will increase. Increased head size would increase the excursion or the jump distance. Which is the distance the federal hate has to travel to dislocate.
You could see in this image how a larger femoral head has to travel a lot more to dislocate in comparison to a smaller femoral head to the head size is another implant related factor. Very important factor. OK so to recap again. We have three factors patient factor surgical factors and implant factors.
And the patient factors a gender, neurological conditions compliant patient in non-compliant, patient and poor anatomy. Surgical factors and surgeon experience impingement, prosthesis alignment and soft tissue tensioning. And the implant factor where technical issue and head size.
No, the reconstruction leather for implant related factors. Obviously, if it's patient related factor, we have to treat that patient related factor, whatever it is, if it's surgeon factor. If there is impingement we have that has to be removed, if there is a reduced offset, that has to be corrected. Most of the time surgically, obviously you could put an implant that has a higher offset or extended neck.
If it is an implant related factor. It cannot that cannot be adjusted, it has to be implant treatment, sorry. Change the implant in a way or another. So there is a. I've put up this reconstruction ladder of reconstructing a dislocated hip replacement for implant related factors. So you start with normally with the most simple measure, you could use a lip liner to change just the liner, you use the lip liner, which has the raised lip.
In the direction of the dislocation, that's very important to know whether dislocation was anterior posterior. Next measurement could be to put a device called plant, which is posterior lip augmentation device. Next step is constrained liner. And the final one is dual mobility and obviously revision hip replacement completely is the last resort.
And I doubt it very much examiners will go into any more details than this, there won't be time anyway. Even you've done the best thing by getting here. And I think any further discussion is a more robust exam fellowship standards. Not so. I think if you get to this stage, you'll be fine. So my motto for the exam always to stay, keep calm, stay organized.
Go from ABC. Examiners are testing your ability to cope with pressure, so it's part of the exam. Do you have to stay composed all the time, no matter what's put in front of you, even if you don't know the answer, try to stay some systematic and. And really, you have to show the examiners that what you're talking about.
You have to save and use the right terminology, right system, right approach. And you have the right, not just the right knowledge and the right amount of knowledge, but also the higher order thinking to use that knowledge. In your day to day practice of the patients, OK, so you have to show the examiners that what you're talking about, and that's all my presentation.
And for stability. Well done for us. Any questions, guys? It's a very, very good press. Excellent, as always. You're showing really simple, straightforward way of answering this question with a lot of knowledge in very simple sentences. If you guys just replicate that in your examination and remember, the variations in this can be along the lines of what are the things you would consider in a hip replacement on a certain type of patient or a certain type of anatomy.
And you can then again divide it into patient factors. Your surgeon factors your implant choice. Some questions that have been asked for us or Jose or any of the group I notice at our and for our chowdhury have joined us as well. So first question is, should we consider head neck ratio as a surgical factor as they are surgeon choice while wearing waiwera and loosening as implant factors? Yeah, I think that's a very good question, and when writing this presentation, I thought about it.
Ultimately, the surgeon has. For overall control of most of the factors. And even patient factors, because even the patient has a neurological condition, you could say that the surgeon could have put a constraint liner straight away anyway. However, this seems to be the most agreeable kind of classification that I found. And they seem to be putting it under the implant factor.
But yes, if you put it as a surgeon factor because the surgeon controls the prosthesis. They are using, there's nothing wrong with that. However, surgeon doesn't always have control of the head and neck ratio. There are implants, the block implants they come ready made. And if that's the only implant you have on the shelf, then you don't have much control over that. And so, for example, in the days of Charlie and other things that's stand more prostheses, there are more new block.
And some of them are not obviously over them, but some are block. You don't have a choice of ethnic ratio. It comes as comes. So that's why it decided to put it as an implant factor. Another question is how from agit medina? How do you measure combined version? Also, very good question, and that's advanced question. The combined version would use a CT scan to measure it.
I think it'll be difficult to I'm not sure of any other way to measure it, but a CT scan and a combined first version is important also. So if one component is activated. The other four, all-male aligned, let's say one company is male aligned. The other component can compensate for that. So that's the importance of combined version.
OK, but I wouldn't volunteer that information in the exam, I would if the examiners ask it, ask about it, I would say Yes. Combined version is very important and components can compensate. And the way to the state is doing a CT scan. If if you're being asked about combined version, you've even gone a very difficult direction or you're already at 7. So the other thing is, I'll just add about this complication.
It's more relative to when you do the revisions because sometimes the revisions, actually, you are right about what you can. If you have loosening in the establishment or you cannot put the car up or you have a microfracture or you have all these things or you have deformed proximal femur, or you don't have a proximal femur actually at all and you are doing femur replacement femur replacement, then come strongly into action that you have to have this 3D while you are putting use because you don't have any guide.
How are you going to put the ultrasound? Next question is difference between Lipton platt? Yeah, it's very simple, but important to note. Yeah lip implant is just the liner itself. The liner has a limp, so it's a slightly raised on one side. OK, so the lip implant is an implant that has the liner of the implant, has a small raised lip on one side normally covers about a quarter of the liner or third.
The plot is an additional device that you use to supplement the acetabular cup on the deficient part where it's dislocating. So the line the lip liner is just a normal liner, which has a lip. The plaid is extra device you add to the curve. To increase the coverage area of the cap to reduce dislocation.
Sorry, I didn't bring any images, put any images, I didn't want to complicate this. That's OK. Actually, what you put up is very good for us. I'm really impressed by it. So the next question is what is the meaning of acetabular offset definition? OK I think you covered this already. Yes just again, last question.
The stubble offset is that also the perpendicular distance? Between the floor of the acetabulum. And the center of rotation of the hip joint. Um, or to be more accurate. Between the floor of the acetabulum and center of rotation of the acetabulum itself.
And the floor of the acetabulum is marked by a line that could be asked about this in the exam, which is the a line you perpendicular distance between that line and the center of rotation is called the acetabular acetabular offset. OK we still have a little bit more time.
About 10 more minutes in total. So does anyone want to discuss any other questions or any other comments from our mentors? I'd just like to say this is a common, commonly tested question, I think you'll find a lot of people have been asked about this gift. It's a gift, really. You don't need to say more than this.
You can score really high in this question. This is one of those questions the examiner should not really talk to. The examiner should just sit back and listen to you. So if this question gets you understand, first of all, it shows your ability to deal with a complicated situation and divide it into simple, organized answers. It's also a question that delves into your knowledge of the operation and the process of selection, and they can divert off into any direction, depending on where the marks are in this question.
I think also, as always, this is a general rule, and even when I present an actually all what Russell said, it's about basic science. So you can take them there. You can start to talk about them. OK, I want to. I see here I'll be a little bit concerned about the offset. And for this, I want to first to do my templating. I want to see.
If there is any discrepancy, how they were doing before the surgery, and this will affect the implant choice. And what about the head size? Because this will affect the excursion distance. This will affect the head neck issue. And it will affect the range of motion. And when I increase these and make sure that these measurements are optimized, then I am actually optimizing also by my outcome, by decreasing the risk of the dislocation within the functional range of movement.
These are the buzz words you need. You need to talk like these buzzwords and usually once you started to talk like this. Thanks whoa. He knows what he's talking about. You know, and all this from the basic science, not that your hip surgeon, you saw many hips or you did many hips. No, no, no.
This is the basic science. So always concentrate on this while you are reading, please. And you are winning. Don't worry. Thank you. Thank you, so. That's absolutely correct to say after this session, we will log off and will log in against one will send another link.
We'll talk about Hassan next. Also, FRC is talk about pretty pathetic fractures. Another FRC is topic. And also after that will be hot seat session. Please express your interest in Hot Seat fashion, qingchuan and message with your interest and also with date of your bar to exam so he knows how to prioritize people. We will try to offer more of these sessions in the future. Just regaining it by interest from people.
And I think interest is increasing, so we will try to accommodate that demand. OK all right, everyone, thank you very much. We'll close a couple of minutes early so you can all have a little tea break. Get your tea ready. I'll send another invite in about three minutes or so. OK, thank you, everyone.
Thank you. Thank you.
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