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Commonly Quoted Literature Evidence for Postgraduate Orthopaedic Exams
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Commonly Quoted Literature Evidence for Postgraduate Orthopaedic Exams
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Segment:0 .
Hello, everybody. Thank you for joining us again. First, this mental group is running again. We've got a good showing from our mentors again. They're volunteering to their free time to help our participants. Abdullah, Samir, Samir goradia and honey, I see, are here.
They'll be asking questions at the end of the session by the questions. And today we have kamat, who's one of our newest mentors and has recently passed exam, and he's going to talk to us about how he's going to sorry, most cited evidence in the exam papers and evidence in the exam. As always, this part will be recorded and put on to YouTube, but the Viva session afterwards will not be.
And of course, all participants can request a CPD certification through the telegram group at the end. Sara, thank you very much. If you'd like to share your screen and start. Hello, everybody. So here we go. Today's topic is commonly quoted evidence a lot is spoken about evidence in Air Force exams and actually everybody talks about it.
The reason why everybody talks it is because of one very simple and common fact that one of the stations of your entire mind political will be bad. Definitely and you might score phi, which needs to be updated somewhere else. And only way other than talking logically, you can create it to 7 or 8 is by committing a sensible evidence.
The evidence, the way you tell evidence is very important to you to basically a good candidate will tell what type of study it is, how many patients were there and details of it. But if you tell whether the level of study title of study, whether it's a multicenter or in one central what's the conclusion? Clearly, I think that should suffice for the examiners to give you a seven or eight.
So we go to this thing called sorry, excuse me. So it's evidence based orthopaedics, which is practiced nowadays. There are lots of evidence. And basically we pick the evidence which is strong and applied to the practice and then appraise it and see how does it work and then do further studies or meta analyses, et cetera.
So there is a pyramid. So before we go to pyramid, I tell you about what is evidence. If you really read a textbook, those classification and those concepts which are there in the books, for example, like CMC, joint arthritis is associated with carpal tunnel syndrome is actually evidence. So if you go on living, there'll be there's a lot of evidence which actually theoretically can say this is if you've got a rival station with CMC.
Joint arthritis in history also asked symptoms of carpal tunnel because there's evidence that 38% of people with arthritis got carpal tunnel. So then what? What evidence if you are doing all right or average, it gives examiner a opportunity to tick a box and take you to this next level. So when you can use evidence, you can use evidence. Any scenario nowadays other than basic science is either excellent clinical situation or photograph.
You have to start with history so you can use evidence in history. Examination while investigations and treatment, for example, is there already given an example, you can say that the CMC joint arthritis associated carpal tunnel syndrome or in examination, you can see like he's got a hammer process, so it is 70% associated with ACL injury in an investigation, you can use, for example, musculoskeletal Infection Society score or visit score to say that this investigation, we got a predictable outcome score, which can quantify a condition or diagnose the condition and how you lose.
That's important. A very good candidate will tell about everything about the paper. I'll tell about the title, which is what level it was, what type was the study and everything. But generally our average candidate like me or some of us will show will tell about somebody just the title and somebody, what's the conclusion of study? And I think that is quite enough because I dump it out, really, unless one of if they have read the paper completely and they know exactly details you don't really know.
You just need to know what it means. So if you see a big of a pyramid of the levels, there are five levels. Level one is either our city, which is randomized. Controlled trials often find often double blinded or systemic reviews of that. Level two is cohort studies, level 3 is case control studies, level 4 is histories and level five, the general consensus or expert opinion or professors opinion, et cetera so there are some common evidence, which I want to just highlight to you.
It's not an exhaustive list. Neither it's a very detailed thing about each and every study just to highlight which group A Black point for you to mention, or if you're interested, you can read it further. So this is very important paper and examiners love it because this is a paper which was released when arthroplasty has really picked. The examiners were at the time, really enthusiastic and in 35 '40s.
So it was done by you. And it shows the effect of ultra clean air, which means one with the laminar flow in operating theater on deep substance and deep subsisting joint replacements, they found that the ultra clean theater is the most productive predictor of the infection, and the infection rate drastically comes down with our treatment. There are figures available.
I don't want to mention because you have to remember them. They also studied same time about prophylactic antibiotics, and they found that prophylactic antibiotics also reduce the chance of deep sepsis in joint replacement. They are talking about hip and knee replacement. This was this is actually a classic paper. Now there are studies after that in Australia, we visit ulnar claw. It's not really that important, but this.
Nobody will blame you to mention this because this is a very important. This can also come in basic sciences when you're asked about how to prevent infection or joint gets infected. What you'll do. So the next one is just randomly pick them, but it will give a variety about clavicle fractures, clavicle, which of clavicle displace fracture is not really uncommonly asked.
So Robinson in 2013 had compared non operative versus operative treatment of displaced clavicle fractures. It was a randomized controlled trial, and they found that the better, better outcomes for this fracture were treated operatively. There was a better functionality, reduced non-indians rate, but it was expensive and complications were high.
So this is now this is quite a lot forward because most of us see the indication when you feel there's a clavicle fracture and say the indication of physicians are standing on skin. It's compound neurovascular injury, et cetera, et cetera. But you ought to mention this paper because you can say Robinson has said that if the fracture displaced short term easily more than two centuries then the risk is a better outcome.
The next thing is a proper trial, which is quite it's a very heterogeneous trial, it is basically talking about the displaced fracture of proximal humerus in Italy, and they tried various things like blade fixation and compared them with the non-surgical treatment. And they have shown that there is no difference how there's a controversy as the daily.
The trial is really heterogeneous. They've taken a wide age group of people. And there are different surgeons. Some of them are experiencing treating shoulder fractures, some are trainees. There's no a strict explicit criteria. But you have to maintain this profit trial, and I think the next profit profit through trial is coming up on or in the process, which I don't know about.
So one of the authors is rangan, whose it was published in 2015. Then again, draft trial this was in made in 2015, we got Matthew, one of the authors. It was a randomized controlled trial of percutaneous fixation with cavers and compared it with the DVR fixation, which is a water locking plate.
And this was done for dorsally in adults. And again, they found that there was no difference between two groups. However, this is a general, general and general feature, which is much and many times evidence can be mentioned in a negative way. For example, if you are showed a displaced, dorsal displaced fracture, which in particular element and there is some think it's unstable fracture, you can say I have, I would.
In this situation, you'll be wondering how I can use this because the evidence is that no different and you want to say, I'm going to plate it so you can say I'm going to treat this patient surgically because this is an intraocular displaced, unstable fracture. However, I know about rough trial, which did not show any difference. So you're adding evidence and helping examiners to protect tick box.
One of the very important things you ought to know is that on the day of examiners, your knowledge is much more fresh and probably wider. But examiner knows when you do wrong things. So unless you are the wrong thing, you utter something which is not drastically wrong. Examiner it really doesn't take the minor points unless you say something really drastically wrong. So next is just about.
You're absolutely correct in what you said about the draft trial that there is no evidence of difference between treating an inquiry, but it's very important to understand the exclusion criteria for this and the large drop outs or crossover of the patient group was the patients. The inclusion criteria was patients that you could reduce the articular surface congruent be. So be very careful in saying all risks are the same in the example.
They're not. It's the draft trial was very specific. If you could close reduce the fracture, then it makes no difference. Sorry to disturb you. It's just I know that that's what you meant, but it's quite important that distinction is made. Yeah so next paper is actually really important paper, and I would really advise candidates to read it.
This is an old 2005 which basically tells about how to fix in epicondyle distal humerus fracture. He his mentions, actually, he's got two aims, which say that fixation in the distal part of fragment should be in. Distal fragments should be maximized, and whatever you do in distal fragment should add to the final stability of the reconstruct.
And he given several points like the school should catch multiple fragments to catch as many articular fragments as possible, and they should interlock with other side screws. Plate should be 990 degrees and so on. So this is one of very important paper. If you got a patient or a survivor station built into condylar for activity displaced and you're sick talking about or if, then you have to tell about this paper.
It's all this paper into the fine, which just about fixation in epicondyle distal fracture humerus fracture. So next one is about 10 to Achilles. This is another important meta analysis. I put one of the authors, which said that there is no difference between the no significant difference, no statistical difference in rupture rate as well as planned.
Whether you treat patients with the operative or non-cooperative and what when they say non operative, what they mean is using a functional splint like a hurkacz, but very can use veggies to plant a flex. You can make the patient bed bed, et cetera. So they found that no difference in two rates, but the operative who definitely gives more complications.
This is for a fresh Achilles tendon. If is a rupture, then it's a different issue altogether. All right, this is another important paper, it is about a displaced intra articular calculi fracture. It is a city done by Buckley in 2002, which shows that the treatment of non-operated are almost equivalent to that of operative groups.
However, there identified some subgroups which get which due better outcome, which are like women, people who are less than 29 and people who are not having worker's compensation. I'll briefly go on to the hill trial, which was done in the UK, which also shows there is no difference. Right so another trial is all white pretrial for Thompson versus Exeter, and you need two legs for dispersing into a capsule of axilo feet.
They have written something like no difference in health outcomes. Now, many of these patients had lost follow up, and they could not get enough data, so they are the way they told the summary. It appeared that they were not really strong in the strong in the committing themselves. They did no definite outcome. However, they are basically saying the complication rates and they were not much statistical difference between all three.
Then this is important trial if we get to patients with trauma. Axilo of open book pelvis and you're talking about resuscitation and then you have to talk about clinic stomach acid and then you have to tell about crash through trial. There was one trial on this crash Ii trial and there'll be another crash three trial, which tells about head injury and what's the effect and on the risk of death injuries.
So crash to stage two trials should the bleeding trauma patients, tonics and acid reduces the risk of death. All right. And it is going two ways, one, it's one Trump state and then 1 gram or Ivy or eight hours in infusion. Now you know about caucus criteria, which is differentiating between the trans sign '20s and 30s.
If you had to ask about a limping child mentioned this, I will use caucus criteria. When you're talking about differentiating between transient sinusitis and septic arthritis, it goes it gives a score and prediction. For example, after all four points possible, then around 99% If you reach 93.94 percent, et cetera, there is another paper which talks about CRT being most important predictor of septic arthritis, which you can read further.
Right now, this is another very important paper, and it's almost like saying, to be Frank with you, Sophia is a really controversial paper and this is an algorithm and a by South tenotomy and Mr ulnar claw has put it really well. I can put I can show you the algorithm. Just give me one second because I thought, it's very important for you to know this is the algorithm for Sophie.
So what he says is basically if it's stable or it's unstable, or to differentiate between two so stable ones, you can screen into two. If it's one or two words next to me, if it's unstable, then you have to operate within 24 hours. Now, if I thought, if it's unstable, you have to again operate immediately and ideally take him to the children's unit and to be done there.
Grade three. If it is less than 24 hours, you can do next to me if it's more than 24 hours. You can put into action and do next to me later. And this is really important if you really understand this algorithm. It is a really life saving philosophy. Right oh, sorry.
And then there's common people that's very, really commonly talked people by hand surgeons, especially with the Davis people 2009, which shows about the tells about them where they can just do a typekit to me or you want to do a charity or stabilization with choir. And Davis said that a three month and one year, there's no difference between all these procedures, and there are more studies which really go in this line.
Now about the head of a muscular skeletal Infection Society score, major and minor criteria. And this is a pervasive paper in 2008 in which you more point wise and it takes into consideration major criteria, as well as some extra criteria like Samuel Samuel, WPC, Samuel cerp, d-dimer, leukocyte traject, et cetera.
And the score. If the score is more than six, then it is surely septic if the last entry is not septic and between two is intermediate. So this is another important paper when there are some trials, which really is important to mention because one is if you put an ankle arthritis axilo, you can say with whatever expert you experience and the patient's condition, whether you would like to go for a arthritis or arthroplasty.
But terror trial is ongoing. Trial is a multicenter which which compares ankle tenodesis with ankle arthroplasty. So we can mention the terror trial is going on, but I would like to do this, depending on the situation. Press three trial, as I said earlier, also compared a head injury and stomach acid when you go for a patient for trauma and got head injury. This trial is actually on impingement syndrome of shoulder that there is some data which tells there is not much difference between conservative treatment, with steroid and physiotherapy with the.
With the arthroscopic decompression, and there is another asked for a reverse or hemiarthroplasty for fracture proximal humerus in elderly people. Now other things which can be used as evidence probably is a Bush guideline. There are a lot of them. There are 13 of it ankle fractures, wrist fractures, spinal fractures and zuckerkandl fractures, et cetera you can also not really.
Many people go to the NICE guidelines for osteoarthritis in osteoporosis. It is quite a good thing to go because these are sorry for that. So it's worth mentioning and it counts a. What's are? What is India data? And this austere arthritis osteoporosis guidelines are really easy to know, and you can just get a tick mark.
Now it might not really make a big deal in practice, but to pass this exam, it definitely has some impact. And thank you for listening. It was my first attempt in presenting, so. Well, Melton said there are quite a few papers there that you've shown. Yet is there any questions from the.
There's any questions from the participants. I just want to add two important papers. The first is paper from Cambridge when to do all through this and want to do arthroplasty for the ankle osteoarthritis? It's very important to be able to quote the next one, the paper from Cambridge as well for. It summarizes the treatment for hallux fungus is very good.
And lastly is the post deadlines, which should be obesity for pathological microfracture or mix in the bone. There is important guidelines for that. Yeah, absolutely. First of all, the most, Uh, we use the word guideline, but they're not guidelines. Their standards? No, no, I appreciate.
It's just I remind myself because I use the word guideline or guidelines I would like to mention one is a guideline. The nice guideline of people who present with metastases with unknown primary. It's wonderfully, wonderfully given in nice guidelines, and we practices. A nice protocol for that. And as Henry said, the spine metastatic spinal cord compression, which is again a very good guidance from nice.
Yeah so anywhere where there is these type of guidance and/or standards that are published, they literally are literature reviews and best evidence. So if you quote them, that is quoting a paper, but you have to be sure that you're quoting them correctly and accurately because if you make one mistake in them, they will pin you down on it because it is. They're all standards. They are the standards of care and treatment and be expected to provide sort of thank you so much.
Thank you very much, Siddhartha. That is a very good view. So a review of all these important papers that are very, very commonly quoted. I congratulate you on your choice of the papers. These are the ones that are very common. However, like everything else in life, there is a hierarchy of evidence. So not all evidence is equal.
So, for example, things like the nice guidelines, the post guidelines or standards. It's not only that you have to quote them to get eight. I believe, and I'm sure that it is shared by some, if not all, the mentors. If you misquote them or you don't know them, that means you are unsafe and probably they may harshly downgrade you because, for example, management of open fractures if you don't know those guidelines.
OK they can say you are unsafe. The same thing for supracondylar fracture of children, the same thing, so these are the best the top of the hierarchy. So if it's not, you don't have an option. Whether to quote it or not, it is a must. Same as got NICE guidelines. Then the next level down will be the multicenter center trials that are run by the UK, including the prof.
The CISO. The digital radius draft. And all of these just because they are multi central and they are done in the UK. And it is quoted and discussed and debated and created a big wave that you would be buried. You you would have been burying your head in the sand if you are not aware of them again. So this is the next level down.
The next level down would be a well sent, well done classical papers, for example, mural score, for example, all these international crash trials, and things like that. Again, this is the next level down, and then they obscure smaller results. So these studies that are done here and there and marking you will differ depending on the evidence. For example, missing a nice guideline, as I said, means that you are unsafe while misquoting a small, obscure trial that the examiner may not have heard of.
You may get away with that. I'm not. I'm not encouraging anyone to make things up, but what I'm trying to say is there is a hierarchy and in your studying, you have to focus on the more important ones. First, make sure that you understand them very well and that you understand the ins and outs of them before moving to the next level before moving to the next level.
The thing that would fail you is if you start chasing all these small studies before making sure that you are very strong in the big ones. And this is my quote in the matter. Yeah, so just to remind people the hierarchy of evidence is actually we call the pyramid of evidence. We're not talking about that here, that pyramid of evidence is a basic science question. So really well.
Yes one is the pyramid of evidence or the hierarchy of evidence for the UK, FRC exam, et cetera that was excellent, as always. Anybody that wishes to claim a CPD point a certificate from us can make the request in the telegram group to or. And we will end the session here and we will start the Viva sessions straight afterwards. Do not go away. Thank you very.
Well
Segment:0 .
Hello, everybody. Thank you for joining us again. First, this mental group is running again. We've got a good showing from our mentors again. They're volunteering to their free time to help our participants. Abdullah, Samir, Samir goradia and honey, I see, are here.
They'll be asking questions at the end of the session by the questions. And today we have kamat, who's one of our newest mentors and has recently passed exam, and he's going to talk to us about how he's going to sorry, most cited evidence in the exam papers and evidence in the exam. As always, this part will be recorded and put on to YouTube, but the Viva session afterwards will not be.
And of course, all participants can request a CPD certification through the telegram group at the end. Sara, thank you very much. If you'd like to share your screen and start. Hello, everybody. So here we go. Today's topic is commonly quoted evidence a lot is spoken about evidence in Air Force exams and actually everybody talks about it.
The reason why everybody talks it is because of one very simple and common fact that one of the stations of your entire mind political will be bad. Definitely and you might score phi, which needs to be updated somewhere else. And only way other than talking logically, you can create it to 7 or 8 is by committing a sensible evidence.
The evidence, the way you tell evidence is very important to you to basically a good candidate will tell what type of study it is, how many patients were there and details of it. But if you tell whether the level of study title of study, whether it's a multicenter or in one central what's the conclusion? Clearly, I think that should suffice for the examiners to give you a seven or eight.
So we go to this thing called sorry, excuse me. So it's evidence based orthopaedics, which is practiced nowadays. There are lots of evidence. And basically we pick the evidence which is strong and applied to the practice and then appraise it and see how does it work and then do further studies or meta analyses, et cetera.
So there is a pyramid. So before we go to pyramid, I tell you about what is evidence. If you really read a textbook, those classification and those concepts which are there in the books, for example, like CMC, joint arthritis is associated with carpal tunnel syndrome is actually evidence. So if you go on living, there'll be there's a lot of evidence which actually theoretically can say this is if you've got a rival station with CMC.
Joint arthritis in history also asked symptoms of carpal tunnel because there's evidence that 38% of people with arthritis got carpal tunnel. So then what? What evidence if you are doing all right or average, it gives examiner a opportunity to tick a box and take you to this next level. So when you can use evidence, you can use evidence. Any scenario nowadays other than basic science is either excellent clinical situation or photograph.
You have to start with history so you can use evidence in history. Examination while investigations and treatment, for example, is there already given an example, you can say that the CMC joint arthritis associated carpal tunnel syndrome or in examination, you can see like he's got a hammer process, so it is 70% associated with ACL injury in an investigation, you can use, for example, musculoskeletal Infection Society score or visit score to say that this investigation, we got a predictable outcome score, which can quantify a condition or diagnose the condition and how you lose.
That's important. A very good candidate will tell about everything about the paper. I'll tell about the title, which is what level it was, what type was the study and everything. But generally our average candidate like me or some of us will show will tell about somebody just the title and somebody, what's the conclusion of study? And I think that is quite enough because I dump it out, really, unless one of if they have read the paper completely and they know exactly details you don't really know.
You just need to know what it means. So if you see a big of a pyramid of the levels, there are five levels. Level one is either our city, which is randomized. Controlled trials often find often double blinded or systemic reviews of that. Level two is cohort studies, level 3 is case control studies, level 4 is histories and level five, the general consensus or expert opinion or professors opinion, et cetera so there are some common evidence, which I want to just highlight to you.
It's not an exhaustive list. Neither it's a very detailed thing about each and every study just to highlight which group A Black point for you to mention, or if you're interested, you can read it further. So this is very important paper and examiners love it because this is a paper which was released when arthroplasty has really picked. The examiners were at the time, really enthusiastic and in 35 '40s.
So it was done by you. And it shows the effect of ultra clean air, which means one with the laminar flow in operating theater on deep substance and deep subsisting joint replacements, they found that the ultra clean theater is the most productive predictor of the infection, and the infection rate drastically comes down with our treatment. There are figures available.
I don't want to mention because you have to remember them. They also studied same time about prophylactic antibiotics, and they found that prophylactic antibiotics also reduce the chance of deep sepsis in joint replacement. They are talking about hip and knee replacement. This was this is actually a classic paper. Now there are studies after that in Australia, we visit ulnar claw. It's not really that important, but this.
Nobody will blame you to mention this because this is a very important. This can also come in basic sciences when you're asked about how to prevent infection or joint gets infected. What you'll do. So the next one is just randomly pick them, but it will give a variety about clavicle fractures, clavicle, which of clavicle displace fracture is not really uncommonly asked.
So Robinson in 2013 had compared non operative versus operative treatment of displaced clavicle fractures. It was a randomized controlled trial, and they found that the better, better outcomes for this fracture were treated operatively. There was a better functionality, reduced non-indians rate, but it was expensive and complications were high.
So this is now this is quite a lot forward because most of us see the indication when you feel there's a clavicle fracture and say the indication of physicians are standing on skin. It's compound neurovascular injury, et cetera, et cetera. But you ought to mention this paper because you can say Robinson has said that if the fracture displaced short term easily more than two centuries then the risk is a better outcome.
The next thing is a proper trial, which is quite it's a very heterogeneous trial, it is basically talking about the displaced fracture of proximal humerus in Italy, and they tried various things like blade fixation and compared them with the non-surgical treatment. And they have shown that there is no difference how there's a controversy as the daily.
The trial is really heterogeneous. They've taken a wide age group of people. And there are different surgeons. Some of them are experiencing treating shoulder fractures, some are trainees. There's no a strict explicit criteria. But you have to maintain this profit trial, and I think the next profit profit through trial is coming up on or in the process, which I don't know about.
So one of the authors is rangan, whose it was published in 2015. Then again, draft trial this was in made in 2015, we got Matthew, one of the authors. It was a randomized controlled trial of percutaneous fixation with cavers and compared it with the DVR fixation, which is a water locking plate.
And this was done for dorsally in adults. And again, they found that there was no difference between two groups. However, this is a general, general and general feature, which is much and many times evidence can be mentioned in a negative way. For example, if you are showed a displaced, dorsal displaced fracture, which in particular element and there is some think it's unstable fracture, you can say I have, I would.
In this situation, you'll be wondering how I can use this because the evidence is that no different and you want to say, I'm going to plate it so you can say I'm going to treat this patient surgically because this is an intraocular displaced, unstable fracture. However, I know about rough trial, which did not show any difference. So you're adding evidence and helping examiners to protect tick box.
One of the very important things you ought to know is that on the day of examiners, your knowledge is much more fresh and probably wider. But examiner knows when you do wrong things. So unless you are the wrong thing, you utter something which is not drastically wrong. Examiner it really doesn't take the minor points unless you say something really drastically wrong. So next is just about.
You're absolutely correct in what you said about the draft trial that there is no evidence of difference between treating an inquiry, but it's very important to understand the exclusion criteria for this and the large drop outs or crossover of the patient group was the patients. The inclusion criteria was patients that you could reduce the articular surface congruent be. So be very careful in saying all risks are the same in the example.
They're not. It's the draft trial was very specific. If you could close reduce the fracture, then it makes no difference. Sorry to disturb you. It's just I know that that's what you meant, but it's quite important that distinction is made. Yeah so next paper is actually really important paper, and I would really advise candidates to read it.
This is an old 2005 which basically tells about how to fix in epicondyle distal humerus fracture. He his mentions, actually, he's got two aims, which say that fixation in the distal part of fragment should be in. Distal fragments should be maximized, and whatever you do in distal fragment should add to the final stability of the reconstruct.
And he given several points like the school should catch multiple fragments to catch as many articular fragments as possible, and they should interlock with other side screws. Plate should be 990 degrees and so on. So this is one of very important paper. If you got a patient or a survivor station built into condylar for activity displaced and you're sick talking about or if, then you have to tell about this paper.
It's all this paper into the fine, which just about fixation in epicondyle distal fracture humerus fracture. So next one is about 10 to Achilles. This is another important meta analysis. I put one of the authors, which said that there is no difference between the no significant difference, no statistical difference in rupture rate as well as planned.
Whether you treat patients with the operative or non-cooperative and what when they say non operative, what they mean is using a functional splint like a hurkacz, but very can use veggies to plant a flex. You can make the patient bed bed, et cetera. So they found that no difference in two rates, but the operative who definitely gives more complications.
This is for a fresh Achilles tendon. If is a rupture, then it's a different issue altogether. All right, this is another important paper, it is about a displaced intra articular calculi fracture. It is a city done by Buckley in 2002, which shows that the treatment of non-operated are almost equivalent to that of operative groups.
However, there identified some subgroups which get which due better outcome, which are like women, people who are less than 29 and people who are not having worker's compensation. I'll briefly go on to the hill trial, which was done in the UK, which also shows there is no difference. Right so another trial is all white pretrial for Thompson versus Exeter, and you need two legs for dispersing into a capsule of axilo feet.
They have written something like no difference in health outcomes. Now, many of these patients had lost follow up, and they could not get enough data, so they are the way they told the summary. It appeared that they were not really strong in the strong in the committing themselves. They did no definite outcome. However, they are basically saying the complication rates and they were not much statistical difference between all three.
Then this is important trial if we get to patients with trauma. Axilo of open book pelvis and you're talking about resuscitation and then you have to talk about clinic stomach acid and then you have to tell about crash through trial. There was one trial on this crash Ii trial and there'll be another crash three trial, which tells about head injury and what's the effect and on the risk of death injuries.
So crash to stage two trials should the bleeding trauma patients, tonics and acid reduces the risk of death. All right. And it is going two ways, one, it's one Trump state and then 1 gram or Ivy or eight hours in infusion. Now you know about caucus criteria, which is differentiating between the trans sign '20s and 30s.
If you had to ask about a limping child mentioned this, I will use caucus criteria. When you're talking about differentiating between transient sinusitis and septic arthritis, it goes it gives a score and prediction. For example, after all four points possible, then around 99% If you reach 93.94 percent, et cetera, there is another paper which talks about CRT being most important predictor of septic arthritis, which you can read further.
Right now, this is another very important paper, and it's almost like saying, to be Frank with you, Sophia is a really controversial paper and this is an algorithm and a by South tenotomy and Mr ulnar claw has put it really well. I can put I can show you the algorithm. Just give me one second because I thought, it's very important for you to know this is the algorithm for Sophie.
So what he says is basically if it's stable or it's unstable, or to differentiate between two so stable ones, you can screen into two. If it's one or two words next to me, if it's unstable, then you have to operate within 24 hours. Now, if I thought, if it's unstable, you have to again operate immediately and ideally take him to the children's unit and to be done there.
Grade three. If it is less than 24 hours, you can do next to me if it's more than 24 hours. You can put into action and do next to me later. And this is really important if you really understand this algorithm. It is a really life saving philosophy. Right oh, sorry.
And then there's common people that's very, really commonly talked people by hand surgeons, especially with the Davis people 2009, which shows about the tells about them where they can just do a typekit to me or you want to do a charity or stabilization with choir. And Davis said that a three month and one year, there's no difference between all these procedures, and there are more studies which really go in this line.
Now about the head of a muscular skeletal Infection Society score, major and minor criteria. And this is a pervasive paper in 2008 in which you more point wise and it takes into consideration major criteria, as well as some extra criteria like Samuel Samuel, WPC, Samuel cerp, d-dimer, leukocyte traject, et cetera.
And the score. If the score is more than six, then it is surely septic if the last entry is not septic and between two is intermediate. So this is another important paper when there are some trials, which really is important to mention because one is if you put an ankle arthritis axilo, you can say with whatever expert you experience and the patient's condition, whether you would like to go for a arthritis or arthroplasty.
But terror trial is ongoing. Trial is a multicenter which which compares ankle tenodesis with ankle arthroplasty. So we can mention the terror trial is going on, but I would like to do this, depending on the situation. Press three trial, as I said earlier, also compared a head injury and stomach acid when you go for a patient for trauma and got head injury. This trial is actually on impingement syndrome of shoulder that there is some data which tells there is not much difference between conservative treatment, with steroid and physiotherapy with the.
With the arthroscopic decompression, and there is another asked for a reverse or hemiarthroplasty for fracture proximal humerus in elderly people. Now other things which can be used as evidence probably is a Bush guideline. There are a lot of them. There are 13 of it ankle fractures, wrist fractures, spinal fractures and zuckerkandl fractures, et cetera you can also not really.
Many people go to the NICE guidelines for osteoarthritis in osteoporosis. It is quite a good thing to go because these are sorry for that. So it's worth mentioning and it counts a. What's are? What is India data? And this austere arthritis osteoporosis guidelines are really easy to know, and you can just get a tick mark.
Now it might not really make a big deal in practice, but to pass this exam, it definitely has some impact. And thank you for listening. It was my first attempt in presenting, so. Well, Melton said there are quite a few papers there that you've shown. Yet is there any questions from the.
There's any questions from the participants. I just want to add two important papers. The first is paper from Cambridge when to do all through this and want to do arthroplasty for the ankle osteoarthritis? It's very important to be able to quote the next one, the paper from Cambridge as well for. It summarizes the treatment for hallux fungus is very good.
And lastly is the post deadlines, which should be obesity for pathological microfracture or mix in the bone. There is important guidelines for that. Yeah, absolutely. First of all, the most, Uh, we use the word guideline, but they're not guidelines. Their standards? No, no, I appreciate.
It's just I remind myself because I use the word guideline or guidelines I would like to mention one is a guideline. The nice guideline of people who present with metastases with unknown primary. It's wonderfully, wonderfully given in nice guidelines, and we practices. A nice protocol for that. And as Henry said, the spine metastatic spinal cord compression, which is again a very good guidance from nice.
Yeah so anywhere where there is these type of guidance and/or standards that are published, they literally are literature reviews and best evidence. So if you quote them, that is quoting a paper, but you have to be sure that you're quoting them correctly and accurately because if you make one mistake in them, they will pin you down on it because it is. They're all standards. They are the standards of care and treatment and be expected to provide sort of thank you so much.
Thank you very much, Siddhartha. That is a very good view. So a review of all these important papers that are very, very commonly quoted. I congratulate you on your choice of the papers. These are the ones that are very common. However, like everything else in life, there is a hierarchy of evidence. So not all evidence is equal.
So, for example, things like the nice guidelines, the post guidelines or standards. It's not only that you have to quote them to get eight. I believe, and I'm sure that it is shared by some, if not all, the mentors. If you misquote them or you don't know them, that means you are unsafe and probably they may harshly downgrade you because, for example, management of open fractures if you don't know those guidelines.
OK they can say you are unsafe. The same thing for supracondylar fracture of children, the same thing, so these are the best the top of the hierarchy. So if it's not, you don't have an option. Whether to quote it or not, it is a must. Same as got NICE guidelines. Then the next level down will be the multicenter center trials that are run by the UK, including the prof.
The CISO. The digital radius draft. And all of these just because they are multi central and they are done in the UK. And it is quoted and discussed and debated and created a big wave that you would be buried. You you would have been burying your head in the sand if you are not aware of them again. So this is the next level down.
The next level down would be a well sent, well done classical papers, for example, mural score, for example, all these international crash trials, and things like that. Again, this is the next level down, and then they obscure smaller results. So these studies that are done here and there and marking you will differ depending on the evidence. For example, missing a nice guideline, as I said, means that you are unsafe while misquoting a small, obscure trial that the examiner may not have heard of.
You may get away with that. I'm not. I'm not encouraging anyone to make things up, but what I'm trying to say is there is a hierarchy and in your studying, you have to focus on the more important ones. First, make sure that you understand them very well and that you understand the ins and outs of them before moving to the next level before moving to the next level.
The thing that would fail you is if you start chasing all these small studies before making sure that you are very strong in the big ones. And this is my quote in the matter. Yeah, so just to remind people the hierarchy of evidence is actually we call the pyramid of evidence. We're not talking about that here, that pyramid of evidence is a basic science question. So really well.
Yes one is the pyramid of evidence or the hierarchy of evidence for the UK, FRC exam, et cetera that was excellent, as always. Anybody that wishes to claim a CPD point a certificate from us can make the request in the telegram group to or. And we will end the session here and we will start the Viva sessions straight afterwards. Do not go away. Thank you very.
Well
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