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Principles of knee replacement for Orthopaedic Exams
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Principles of knee replacement for Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone, welcome to this orthopedic teaching session, organized jointly by the farc, a splinter group and orthopedic Research UK. Something else to note, and I will be moderating this session. And to help me is Ruth, the head of education from our UK.
And the speaker this evening is Mr Mahalakshmi mavela, and he will be teaching us about total knee replacement, the main difficult concepts, he will make them easy for us all. The presentation is pitched across a level. Mr Zavala is a consultant, orthopedic surgeon at the princess Alexandra Hospital in Harlow and the Ramsay rivers hospital. And he's special interest in is in lower limb joint arthroplasty, including revision surgery.
He completed his training at the Royal National Orthopedic Hospital in Stanmore. And has done this fellowships in North America. He's a co-director of the formerly known Royal College of surgeons, FARC escorts, and he now runs it as mal extremophile chairman of RCS ortho Viva Cos. It's very popular course. Many candidates who pass the exam have been through this course.
Mr mavela is an invited speaker on several national and international conferences. He's a faculty of several teaching courses, including near replacement courses at Harlow and Cambridge basic sciences course and various other instructional courses. Mr Mark Zavala has been working with us actively on the FARC splinter group since its inception. And he's been involved with us in online teaching and webinars for the last 2 and 1/2 years.
So we are very pleased that he's kindly accepted our invitation to present tonight. As you can see, the session includes a lecture presentation, which Mr Maxwell is very keen to run interactively, which is which worked very well in the past. And there will be some discussion there would discuss the concept, followed by some case discussions, and at the end there will be some.
There will be three interviews to test that you've been focusing with us during the session. If you have any questions, please feel free to ask in the chat box. The chat option is at the bottom of the screen or and also after the session, there would be 5 hot seat practice the hub. The Viva practice is not recorded and you are all invited to take part.
Anyone interested to take part, please raise the hand symbol that you find next to your name. And to the participant list, there is a handsome symbol, which you can raise, so we know you are interested in Viva and it doesn't first come, first serve basis. And obviously, there will ask you, you'll be entitled to have CPD certificates, I will ask you for a survey also, and Ruth will be already been in touch with you about this.
If you missed any part of this presentation, please don't panic. It will be. It is recorded and will be posted on the Force's mental YouTube channel and our UK website. Without further ado, I will leave you with Mr mavela to start. Lovely so thank you for us for that very kind introduction. And I would first like to thank Ruth treadgold and duke, but especially Ruth, who really has the pulse or as a finger on the pulse of all the orthopedic education in the UK.
She really runs her courses like clockwork and we need to thank everyone who has passed, needs to thank her for all the courses she runs. I'd like to thank her very much for that, and I think everyone who's boss needs to thank her and I want to thank her for the invitation as my affiliation. I have been involved with the Cambridge basic science course since its inception. It's about more than 10 years with because do and also obviously they are UK.
So with Ruth, I in my capacity as training for London and East of England, I will be involved with auto hub and East of England websites and all these are going to give talks on which I think only help to improve education in the UK. I really feel that the FARC has meant a group. I need to thank them for the invite and I'm very pleased and proud to say I've been with them right from this inception.
I didn't realize it's 2 and 1/2 years, but all these webinars, which are happening now during the corona lockdown. This group had started and had the foresight to see online Zoom teaching for 2 and 1/2 years. And I think all of them, all the senior mentors who have contributed tirelessly every Wednesday, we continued sessions, all video recorded. I think need to be commended for that. And in addition, of course, therefore, with this new collaboration between our UK and epimysium intergroup, I think it's excellent for all to be educational training, especially for the FARC as autumn international, both in the UK as well as abroad.
So thank you for us for that. So can I carry on with my talk for us? Yes, please. So the way I've planned this and I would like to do it is that we'll start with common FRC is all the questions we'll talk about terminology and in that the terminology which I think you'll get confused with the most of the time people use interchangeably is when you use words like constraint, when you use words like stems and augments, and then we have cases that very kindly put together this format where we had cases.
And that's good. But I want to do it leading on from this lecture. And it's very important that in knee replacements or hip replacements or common topics, we all feel when we go for the exam as candidates or we know that let's concentrate on something else. But the issue is, can we truly verbalize that concept? So it's not for me to talk on this. It's whether all can talk.
So I don't mind going slow. And I think as you all have realized as candidates for topics like hip and knee replacements, you need to have a seven or eight, but you can't get there unless you verbalize your concepts clearly at the basic level. So that's what I want to try to do for this. 45 minutes or half an hour and I don't mind, it's interactive. I don't mind skipping slides or mind repeating slides, but I want everyone, whoever is attended today to go away with at least a 60% retention information.
That's my goal. So let's start with the common policy, all the questions for us, if we can, and just for everyone in the audience, I feel making it interactive is more or less what you will want to know as to what we are doing in the exam. So if you don't mind, I may ask for us to nominate or if someone volunteers to just I'll ask a question. You give whatever answer you want to give.
It doesn't have to be right or wrong. It just starts to introduce that concept to me and then we can take it forward. So I hope that's all right for us. And if you don't mind, is there anyone who you would like to nominate or volunteer? We have Joey here who is interested to be your sort of candidate for this lovely casual introduction. Yeah, thank you.
Can you hear me? Yes, I can hear you. Thank you. So, Joey. And once again, for all of you, all who are in the audience, all of you are preparing. If you are practicing vivas with each other, ask yourselves and tell yourselves, Joe, that are you sitting on the basic science table or the adult reconstruction?
OK Yeah. So in this day, I'm telling you that we are both sitting or I am grilling or am asking you and it's your exam and we own the basic science vyver, not the adult reconstruction. OK and tell me. So you've been involved with knee replacements, haven't you? Yes Yes. No, and I'm asking you this as a candidate, not as Joe said, as a candidate took you tenotomy me on the left is a femur.
And what do these two lines represent? So tell me, what does this line represent? This line represents the anatomical axis of the femur along the longitudinal axis of the bone. And what is this is the mechanical axis of the femur, which is the line connecting the center of the head of the femur, center of rotation of the head. And tell me why this is important when we are doing knee replacements, either adult reconstruction or in the basic science level.
It's important to calculate the vulgar angle to have a Precice perpendicular to because my aim in total knee replacement into is to restore the mechanical axis of the knee. So my distal femoral cut has to be perpendicular to the mechanical axis because I am using an intramedullary guide, which is the anatomical axis to the femur.
I need to have six to 7 degrees pelvis perfect. So I would say, Joe, you answered it. Excellent and at the same time, just now for clarification to everyone in the audience when you're asking questions like this answer exactly like Joe has, but I'll just put it together for everyone. So the first thing you say is Yes. Tell the examiner that the left this line is your anatomical axis.
Tell your examiner that this line is the mechanical axis, then say these two lines are important and knee replacements because and always say my goal of knee replacement is what? So we can tell the examiner and for everyone, my goal of knee replacements is to place my femoral component and use these words base my femoral components perpendicular to the which axilo mechanical right mechanical axes.
All right, so say that that's your goal. Then say, however, practically when I do my knee replacement, I use an intermediary jig or an intermediary rod for my jig. And hence I do know there's a difference between these two, which is between 5 or seven degrees. And hence I dial that and use these correct words, which are impressive. I dial that difference into my jig, which gives me my correct values cut angle.
So the 7 to 8 on this question would be Joe, you were absolutely there, and that would be the words you want to use is most of the time, 90% is intermittent rejigging. I do know that my aim is to 90 degrees to my mechanical axis. Hence I want to divide it between. I know the differential between the two not leading up from 1 to the other, it just introducing different concepts.
So let's start on this one. Uh, so many other candidates and you're sitting on the basic science Viva again, not on the adult reconstruction. And I show you this. So what is this, please? Can you tell me what this is? This is a project to do the referencing. Yeah, the numbers at the bottom, starting from two, three, 4 and 5 correct, are the ones we are just to get to achieve the posterior thing.
That's fine. Thank you. So in other words, this is the correct word for this would be this is a sizing jig for the femur. Now, everyone for the exam, right? I want to give you this point that in the vivus, Zubin and everyone else, you will be shown a photograph. And that's what it's called as a sitting question now for a sitting question.
There are no true marks now. Whether Zubin, you got it right or wrong, I would guide you to what it is. So let's suppose you didn't get it wrong. I don't want you all to panic. OK, so it just the set in place. So I'm telling you this is a sizing jig for my femur, and I'm telling you, Zubin, that there's one whole thing, right? Lateral here, and there's another whole thing, right?
Media so they're not at the same level and any modern jig will be at a different level. Can you tell me why that is zooming? So these holes are at different level in order to achieve a. A rectangular gap, because if we. Because if we don't use this, these holes, then we can put our component in internal rotation. Mm-hmm So why do you want that external rotation? I agree.
You want the external rotation and all modern jigs will incorporate that. But why do you want that, zubin? It is due to the anatomy of the posterior epicondyle. Mm-hmm It is because in order to, I want to achieve a rectangular gap. OK, so I would say Zubin for this one. Start by saying and I just now this is I'm giving it the right answer to introduce the concepts.
So the first thing you say that this is a sizing, it doesn't matter. We knew it or not, then say yes, all modern jigs will have it at about three degrees of giving a degree of external rotation. You agree that's what the jigs will do then you say. Remember the same way? Try to answer all questions. Let's say it's a kneeling or a femur or a hip replacement is what is your goal?
So say my goal in hip and knee replacements is to balance my flexion and extension gaps. Is that correct? Is that a good phrase? Yes and then say, I need therefore a rectangular slap both in extension and inflection, right? Yes then say, however, however, and I do my knee replacement. So this is what when I do my knee replacements, I do know that anatomically in the Virgin tibia, so in an uncut, in your tibia, in the world there, you agree that there's a three degree, very, very slope in everyone.
Yes Yeah. Yes, so you can say then the Virgin TBA, there's a three degree of various. However, when my goal like, what is your goal to balance your flexion extension gap? However, in practice, all surgeons will cut your tibia. You agree at 90 degrees to the long axis of the tibia. Not at three degrees. Correct Yep.
And hence, I need to dial in and that's the correct word again. My three degrees, which is done on my femoral side by external, shouldn't be incorporated, right? So once again, you were right in what you were saying. But just keep in mind that it is the reason for that is the problem or the issue on the tibia. Right, OK. Most surgeons will say your answer was very good because you immediately said it's the getting your rectangular gap, however, and this is the, however, is that most surgeons, when I ask this question in my course or in my course, in Cambridge or in wherever I teach, they always say it's due to external rotation for patella tracking.
It is, but that's your secondary benefit. OK the primary reason is this what we've talked about and then say any further, and that's what I wanted to tell you. Any further correct rotation for that knee will depend on the femoral complete correct rotation. And for that, Zubin, what are your lines you'll say? I do know that I use different lines. Correct we chose the Whiteside's line.
Yes and the. Epicondyle traject, Yes. Alexis, Yeah. So I hope I've introduced this concept again, that very simply, no confusion, if any part of this is introduced to you in the basic science or actually in true life, this is what you're going to say. So you're three degrees on the jig is for your tibia, any other, and you have to make sure you get correct rotation.
And we do know in life we use three accesses and all of you all in the audience. And Zubin, you remember, the answers would be the common one would be what, 90% or 80% surgeons would use the epicondyle traject epicondylitis claw palsy axis. Yeah, correct. So most of us will use the posterior condyle. If, however, there's any problem of where which happens enough, for example, of alleghany, we will not use that.
Then we have to use another axis. And you can use the epicondylitis or the Whiteside's line, right? Happy with that, Zubin. Yes OK, now for us, is there anyone else volunteered or can I carry on with Joe or zubin? It's something like this. So yeah, we have. Mohammad egawa wants to chat also.
OK, so if you don't mind, can I see zubin? Thank you very much. That was fine. Absolute pass for what you've said. You're welcome. And I, Mohammad, Yes. Was you? For us, is it clear, are we seeing both of me and the end? Is that all right for you all to see your presentation?
Very nice illustrations to display the concepts and we can see yourself also when you talk here. Thank you. So, mumma, thank you very much. Now, once again, once again, this is you're sitting with me on my basic science vibha table. Yeah and I'm asking you a question that I reserve all my patella. So I'm asking, what am I doing here?
Can you answer me? You are sizing the battle, correct? So I tell you. Thank you so much. So once again for everyone, this is my second question. All right. My set in question by setting means I'm not going to mock you on it now. I'm going to ask you a question that I reserve all my patella.
And you've joined me as my consultant colleague in my hospital and I'm asking you, are you going to resurface all your patella or not? Or some of them? Please tell me what your answer would be and what do you do? This is a controversial issue. I work in a hospital, which where all the consultant doesn't don't resurface the patella. And as a hospital, I work with a consultant.
Here he is researching all the Bathorly. Excellent So what will you do? But in my opinion, I will go for resurfacing. Why? because it will decrease the risk of development of Anthony pain after the knee replacement. Yeah thank you for that great moment, at least this is a common question which most people may be asking, and it's a very difficult question to answer.
Do you agree? Yes yeah, because you've been an examiner or, you know, you've done so much training, do you agree this is a reasonably common question which stumps people? Yes, it's one of those difficult questions because there isn't a real one correct answer for it. And the candidates just need to have one answer and back it up, basically. That would be generally, but I agree with you, this is a question of yes, which which which is difficult to answer from all our sides.
So I would like to introduce this concept that in orthopedics, in we go by 3 studies and use these terms all the time. Mohammed uses them for trauma, for hip replacements, knee replacements, kneeling, et cetera. What we look for is long term implant survival studies use this phrase OK, so you can say that's one. The second study we look into is patient reported outcome measures.
You agree. That's all we want to know. And the third is laboratory based studies. So this is a good opening line. So if there's a controversy of topics, for example, you're right, there's a controversy in the world for knee replacements for patella resurfacing in hip replacements that may be cemented versus one cemented.
It's best to start off by saying very clearly, I do know that there's a controversy in surgeons in the world. So no, that was correct to say. Second, we say, however, because I practice evidence based medicine. Are you happy to use that word moment? Yes, Yes. So you can see because I practice evidence based medicine.
I do know that at the present time, there is no true literature, which which says there's a difference in long term implant survival studies. If you resurface or not, you can say there's no true patient reported outcome major studies which say Yes or no. And there are no laboratory based studies, so you can start with that. So start with the usual line, then say, however, because it's the basic science Viva you can say.
I do know, however, that the patella is important for what quadriceps function. All right, so that's your second phrase you use that I do know the patella is important for quadriceps function and in say, I do know that the height of the patella is important for that to optimize that correct moment. Yes so happy with these statements. So say the basic thing.
I know the patella is important. And I do know the height of the patella is important for that. Then proceed and say, let me draw you a diagram of the forces around the knee. So you draw a patella, you draw a quadriceps tendon and you draw the patella tendon, right? And then you say, I like to resurface the patella as I want to recreate the height to optimize quadriceps function.
Or you can say, I do know that re-creating patella height can help in quadriceps function, but is not borne out in studies. That's why not do it. So the answer is not whether you do it or not, it's whether you do know what the role of the patella is. You get what I'm saying. Yes, Yes. This is very difficult. Yeah, but do you get my concept that it's a basic science Viva and it's, you know, all of your ROU he failed me because he's a research officer.
He failed me, you know, nothing. It doesn't matter what you do or not, as long as you know, there's a concept which is controversial. And secondly, I'm leading you to the basic science part of it, where you should know, do you agree that everyone should know why the patella exists and you should know that the height is important, you know, for quadriceps function, right? So that's all the concept is.
So happy with that. Yes so that's how you'll answer resurfacing Yes or no. Right so thank you, moment. If you think now this is an easy one, so moment, I may just stay with you. You joining me in my hospital? Would you use a cemented or cemented implant? Um, almost all total knee replacement. I was involved with was cemented because what might stick to my three words?
Just say that at the present time, the world richer does support long term implant survival studies correct with segmented implants, right? Yes, you can say that you can say that, yes, they are very clear, good documented patient reported outcome measures and hence I user cemented me right. So there is no controversy. At the present time, 90% of surgeons would be using segmented implants for the reasons which I give.
Yeah Yes. And which cement would you use? Which type of cement? You can say this is mind. Just remember the word once again, this is to get a 7 or 8 for everyone in the audience say I will use a cemented and implementing and you say the word is a standard. It's not say I'm sorry, it's a standard viscosity cement, so you can say it's a standard viscosity.
In other words, you do not use low viscosity cement in knees sometimes. Sometimes we use medium and sometimes we use high viscosity. Yeah, but the correct word moment, if you just do it, you know it's standard. Yeah so in the world, we have standard viscosity. That's exactly what you are, right? We use standard, but we never use low.
So you know that, you know, use low in hip. So say it for now. Happy with that. Yes and the gold standard, therefore, at the present time, supported by evidence based is your. Yes now everyone. This leads nicely to a next. Tell you how I would like this concept on this question answered.
So so this nicely leads to which we would use and why. OK so I would say, and I'm just giving you an example. I use a posterior substituting total knee replacements and you can use the word. You can see the name example PFC sigma. It is cemented and I do a patella resurfacing or and I'm using the word. Or you can say I use an Austria retaining total knee replacement, which is a Zimmer knee.
You can see that or a triathlon knee, which is Stryker. I don't mind. It doesn't matter, but you see what you use. It is cemented, but without patella resurfacing. All right. And then but you have to say why you do it. OK, so say the reason I use either it doesn't matter is I need a knee system. And this is what I want you to say.
I need a knee system, which can cater for all anatomic covariance is a good phrase to have more. So you're saying that I want the knee system which can be there for various needs, various needs, et cetera. Happy yes, we need to, and I can say, yeah, then I can say I want a system which incorporates, stems, augments and offset grace for complex needs. You want one system leading to another. So most of the modern systems have that, but that's the reason we use it, right?
Third, you can say I want a knee system which incorporates my philosophy of balancing, and we don't have time because I only have 45 minutes, but I'm just introducing. That is a good time to know in your mind, in your preparation that you have two or three lines on how to balance a knee, right? So you know you're going to prepare that moment. OK, so you can say I need one knee system which allows that. Then say I need a knee system, which got a proven track, records for long term survival, and this is where you can go to your enger for the knee or the hip you want to use.
And then say, I need a knee with a proven track record for outcome measures with a high Def reading, so all this in 30 seconds to 1 minute you've scored a seven or eight. Yeah, rather than just saying, oh, I use this and not knowing why, so I've tried to distill out, I try to put you six points on which you talk on four joint replacements. I'll be with that moment.
Yes OK, thank you. Ask anyone. Thank you for a moment. Very good. Thank you for that. Anyone else for us? I think this is the gold standard, the method of how to answer this question about any implant. Isn't it any implant to use?
You could use this method of answering the top rather than waffling around. So, yeah, so what if? Um, is the. OK, so now on my next one. I'd like to introduce terminology. So so far we've introduced a concept I can't like. I said I have there are many other concepts like poetry substituting retaining gap.
Believe we can do it at a next time, but at the present time, let's go onto terminology. So the three terminologies I want you to know is constraint stems and leaves and augments. So happy with these three phrases. So anyone for me, for us to just ask, yeah, do you think there's a difference in? Tell me what you understand by constraint, if you don't mind. Actionscript mean that the implant providing the stability to the joint.
Correct, yeah, it's a very simple, correct way of saying it and therefore just tell me how you go higher up in constraint. What are your levels of constraint in knee replacements? First one is the unique Andiola, which are least constraint, and then in the epicondyle replacement, the cruciate retaining is the first and then sacrificing that is to stabilizing and then where work is constrained.
And then hindered me. Fantastic so that's a very good answer for you as you agree he straight away on to a higher level of 6 directly and use the correct words so mom would stay there. But for the remaining audience, I just want this concept to be there that I know even in the Ngo, they talk about post-recovery retaining and peas being different in constraint, truly. And I'm looking at the true neo kinematics.
The medial lateral stability should be the same for both and why I say this is important as a knee surgeon that. I'm not introducing the concept now, but let's say you were talking about substitute of a BS or a knee, of course, retaining or substituting need. Don't say that I will use a positive knee because my balance was not good. My message I want to give is balance has to be perfect for medial epicondyle for both types of knees.
So don't fool yourself or don't fool the examiner by saying, oh, my balance is not good, let's why. Let me use a BS that's the message I want to give, right? So that's one. And the next level up is the. Correct word for everyone. I want everyone to use the correct word, which is a partial various well, guess constrained needs. OK and this is the terminology, which is correct, and the next level up will be a hinged fully constraint or a hinge rotating hinge.
So tell me, when do you need more constraint? Moment, when do you want to have more constraint? It depends upon that our ligaments, ligaments are intact or no, the flexion extension gap, which we are doing by doing that, if we can still retain the stability of the joints, then we will not use the skinny if, OK, what about with bone loss? Interfere with that or not necessary?
Yes, bone loss, soft tissue loss, both will be common. The good point. I mean, good, you mentioned that. But now I'll give you a point, which is important for the whole audience to understand. As a knee surgeon, I'll tell you and also on your level. So the first thing you say that when you need more constraint, use a high constraint and it's done only for collateral ligament laxity or an issue or laxity issue.
It's not for severely deformed knees. So when you see a severely deformed knees in the clinic, really deformed, you may have a judgment that you may have to go to a higher constraint, but you cannot make that final answer unless you restore bone stock. That's the point I'm making. OK, so the next question that is your basic science favor, and I'll just move on because of speed. The reason why you get to higher constraint in awareness, where is constrained constraining, which is your next level up from a normal posterior stabilized knee is what more do you want answered quickly?
What is this? This is your. Box this PBS me. Yeah, but is it a sneeze or is it? Exactly so for everyone in the audience, a knees will have a block, which is only so far. So the word you have to use as how do you get more constrained? And this is important in the Bible in case the implant is shown to you.
Moment it is. I do know this is a virus that is constraining because they've got a higher box. Yes, and it got a corresponding higher spine of the insert race. Yeah, with a reinforcement bin. So what are the three aspects will give you more stability or more constraint is a higher box a corresponding higher or longer spine.
The spine is also broader and it got a reinforcement bin. Yeah, forwards, right? Yeah so next we move on to the truly constrain, which is a loss of collateral, which gives you this. Yes for us, I find myself that I'm just about 34 minutes. Can I go 5 minutes more on this? Yes, of course. Thank you. Can I stick with moment because you're answering quite well?
Yeah a moment now I'm going to introduce a concept called so I've introduced so far for the audience constraint, right? And we very clearly said when you need constraint is only for a egawa test laxity issue. And now I'm asking you a question that I'm sure you on your basic science. Viva forget about this. I'm just showing you this. So I tell you, what is this?
This is Colder. This is spine or the stem stem. So everyone in the audience, the correct word for this will be a stem. So I'm asking you a moment not in this because it's a routine, but generally even on a normal knee when I just want to use a stem, why do you use a stem and when do you use a stem? We usually use this term in a highly constrained me.
Fantastic, so you need a stamp whenever you're going up and constraints, so everyone in the audience, Mambo dancer is the first dancer. So whenever you go up in constraint, I will use a stamp. Happy with that, everyone, and you might correct. That's correct. Answer so the answer is whenever I go up in constraint, I will use a stamp. Thank you.
Next, the next one moment. Next one is that when I went this bone loss, we need to stabilize the implant. Correct? now, if, yeah, correct. And if there is bony defect, we have to pass that point defect also lovely. So the first answer to everyone is when I use a stem is when I want to. Whenever I go up and constraint, I will use the stem.
Then you want to verbalize this concept to moment that say the reason stems are used is that you tell the examiner that by using any stem either on a rotating hinge or a semi constrained knee or on a normal need to be play, I increased my surface area of the construct. Happy to use that phrase moment. I have increased my surface area of the construct and say the reason I want to increase my surface area construct is by doing that, it dissipates.
The correct word is dissipates the forces on the bone implant interface. Happy with that. Yeah, Yeah. So the increased surface area of your construct dissipates or takes away the forces from your bone implant interface and prevents loosening. Yeah so that's the reason you use it and say therefore, the conditions I'm worried about is when there's bone is not of the best quality.
So you can say, and that's weaker. So whenever you use a high constraint bone definitively are not large enough for the next step of which I'll come to full bone quality and I do it. I as a knee surgeon, which I take on complex needs. I do it for all those tibial fractures or at moment, happy with that. Yeah, Yeah. And next, and I'll finish with this is.
Now you see this knee, you agree it's very deformed every one moment you agree deforming. Do you believe it's going to walk through your door? Do you agree it's going to be a severe deformity? Yes most of the time and I asked my registrars and Fellows their first line would be, oh, this is a severe deformity. I'll need something. It'll need the first answer. They gave it a very severely constrained knee or something.
No, it might. I'm not saying don't keep it in your background of your theater, but the first, you can't judge that because this issue is due to bone loss. You agree moment. Yes now, do you agree just putting a stem here will not help that bone loss? You agree. Yes, you need something else.
The word I want you to use and I want the audience to use you will use two words I for the last 10 years, use something called up. What? I use my artificial sleep. Yeah so see this here. This is a simple artificial sleeve. Or you can use the word I will use augments which come in the world of steps or.
Ledges OK. Yeah so when you want to recreate or you want bone loss to be better. Don't say if it's mild, you just use a stem correct moment like you said, yeah, yeah, if it's severe, you will use the word tibial metaphysical sleeve. Or you will use a step or augment, augment, but all I think we as knee surgeons have gone a little away from that chin from Mikhail Jean.
He wanted to clarify the rotational element on the femur with, you know, indirectly, I think, just to convey his message clearly rather than be passing it on to talk. Yeah OK. So you mentioned, can you hear me? Mr yeah, thank you. Very well. Yes, we can hear.
Yeah, OK. Yeah you mentioned about the dialing of the external rotation on the femoral component, which is based on the inherent virus of the tibial plateau. Correct Yeah. Yeah so my I don't quite understand that about a slight deformity of the tibial plateau is an angulation deformity. How you can compensate that by correcting the rotation component on the other aspect, or whether it's based on the anatomy of the femoral contents, which is why you need the axilo rotation.
It's a good, good. Yeah, good. You answered that. The reason is this is all comes down to traditional knee replacement philosophy. Now if we have to accept that a normal virgin. tibia of anyone right is in 3 degree of areas, do you accept that at least mikael? Yes yeah, Yeah.
Now that means your collaterals, right, aren't inherently at a different tightness in you because your, you know your variances of three degrees, right? You know? OK Yeah. Now, when we do knee replacements, we want to balance our extension and flexion gaps, right? Yeah now your flexion gap, right? Your flexion gap depends on what do you agree of flexion?
Gap depends on your posterior femoral condyles how much you got and where you cut. You agree with that. Yes right. So now imagine if you don't cut now. Now the next point, therefore, to clarify your point is when you do your tibia cut, you agree that we cut the tibia, not in 3 degrees, because most people don't x-rays what we want to do at 90 degrees, even though it's not the Virgin tibia, because that's we surgeons cannot be so good to cut at three degrees.
You agree with that point. Yeah, we got it. We cut it perpendicular to the egawa test. Yeah, and that is three degrees away away from what the normal human nature has given us. Correct? Yeah. So therefore, in flexion, the only way to balance that part is to cut your distal femoral epicondyle in a different amount.
You agree what you've got because now you've got a 90 instead of 3. So those people who propagate this new concept called, you know, anatomical knee replacements, which which is, you know, they say will cut out. You know, it doesn't matter. You can cut your tibia, you're in there. The answer is that we don't have the skills. Yes, with robotics coming in, we may be able to.
But as a surgeon, I've done thousands and even my colleagues have done even more than me. They can say they'll never cut to 3 degrees. You see what I'm trying to say. So if we are cutting, you're 90, we need to recreate that. So Thanks for asking this question and I hope I have clarified it to everyone in this manner. OK Yeah. OK, thank you.
Yes, thank you. That was very clear. Thank you for your question. Question that came in from Rajan. He's asked, what's the difference between a sleeve and a cone? Yeah, I would say I leave this to who's asked this. Rajan, yeah, Rajan, I would say, Rajan, thank you for asking this.
If you ask at the FRC board level, there are some questions which are we need to know, and there are some questions, which I call fellowship level questions now for us may agree with me that truly saying, knowing and knowing the difference between cones and sleeves is something which I know as a surgeon because I do it in complex surgery. The difference is that the metaphysical sleeve incorporates the entire metaphysics.
All right, and the stability and in growth happens because of this metaphyseal fixation throughout the metaphysics and the cone will be used within that area, but it can be used as a semicolon or trabecular metal, which can also incorporate to make up bone issues, not necessarily only in the metaphysics. All right. But I don't think I mean, I'm answering this as a knee surgeon, but Faraz will agree that as a concept for FRC sort, it's not an important concept.
All you know is a cone can be used interchangeably, but it can be used also for only parts of bone which need to be looked into. Yeah, but I only use a tibial material slip if I have to remind everyone. When you go for their first case exam, you test it at day one consultant level and they one consultant is unlikely to be asked to put them to do a knee replacement with cones and sleeves and things like that.
But you're expected to know the principles, obviously, and you say exactly supplement this or with the bones of steel. So I wouldn't expect that to be drilled into this any further. Yeah, that's why I don't want to take it more now for everyone, for us, you know, just as a concept, it's done for bone loss, and I think that's a good enough answer. If there's one more question from Norman, he said, I think you went through this in your presentation, but he wanted clarification on how do you define constraint?
How do you define constraint, what is exactly constraint and there stability given by the implants, the inherent stability given by the implants irrespective or dependent on the soft tissue envelope? All right. Is that? Yeah and therefore, for that, I would say need to know that the levels of constraint.
And you can say after the posterior cruciate retaining and your substituting knee replacement, which are the standard knee replacements in the world, the next level up for constraint is a partial various well constrained knee where the constraint is higher. And that is an the next level up would be a hinged knee. Yeah, I think other questions here are towards revision because it's difficult concepts.
But again, if you get in the exam, if you get to that, that's fine. You definitely pass the question. Mm-hmm And we worry too much about that, so next, we have another question about the tibial slope and how important it is that someone is going, you want to be clear, clarified whether increased tibial slope increases the flexion is it? How much is it recommended 0 or 3 or seven degrees?
Good question. Can I who ask? That is a very good question and I can answer. I mean about. So no. Thank you for that. Let's start first by because the target audience of this is farces and passing. But obviously it's very important good concept to have as surgeons because whatever we talk about is in real life.
The answer for this slope right is, first of all, you have to say that if you're using a posterior cruciate substituting knee cruciate substituting knee, you do not have to give a slope because the post and the Cam. Meet together at a particular flexion and you get a reliable or reproducible flexion, OK, in a posture most requested retaining knee.
Yes, there's a degree of slope needed to recreate your flexion. Now I am a true or straight cruciate substituting knee surgeon and all of us in Harlow, all because of all-irelands and our philosophy of posture because of a knee. Only now the reason why we don't give slope in a knee and you don't need a slope knee is that you agree that when you're cutting your tibia, you put your jig on the front of the tibia.
You agree. Yes Yeah. Now, if you know where the true front of the tibia is, then when you cut your proximal tibia, you get a perfect cut, which is not in Vegas or various right, but in real life. When you put your jig onto that front of your tibia, you agree your patella tendon, your tibial tuberosity. Everything is biasing you, not on the front.
True front of the tibia, it's biasing you more immediately. Yes Yeah. And therefore, when if you put slope right, and then you cut, you are propagating or making your values where it's got worse, so you choose your two Devils. You want to have your values where it's got worse. No, because posture, your lack or posture immediately if you have a slope that becomes worse. So therefore, I don't go for a particular slope, but make sure that we don't have any upslope.
OK, so the answer to your question is it makes a difference in the two knees you're using in a posterior cruciate substituting knee. You don't necessarily need a slope. And the reason why that could be advantages is that you're cutting in the front of the tibia, but you do want to cut and give you a values fairness issue with your gut. But in a posterior cruciate retaining knee, yes, there's a degree of slope required, but I'm telling you as a practical knee surgeon, reducing slopes, you know, saying three degrees, seven degrees is a lot of you have to use some slope.
But getting it exactly how much is not reproducible unless you're using robotics or computer typekit. That's my practical answer to you. I said, that's enough. No, sir. Yeah, thank you. Thank you very much. I can. The clarification?
You ok? Yes lovely. Yes, Yes. Thank you. Thank you. Thank you. So we have next question from ative and it is a reasonable question. I think he wanted to make sure he's using the right terminology.
When he answers, he wanted to know the difference between constraint and conformity that obviously completed two different aspects. I think he wanted them clarified. Conforming is a very important word. I didn't want to introduce it here because I've not that too many concepts for, but that would come under the heading of Austria cruciate substituting versus retaining knee.
Now in that, you know that there are two types of polley's which are different in the retaining and the substitution you agree in the retaining, you do not have a Cam and post, right? Yes and in. Yeah correct. You don't have a command post in your retaining now in your regaining knees when originally 30 years ago, 20 years ago, that design was called a flat design.
You agree with it? Yes Yeah. And we realize that flat designs did cause more wear, especially especially in the CR knees. Right? so over years, the new poly is called a conforming poly, right? So at the word conforming is a word you use when the police is given to you in your hands.
Or when you as a practicing surgeon, I do know so you can say modern polyethylene are conforming. So you can save and pick it up, you can say this is a modern poly. I know it's conforming while the old ones would have been flat on flat designs, which were not good. So that's where I would like you to say. So the message would be conforming is a word for polyethylene.
All modern new systems have a conforming poly. Vote for us as well as c.r, but is more important for your Sr. part of it because in the old days, the flat cars were way more. That would be my answer. Thank you. Happy with that. Thank you.
That's lovely, thank you very much, I think we have Abhishek who wanted to ask a question about the longevity of the constraint implants. I'm not sure exactly what he wants to know about it and how relevant it is for, I think I think for us, it's relevant to a degree that, let's suppose examination your exam an X-ray with, you know, that it's a constraining plant, right?
You see it or he gives you a polyethylene or implant, which, as a constraint. He may ask you that why does this not last in studies as long as your normal knee? Yeah, that would be a basic science level. And therefore, you can say that as the constraint goes up. The problem happens is that the same words are used before that the forces on the metal bone interface become worse.
And I need to dissipate those forces. And therefore, if I'm using constraint, I need longer stems to dissipate those forces. And therefore I do know that the long term survival of them may not be as much as your primary knees, but with modern knee techniques with more than knee metallurgy. We are hoping we'll get that, so that will be a fellowship level. But what he was asking for?
You need to know that the higher the constraint, the more you have forces on your correct word metal bone interface or cement, bone interface, whatever you want. Thank you. How many ask questions about anterior and posterior referencing? He wanted this also clarified, and that was the difference between India and Brazil referencing. OK that the first thing to tell someone and once again, ferrous and fall.
You'll agree that no one is going to ask this question directly at the physics level, right? I mean, it's a more practical knee surgeons rather than a concept. But I think it's important to know because all of your audience are going to be doing knee replacement. I mean, you teach good concepts. So the first thing to say is anterior and posterior, referencing both of them reference off the jig.
Right? this is your jig. Both of them sit on your posterior femoral condyle. So that's the first message I want to give everyone which everyone gets confused. So the lugs of this will sit on your condyles happy with that. Everyone that you sit there. Yes is that the outrigger? You know, the front part will fall on the front of the femur. Yeah, that's on your anterior cortex.
Now, the issue of entry and postural reference only becomes an issue if you're between sizes. So if you're a straightforward three, it doesn't really matter whether you've done a posterior referencing or anterior person. All right, because you're going to be using a three implant and with modern systems with more and more sizes coming in, this issue of anterior and posterior reference is becoming less of an issue.
So that's the fundamental message. OK but at the but still in posterior up referencing what we are saying is when your outrigger falls on the front, you see that it falls in the front of the femur. I'm sorry, it wasn't part of my talk. That's why I don't have it to show you, but it folds here. Where it falls gives you a number. Let's say it falls here and it says it's a two.
It's not an issue, but what happens when you're between sizes? That's when you have to decide whether you want to violate your. Back of your knee, that's a posterior part of me or the front of me. So with a down referencing with a down referencing, you're telling yourself that you will never notch the fever. All right, so I can repeat again with people who use an A down referencing.
You're telling yourself you will never notch the FEMA if you're a posterior up province in which I am, that's why Zubin works with me, picked it up that we in Harlow, everything is standardized. We only use apostrophes up. We are telling ourselves we'll never violate the flexion gap. All right. So the two concepts. And I think I'll stop there.
I don't want to make it too complicated because I don't have slides to show you. Is that a.? Posture referencing only are important if you're between sizes. If you're a down referencing, you're saying you will never violate or never notch the femur. If you're a posterior presence. You're saying you will never go into or violate the flexion gap.
And these are the three messages, but I would say is important for this. One more question from Norman he's ask about in. Christian sacrificing knee replacements. He said there are two types a stabilized and posterior stabilized. Is that a concept that we need to worry about for the first year or that you need if you're sacrificing your posterior cruciate, then you will use the correct word is a posterior cruciate stabilized knee where you use a box?
Yeah, and a can. But there are some surgeons, and I don't know whether this is what he's asking for, the sacrifice, the. PCL, right, but they don't necessarily use a posterior cruciate knee. They use a CRT with a different type of a insert, which gives this degree of conformity instability.
Now I'm very clear all the 1,000 needs we do in Harlow, we have standardized, we get fantastic results. We stick to 1 knee, so we lose only post-trade with substitute winning. But I think this is what he was asking about. But once again, for the audience, I don't want to confuse it by going in doing anything more. And one more question is, is congruence see the same as conformity as far as knee replacement surgery?
To a certain degree, you can use them interchangeably. But for the polyethylene, let's use the word conformity of the. And, OK, you wouldn't use congruent, see design. It's a correct you can use it as interior, but it's a design. Philosophy is congruent. And the polyethylene will be. Yeah thank you, Mr Mike Zavala. You know, you spent all this time considering all these questions and answered them very nicely and carefully.
Everyone who's attended a very appreciative of your efforts. Thank you. You got a couple of case discussions, isn't it? Yeah and then after that, we'll put that to use, yeah, sure, sure. And I hope for the audience, I think all the questions for us were very relevant and I think I hope I didn't. I think for the people giving the example, having the concepts, I think these were important we touched upon.
But all what I gave in my talk is what you need to have your delivery on your verbalization. So that's the message I would like to give. It's perfectly level 4 pitch for the level of the exam. So just before we start again, I would like to encourage you guys to make the best of this opportunity of having a private practice with the experienced examiners we have. So anyone interested in have in being asked questions being put in a hot seat, please raise the hand symbol.
You are interested. No one is judged and and as you say, it's everyone is welcome. So for four, the first case, we have armored. Um, yeah, so he he's kind of discussing this case with yourself, your reconstruction people, not your basic science on it. Can you hear me? Yeah, I can. Yeah and tell me these are the X-rays which and you agreed.
It's a common scenario. You'll be shown difficult hip x-rays, difficult knee X-rays. So my rate of what we're doing now is just to tell you how to talk about a complex need X-ray shown to you. Yeah, that's what I want to show you. So tell me what you see here. Yeah, so. So this is a plain radiograph of a knee. The there's lots of.
The most obvious abnormality is the severe osteoarthritis with a significant bone loss. What seems to be to me on the femur component, specifically on the lateral femur combined? Yeah OK, so that's on your AP, right? Yeah, that's right. So stick to your app and just tell me once again, I didn't hear you too well.
So on the app view, the most important abnormally start with that is sorry, significant arthritis. And there is a significant wear and bone loss on the lateral thumb as well. But yeah, yeah, this is what you mean. OK and do you think there's any bone loss on the medial tibia? Uh, yeah, I mean, it's difficult to get it, but there is some degree of effect, so that's the correct answer.
So you say this is that would you commend the degree on whether it's a very sort of elegance? Again, it's a deformed knee. It's the correct word, would be it subluxation laterally is that you are happy with that phrase so laterally, but to a certain degree, it comes in the realms of a variation. Do you agree?
That's right. Yeah, Yeah. So this is where you get confused, sometimes with gross changes. So let's have a let's have a plan for you and for everyone. So actually shown, do you always start with the app? Don't go jumping from app to a lateral? That's the message. OK, so even in a hip?
Don't jump from your app hip to the lateral hip. All right. So are you going to finish one X-ray and then move to the other one? Happy with that. I have it. Yeah so on an app, you'll say this is an app radiograph new green. Is it a short leg film or is a long leg view?
Well, we have a short view, should we have any, so the correct word is a short leg view, so I want you to always know for low limb as well as upper limb, every X-ray got a terminology, which is correct. Please use that it automatically gives you a four or five. So if it was a hip, you say it's a pelvis or both hips or it's a pelvis, you say it's a pelvis. If the shoulder you see, it's this view that view, right? So this is an AP view, which is a short leg view.
The most common abnormality and speak, you know, a severe significant degenerative changes. Happy with that. Then say from what I see on the tibial side, there is a definite tibial cellblocks, correct? Yes and there is a degree of varus deformity. Yeah radiology can then say my areas of suspected bone loss use these words is that I'm not sure, but there may be some loss on the medial side, but I feel there may be some loss on your bilateral framework on that.
Happy with that. So that's all you say and then say without having a history of any previous fracture above and below, I need that clarification or I need long leg films. Just you have to say that what I mean, because you can't not know what's happening above and below these five statements for this. Yeah and then you go to the lateral the lateral.
Just speak to me about the lateral. Yeah so again, it's a severe degenerative changes with what seems to be a loss of bone loss as well. Again, so when you say a bone loss, what can you say bone loss on your lateral, you normally see bone loss and lateral. Not not in this. No, not really. Laterally, no.
So what do you what do you see for one, you see whether they are posterior fights, correct? Yeah so you agree there is a huge posterior spider. That's right. Yeah so you can see that you agree that there's a significant patellofemoral arthritis. Yeah and you think you can see the joints, you think there's a joint where there's no joint, but it's difficult to see on this view, but it's very clearly a stiffening.
And I'm telling you, when this patient comes, it's zero, maybe 0 to 5 degrees. Yeah, Yeah. So so that's what you have to pick up. Yeah so there is going to be an issue of it's not a few joints. There's a degree of ankylosing, there's a significant posterior device. Yeah now if you have to approach this dynamic, so now I'm going to ask you fine.
Thank you very much. You've clearly passed on this now. How will you What do you do next? So as you highlighted earlier, sir, I would want to know if this patient had any previous fractures to the proximal female or the distal tibia. I want to know the detailed history and examination history.
I want to know the severity of pain, the level of mobility to know if he has passed medical history to the vets for that. You're telling me this, but I would just tell you, just because I'm trying to distill all the teaching rather than your avivah, if you don't mind, is use a phrase that, assuming this patient, I take a complete history examination and all quantitative measures have been exhausted and this patient does not have any definite contraindications to joint replacement surgery.
My feeling is that this patient is a candidate for that, but I do agree it comes under the realms of complex surgery. So, yeah, so rather than saying otherwise, two or three minutes goes away and saying, I'll take this to you, I'll do this. I'll do that. Just use this phrase. Assuming all exhausted and exhausted, I've taken a history, examine them and there are no contraindication to join in brain surgery.
This patient is a candidate for that because that's what we are doing. Thank you. Carry on. So what are we going to next summit? So I want to examine him, so assess the how stiff his knee would be in terms of exposure, what difficulty I'd be facing. So tell me all your problems.
So exposure? Yes, carry on. Thank you. Carry on. So exposure in terms of laxity and the medial and lateral collateral ligament may be assessed preoperatively. But I think what will make a big difference is when you do a intraoperatively in this case. Fantastic very good answer.
Thank you for that, Gary on. In terms of any previous cause, the patient may had, Yeah. OK, so now tell me the only exposure is going to be an issue. And that could be due to previous cause or the fact that it's, you know, you've got this bony type of issue of a 0 to 5. So you agree the exposure is going to be an issue. Don't you go in?
Tell me about your what are you going to next from your bony point of view? So let's go in and you don't have an issue on your femoral site. Let's say the femur canal is fine, right? Correct that's fine, I say. If so, once assessed the exposure. My next thing is assess the bone loss. Steve, we've highlighted that there is a bone loss on the tibial side, on the medial side.
Do you think it's going to be huge? You're going to be it's going to be as bad as the earlier X-ray I showed you or not as bad. As Dexter has previously shown. Yeah, I would have thought it's. And you agree this is much more in very dramatic compared to this potential. And yeah, so in your gut feeling is yes, you're worried about it, but you know that it may not be as bad as, yeah, so remember and I talk, what?
What are you going to use if you have to use something? If we are worried about bone loss, we're going to use an implant with a stem and sleep stem. Yeah so first start with the stem because small amounts of bone loss, you agree, can be tackled by just stemming an implant. Right that's right. Now you are very right and actually you picked it up, which I probably yeah, I thought of it, but I didn't think too much of it agree on the female as well.
If there's not too much, we requires a sleep. What are you going to use? As a again, I'm going to stand anyway, right? So the issue with difficult needs is a talk about where the bone losses. We talk about your lateral, then divide your problem into four parts. A is exposure. Is it going to be difficult or not?
So this is going to be a difficult exposure. So say that be make sure that you don't missing a microfracture or a deformity above and below. Happy with that. I might like you said C is look into the bone loss, where and when, how to tackle. And for. After I tackle that, I will check the integrity of my soft tissue envelope.
And if I feel I do not need a higher constraint, I will not need a higher constraint. I'm happy with that. Yeah, that's right. Is your gut feeling that you lead been screened for this or not? Well, I think the fact that is stiff and enclosed is unlikely. Yeah and let that be an issue. OK, let this issue that once you re-created your bone loss.
Have you got to align me without any issue of the laxity? Yeah, Yeah. OK, so this is what I've done. So all what you said is correct. You agree now. I put a stem on because I was a little concerned, like you, about my integrity of my bone, on the femur. You agree on my tibia. I put a stem on why, because I was a little worried about my integrity.
You see that there? Yes but do you agree it would have been overkill to put a sleeve, right? Yeah and you agree. Once I put all everything in, I did my integrity for my collaterals. It was perfect. Did I need any higher constraint? No, no, I didn't.
So that's how I will say, OK, I bet. So I think you answered it very well for us. You agree he would have definitely passed with a good answer. It was very good answer. And also your feedback was excellent and highlighted the main positive aspects, as well as how to improve the answer. And I had a question for the boss with the amount of subluxation, the constraint when you went inside, what is the state of the collaterals and how did you tackle that?
You see, the sub blocks will be there. The issue of blocks, it's there visually as well because of bone loss. All right. Correct yeah, it's there due to tightness and most people feel and once again, whereas with your permission, this is a true fellowship answer. Yeah, it's not going to be tackled at the seesawed level, but I'll answer it for you.
Is that at the true when you see lateral sub blocks, but in a various type of me? Yeah, those are the ones where I actually divide or do something to the popular discontent. So most people feel that when you're doing a company standard is tackled in the value need. My feeling is most of the time I've done it in my complex, various knees. All right.
So that's one question. And my question of integrity of collateral is very clear. I build up. I cut where I want. I build up my bone to make my tibia and my femur, where it should be without excessive bone loss. So I'll never use or insert more than 10 12, et cetera once I do my trial, I check my integrity, and if the collateral are fine, that is fine.
It does not need higher constraint. I agree. But when you went in this particular place, how is the collateral? Was it? I mean, was, I'm sure, with these knees as collateral? Well, if you ask my opinion, it was, it was fine. The issue with his knee was due to the significant cost of fights.
So nowadays, collateral, you know, lengthening collateral releases all that we've stopped doing because we have now working very much on Oscar capsule, getting implants at the correct level, you know, not proximal. It's not digitalizing. This is where it is. But the answer is they were fine. Good question.
Even I was I have my back up always. But in Harlow, because of Paul Allen's legacy with Depuy in mind, we have everything on the ship. So so everything of DP is on the shelf for us, you know? So we have it. Thank you so much. That sounds wonderful, I think. I think we just, if you don't mind, we'll put on the excuse now for the first question.
Patella resurfacing offers clear advantages for taking our outcomes in evidence based studies and 91% of you. And said its answer number three. Yes, there is no clear evidence to support resurfacing or not. And next question stems by their own are used in total replacement to provide stability and collateral ligament incompetency, 72% says it's false.
And that's the correct answer. Uh, question number three, low viscosity cement is routinely used in total knee replacement practice, and 89% said falls. And that's the correct answer, so well that everyone who answered correctly, you'll be listening. Thank you, everyone. I hope that was clear. Any questions you want, I can come back to your later if you want.
And I just want to end with very glad to say one of the epimysium in the second edition is just starting today. Got published. So this is a book which covers everything all the senior authors have contributed. It's amazing. And a route very kindly, because, like I said, she is passionate about her role in the UK for providing courses, and she's put this up as challenging cases, it's on the website and which anybody can go in.
The contributors have given these challenging cases give your input and then later on to the surgeons who have given their input will give the answer. So this is there on the website now. There are these books which have been traditional books already available from your UK who they support. And lastly, really as a unit or as an entity, you UK does everything for non-profit making and this is the donations are routed.
Kindly said you could just put these up for her and I'm very happy to do so and thank you very much, Ruth, and for us for this excellent day. Thank you. Lovely, thank you, Mr Mike Zavala. I was a wonderful session. Was very, very nicely comprehensively covered the total concepts of total knee replacements, a buzzword to use how to answer questions perfectly well.
We have all used your methods of answering these questions, and they worked very well for us. So I encourage everyone to try to use the same approach to answering questions related to tenotomy replacement. We have certainly learned a lot from you today. Thank you. The one who participated for all the questions that we very good, sensible questions and they're all relevant. I would encourage participation and interaction during these sessions.
Thank you so much. Thank you both. So thank you. Thank you, everyone now.
Segment:0 .
Good evening, everyone, welcome to this orthopedic teaching session, organized jointly by the farc, a splinter group and orthopedic Research UK. Something else to note, and I will be moderating this session. And to help me is Ruth, the head of education from our UK.
And the speaker this evening is Mr Mahalakshmi mavela, and he will be teaching us about total knee replacement, the main difficult concepts, he will make them easy for us all. The presentation is pitched across a level. Mr Zavala is a consultant, orthopedic surgeon at the princess Alexandra Hospital in Harlow and the Ramsay rivers hospital. And he's special interest in is in lower limb joint arthroplasty, including revision surgery.
He completed his training at the Royal National Orthopedic Hospital in Stanmore. And has done this fellowships in North America. He's a co-director of the formerly known Royal College of surgeons, FARC escorts, and he now runs it as mal extremophile chairman of RCS ortho Viva Cos. It's very popular course. Many candidates who pass the exam have been through this course.
Mr mavela is an invited speaker on several national and international conferences. He's a faculty of several teaching courses, including near replacement courses at Harlow and Cambridge basic sciences course and various other instructional courses. Mr Mark Zavala has been working with us actively on the FARC splinter group since its inception. And he's been involved with us in online teaching and webinars for the last 2 and 1/2 years.
So we are very pleased that he's kindly accepted our invitation to present tonight. As you can see, the session includes a lecture presentation, which Mr Maxwell is very keen to run interactively, which is which worked very well in the past. And there will be some discussion there would discuss the concept, followed by some case discussions, and at the end there will be some.
There will be three interviews to test that you've been focusing with us during the session. If you have any questions, please feel free to ask in the chat box. The chat option is at the bottom of the screen or and also after the session, there would be 5 hot seat practice the hub. The Viva practice is not recorded and you are all invited to take part.
Anyone interested to take part, please raise the hand symbol that you find next to your name. And to the participant list, there is a handsome symbol, which you can raise, so we know you are interested in Viva and it doesn't first come, first serve basis. And obviously, there will ask you, you'll be entitled to have CPD certificates, I will ask you for a survey also, and Ruth will be already been in touch with you about this.
If you missed any part of this presentation, please don't panic. It will be. It is recorded and will be posted on the Force's mental YouTube channel and our UK website. Without further ado, I will leave you with Mr mavela to start. Lovely so thank you for us for that very kind introduction. And I would first like to thank Ruth treadgold and duke, but especially Ruth, who really has the pulse or as a finger on the pulse of all the orthopedic education in the UK.
She really runs her courses like clockwork and we need to thank everyone who has passed, needs to thank her for all the courses she runs. I'd like to thank her very much for that, and I think everyone who's boss needs to thank her and I want to thank her for the invitation as my affiliation. I have been involved with the Cambridge basic science course since its inception. It's about more than 10 years with because do and also obviously they are UK.
So with Ruth, I in my capacity as training for London and East of England, I will be involved with auto hub and East of England websites and all these are going to give talks on which I think only help to improve education in the UK. I really feel that the FARC has meant a group. I need to thank them for the invite and I'm very pleased and proud to say I've been with them right from this inception.
I didn't realize it's 2 and 1/2 years, but all these webinars, which are happening now during the corona lockdown. This group had started and had the foresight to see online Zoom teaching for 2 and 1/2 years. And I think all of them, all the senior mentors who have contributed tirelessly every Wednesday, we continued sessions, all video recorded. I think need to be commended for that. And in addition, of course, therefore, with this new collaboration between our UK and epimysium intergroup, I think it's excellent for all to be educational training, especially for the FARC as autumn international, both in the UK as well as abroad.
So thank you for us for that. So can I carry on with my talk for us? Yes, please. So the way I've planned this and I would like to do it is that we'll start with common FRC is all the questions we'll talk about terminology and in that the terminology which I think you'll get confused with the most of the time people use interchangeably is when you use words like constraint, when you use words like stems and augments, and then we have cases that very kindly put together this format where we had cases.
And that's good. But I want to do it leading on from this lecture. And it's very important that in knee replacements or hip replacements or common topics, we all feel when we go for the exam as candidates or we know that let's concentrate on something else. But the issue is, can we truly verbalize that concept? So it's not for me to talk on this. It's whether all can talk.
So I don't mind going slow. And I think as you all have realized as candidates for topics like hip and knee replacements, you need to have a seven or eight, but you can't get there unless you verbalize your concepts clearly at the basic level. So that's what I want to try to do for this. 45 minutes or half an hour and I don't mind, it's interactive. I don't mind skipping slides or mind repeating slides, but I want everyone, whoever is attended today to go away with at least a 60% retention information.
That's my goal. So let's start with the common policy, all the questions for us, if we can, and just for everyone in the audience, I feel making it interactive is more or less what you will want to know as to what we are doing in the exam. So if you don't mind, I may ask for us to nominate or if someone volunteers to just I'll ask a question. You give whatever answer you want to give.
It doesn't have to be right or wrong. It just starts to introduce that concept to me and then we can take it forward. So I hope that's all right for us. And if you don't mind, is there anyone who you would like to nominate or volunteer? We have Joey here who is interested to be your sort of candidate for this lovely casual introduction. Yeah, thank you.
Can you hear me? Yes, I can hear you. Thank you. So, Joey. And once again, for all of you, all who are in the audience, all of you are preparing. If you are practicing vivas with each other, ask yourselves and tell yourselves, Joe, that are you sitting on the basic science table or the adult reconstruction?
OK Yeah. So in this day, I'm telling you that we are both sitting or I am grilling or am asking you and it's your exam and we own the basic science vyver, not the adult reconstruction. OK and tell me. So you've been involved with knee replacements, haven't you? Yes Yes. No, and I'm asking you this as a candidate, not as Joe said, as a candidate took you tenotomy me on the left is a femur.
And what do these two lines represent? So tell me, what does this line represent? This line represents the anatomical axis of the femur along the longitudinal axis of the bone. And what is this is the mechanical axis of the femur, which is the line connecting the center of the head of the femur, center of rotation of the head. And tell me why this is important when we are doing knee replacements, either adult reconstruction or in the basic science level.
It's important to calculate the vulgar angle to have a Precice perpendicular to because my aim in total knee replacement into is to restore the mechanical axis of the knee. So my distal femoral cut has to be perpendicular to the mechanical axis because I am using an intramedullary guide, which is the anatomical axis to the femur.
I need to have six to 7 degrees pelvis perfect. So I would say, Joe, you answered it. Excellent and at the same time, just now for clarification to everyone in the audience when you're asking questions like this answer exactly like Joe has, but I'll just put it together for everyone. So the first thing you say is Yes. Tell the examiner that the left this line is your anatomical axis.
Tell your examiner that this line is the mechanical axis, then say these two lines are important and knee replacements because and always say my goal of knee replacement is what? So we can tell the examiner and for everyone, my goal of knee replacements is to place my femoral component and use these words base my femoral components perpendicular to the which axilo mechanical right mechanical axes.
All right, so say that that's your goal. Then say, however, practically when I do my knee replacement, I use an intermediary jig or an intermediary rod for my jig. And hence I do know there's a difference between these two, which is between 5 or seven degrees. And hence I dial that and use these correct words, which are impressive. I dial that difference into my jig, which gives me my correct values cut angle.
So the 7 to 8 on this question would be Joe, you were absolutely there, and that would be the words you want to use is most of the time, 90% is intermittent rejigging. I do know that my aim is to 90 degrees to my mechanical axis. Hence I want to divide it between. I know the differential between the two not leading up from 1 to the other, it just introducing different concepts.
So let's start on this one. Uh, so many other candidates and you're sitting on the basic science Viva again, not on the adult reconstruction. And I show you this. So what is this, please? Can you tell me what this is? This is a project to do the referencing. Yeah, the numbers at the bottom, starting from two, three, 4 and 5 correct, are the ones we are just to get to achieve the posterior thing.
That's fine. Thank you. So in other words, this is the correct word for this would be this is a sizing jig for the femur. Now, everyone for the exam, right? I want to give you this point that in the vivus, Zubin and everyone else, you will be shown a photograph. And that's what it's called as a sitting question now for a sitting question.
There are no true marks now. Whether Zubin, you got it right or wrong, I would guide you to what it is. So let's suppose you didn't get it wrong. I don't want you all to panic. OK, so it just the set in place. So I'm telling you this is a sizing jig for my femur, and I'm telling you, Zubin, that there's one whole thing, right? Lateral here, and there's another whole thing, right?
Media so they're not at the same level and any modern jig will be at a different level. Can you tell me why that is zooming? So these holes are at different level in order to achieve a. A rectangular gap, because if we. Because if we don't use this, these holes, then we can put our component in internal rotation. Mm-hmm So why do you want that external rotation? I agree.
You want the external rotation and all modern jigs will incorporate that. But why do you want that, zubin? It is due to the anatomy of the posterior epicondyle. Mm-hmm It is because in order to, I want to achieve a rectangular gap. OK, so I would say Zubin for this one. Start by saying and I just now this is I'm giving it the right answer to introduce the concepts.
So the first thing you say that this is a sizing, it doesn't matter. We knew it or not, then say yes, all modern jigs will have it at about three degrees of giving a degree of external rotation. You agree that's what the jigs will do then you say. Remember the same way? Try to answer all questions. Let's say it's a kneeling or a femur or a hip replacement is what is your goal?
So say my goal in hip and knee replacements is to balance my flexion and extension gaps. Is that correct? Is that a good phrase? Yes and then say, I need therefore a rectangular slap both in extension and inflection, right? Yes then say, however, however, and I do my knee replacement. So this is what when I do my knee replacements, I do know that anatomically in the Virgin tibia, so in an uncut, in your tibia, in the world there, you agree that there's a three degree, very, very slope in everyone.
Yes Yeah. Yes, so you can say then the Virgin TBA, there's a three degree of various. However, when my goal like, what is your goal to balance your flexion extension gap? However, in practice, all surgeons will cut your tibia. You agree at 90 degrees to the long axis of the tibia. Not at three degrees. Correct Yep.
And hence, I need to dial in and that's the correct word again. My three degrees, which is done on my femoral side by external, shouldn't be incorporated, right? So once again, you were right in what you were saying. But just keep in mind that it is the reason for that is the problem or the issue on the tibia. Right, OK. Most surgeons will say your answer was very good because you immediately said it's the getting your rectangular gap, however, and this is the, however, is that most surgeons, when I ask this question in my course or in my course, in Cambridge or in wherever I teach, they always say it's due to external rotation for patella tracking.
It is, but that's your secondary benefit. OK the primary reason is this what we've talked about and then say any further, and that's what I wanted to tell you. Any further correct rotation for that knee will depend on the femoral complete correct rotation. And for that, Zubin, what are your lines you'll say? I do know that I use different lines. Correct we chose the Whiteside's line.
Yes and the. Epicondyle traject, Yes. Alexis, Yeah. So I hope I've introduced this concept again, that very simply, no confusion, if any part of this is introduced to you in the basic science or actually in true life, this is what you're going to say. So you're three degrees on the jig is for your tibia, any other, and you have to make sure you get correct rotation.
And we do know in life we use three accesses and all of you all in the audience. And Zubin, you remember, the answers would be the common one would be what, 90% or 80% surgeons would use the epicondyle traject epicondylitis claw palsy axis. Yeah, correct. So most of us will use the posterior condyle. If, however, there's any problem of where which happens enough, for example, of alleghany, we will not use that.
Then we have to use another axis. And you can use the epicondylitis or the Whiteside's line, right? Happy with that, Zubin. Yes OK, now for us, is there anyone else volunteered or can I carry on with Joe or zubin? It's something like this. So yeah, we have. Mohammad egawa wants to chat also.
OK, so if you don't mind, can I see zubin? Thank you very much. That was fine. Absolute pass for what you've said. You're welcome. And I, Mohammad, Yes. Was you? For us, is it clear, are we seeing both of me and the end? Is that all right for you all to see your presentation?
Very nice illustrations to display the concepts and we can see yourself also when you talk here. Thank you. So, mumma, thank you very much. Now, once again, once again, this is you're sitting with me on my basic science vibha table. Yeah and I'm asking you a question that I reserve all my patella. So I'm asking, what am I doing here?
Can you answer me? You are sizing the battle, correct? So I tell you. Thank you so much. So once again for everyone, this is my second question. All right. My set in question by setting means I'm not going to mock you on it now. I'm going to ask you a question that I reserve all my patella.
And you've joined me as my consultant colleague in my hospital and I'm asking you, are you going to resurface all your patella or not? Or some of them? Please tell me what your answer would be and what do you do? This is a controversial issue. I work in a hospital, which where all the consultant doesn't don't resurface the patella. And as a hospital, I work with a consultant.
Here he is researching all the Bathorly. Excellent So what will you do? But in my opinion, I will go for resurfacing. Why? because it will decrease the risk of development of Anthony pain after the knee replacement. Yeah thank you for that great moment, at least this is a common question which most people may be asking, and it's a very difficult question to answer.
Do you agree? Yes yeah, because you've been an examiner or, you know, you've done so much training, do you agree this is a reasonably common question which stumps people? Yes, it's one of those difficult questions because there isn't a real one correct answer for it. And the candidates just need to have one answer and back it up, basically. That would be generally, but I agree with you, this is a question of yes, which which which is difficult to answer from all our sides.
So I would like to introduce this concept that in orthopedics, in we go by 3 studies and use these terms all the time. Mohammed uses them for trauma, for hip replacements, knee replacements, kneeling, et cetera. What we look for is long term implant survival studies use this phrase OK, so you can say that's one. The second study we look into is patient reported outcome measures.
You agree. That's all we want to know. And the third is laboratory based studies. So this is a good opening line. So if there's a controversy of topics, for example, you're right, there's a controversy in the world for knee replacements for patella resurfacing in hip replacements that may be cemented versus one cemented.
It's best to start off by saying very clearly, I do know that there's a controversy in surgeons in the world. So no, that was correct to say. Second, we say, however, because I practice evidence based medicine. Are you happy to use that word moment? Yes, Yes. So you can see because I practice evidence based medicine.
I do know that at the present time, there is no true literature, which which says there's a difference in long term implant survival studies. If you resurface or not, you can say there's no true patient reported outcome major studies which say Yes or no. And there are no laboratory based studies, so you can start with that. So start with the usual line, then say, however, because it's the basic science Viva you can say.
I do know, however, that the patella is important for what quadriceps function. All right, so that's your second phrase you use that I do know the patella is important for quadriceps function and in say, I do know that the height of the patella is important for that to optimize that correct moment. Yes so happy with these statements. So say the basic thing.
I know the patella is important. And I do know the height of the patella is important for that. Then proceed and say, let me draw you a diagram of the forces around the knee. So you draw a patella, you draw a quadriceps tendon and you draw the patella tendon, right? And then you say, I like to resurface the patella as I want to recreate the height to optimize quadriceps function.
Or you can say, I do know that re-creating patella height can help in quadriceps function, but is not borne out in studies. That's why not do it. So the answer is not whether you do it or not, it's whether you do know what the role of the patella is. You get what I'm saying. Yes, Yes. This is very difficult. Yeah, but do you get my concept that it's a basic science Viva and it's, you know, all of your ROU he failed me because he's a research officer.
He failed me, you know, nothing. It doesn't matter what you do or not, as long as you know, there's a concept which is controversial. And secondly, I'm leading you to the basic science part of it, where you should know, do you agree that everyone should know why the patella exists and you should know that the height is important, you know, for quadriceps function, right? So that's all the concept is.
So happy with that. Yes so that's how you'll answer resurfacing Yes or no. Right so thank you, moment. If you think now this is an easy one, so moment, I may just stay with you. You joining me in my hospital? Would you use a cemented or cemented implant? Um, almost all total knee replacement. I was involved with was cemented because what might stick to my three words?
Just say that at the present time, the world richer does support long term implant survival studies correct with segmented implants, right? Yes, you can say that you can say that, yes, they are very clear, good documented patient reported outcome measures and hence I user cemented me right. So there is no controversy. At the present time, 90% of surgeons would be using segmented implants for the reasons which I give.
Yeah Yes. And which cement would you use? Which type of cement? You can say this is mind. Just remember the word once again, this is to get a 7 or 8 for everyone in the audience say I will use a cemented and implementing and you say the word is a standard. It's not say I'm sorry, it's a standard viscosity cement, so you can say it's a standard viscosity.
In other words, you do not use low viscosity cement in knees sometimes. Sometimes we use medium and sometimes we use high viscosity. Yeah, but the correct word moment, if you just do it, you know it's standard. Yeah so in the world, we have standard viscosity. That's exactly what you are, right? We use standard, but we never use low.
So you know that, you know, use low in hip. So say it for now. Happy with that. Yes and the gold standard, therefore, at the present time, supported by evidence based is your. Yes now everyone. This leads nicely to a next. Tell you how I would like this concept on this question answered.
So so this nicely leads to which we would use and why. OK so I would say, and I'm just giving you an example. I use a posterior substituting total knee replacements and you can use the word. You can see the name example PFC sigma. It is cemented and I do a patella resurfacing or and I'm using the word. Or you can say I use an Austria retaining total knee replacement, which is a Zimmer knee.
You can see that or a triathlon knee, which is Stryker. I don't mind. It doesn't matter, but you see what you use. It is cemented, but without patella resurfacing. All right. And then but you have to say why you do it. OK, so say the reason I use either it doesn't matter is I need a knee system. And this is what I want you to say.
I need a knee system, which can cater for all anatomic covariance is a good phrase to have more. So you're saying that I want the knee system which can be there for various needs, various needs, et cetera. Happy yes, we need to, and I can say, yeah, then I can say I want a system which incorporates, stems, augments and offset grace for complex needs. You want one system leading to another. So most of the modern systems have that, but that's the reason we use it, right?
Third, you can say I want a knee system which incorporates my philosophy of balancing, and we don't have time because I only have 45 minutes, but I'm just introducing. That is a good time to know in your mind, in your preparation that you have two or three lines on how to balance a knee, right? So you know you're going to prepare that moment. OK, so you can say I need one knee system which allows that. Then say I need a knee system, which got a proven track, records for long term survival, and this is where you can go to your enger for the knee or the hip you want to use.
And then say, I need a knee with a proven track record for outcome measures with a high Def reading, so all this in 30 seconds to 1 minute you've scored a seven or eight. Yeah, rather than just saying, oh, I use this and not knowing why, so I've tried to distill out, I try to put you six points on which you talk on four joint replacements. I'll be with that moment.
Yes OK, thank you. Ask anyone. Thank you for a moment. Very good. Thank you for that. Anyone else for us? I think this is the gold standard, the method of how to answer this question about any implant. Isn't it any implant to use?
You could use this method of answering the top rather than waffling around. So, yeah, so what if? Um, is the. OK, so now on my next one. I'd like to introduce terminology. So so far we've introduced a concept I can't like. I said I have there are many other concepts like poetry substituting retaining gap.
Believe we can do it at a next time, but at the present time, let's go onto terminology. So the three terminologies I want you to know is constraint stems and leaves and augments. So happy with these three phrases. So anyone for me, for us to just ask, yeah, do you think there's a difference in? Tell me what you understand by constraint, if you don't mind. Actionscript mean that the implant providing the stability to the joint.
Correct, yeah, it's a very simple, correct way of saying it and therefore just tell me how you go higher up in constraint. What are your levels of constraint in knee replacements? First one is the unique Andiola, which are least constraint, and then in the epicondyle replacement, the cruciate retaining is the first and then sacrificing that is to stabilizing and then where work is constrained.
And then hindered me. Fantastic so that's a very good answer for you as you agree he straight away on to a higher level of 6 directly and use the correct words so mom would stay there. But for the remaining audience, I just want this concept to be there that I know even in the Ngo, they talk about post-recovery retaining and peas being different in constraint, truly. And I'm looking at the true neo kinematics.
The medial lateral stability should be the same for both and why I say this is important as a knee surgeon that. I'm not introducing the concept now, but let's say you were talking about substitute of a BS or a knee, of course, retaining or substituting need. Don't say that I will use a positive knee because my balance was not good. My message I want to give is balance has to be perfect for medial epicondyle for both types of knees.
So don't fool yourself or don't fool the examiner by saying, oh, my balance is not good, let's why. Let me use a BS that's the message I want to give, right? So that's one. And the next level up is the. Correct word for everyone. I want everyone to use the correct word, which is a partial various well, guess constrained needs. OK and this is the terminology, which is correct, and the next level up will be a hinged fully constraint or a hinge rotating hinge.
So tell me, when do you need more constraint? Moment, when do you want to have more constraint? It depends upon that our ligaments, ligaments are intact or no, the flexion extension gap, which we are doing by doing that, if we can still retain the stability of the joints, then we will not use the skinny if, OK, what about with bone loss? Interfere with that or not necessary?
Yes, bone loss, soft tissue loss, both will be common. The good point. I mean, good, you mentioned that. But now I'll give you a point, which is important for the whole audience to understand. As a knee surgeon, I'll tell you and also on your level. So the first thing you say that when you need more constraint, use a high constraint and it's done only for collateral ligament laxity or an issue or laxity issue.
It's not for severely deformed knees. So when you see a severely deformed knees in the clinic, really deformed, you may have a judgment that you may have to go to a higher constraint, but you cannot make that final answer unless you restore bone stock. That's the point I'm making. OK, so the next question that is your basic science favor, and I'll just move on because of speed. The reason why you get to higher constraint in awareness, where is constrained constraining, which is your next level up from a normal posterior stabilized knee is what more do you want answered quickly?
What is this? This is your. Box this PBS me. Yeah, but is it a sneeze or is it? Exactly so for everyone in the audience, a knees will have a block, which is only so far. So the word you have to use as how do you get more constrained? And this is important in the Bible in case the implant is shown to you.
Moment it is. I do know this is a virus that is constraining because they've got a higher box. Yes, and it got a corresponding higher spine of the insert race. Yeah, with a reinforcement bin. So what are the three aspects will give you more stability or more constraint is a higher box a corresponding higher or longer spine.
The spine is also broader and it got a reinforcement bin. Yeah, forwards, right? Yeah so next we move on to the truly constrain, which is a loss of collateral, which gives you this. Yes for us, I find myself that I'm just about 34 minutes. Can I go 5 minutes more on this? Yes, of course. Thank you. Can I stick with moment because you're answering quite well?
Yeah a moment now I'm going to introduce a concept called so I've introduced so far for the audience constraint, right? And we very clearly said when you need constraint is only for a egawa test laxity issue. And now I'm asking you a question that I'm sure you on your basic science. Viva forget about this. I'm just showing you this. So I tell you, what is this?
This is Colder. This is spine or the stem stem. So everyone in the audience, the correct word for this will be a stem. So I'm asking you a moment not in this because it's a routine, but generally even on a normal knee when I just want to use a stem, why do you use a stem and when do you use a stem? We usually use this term in a highly constrained me.
Fantastic, so you need a stamp whenever you're going up and constraints, so everyone in the audience, Mambo dancer is the first dancer. So whenever you go up in constraint, I will use a stamp. Happy with that, everyone, and you might correct. That's correct. Answer so the answer is whenever I go up in constraint, I will use a stamp. Thank you.
Next, the next one moment. Next one is that when I went this bone loss, we need to stabilize the implant. Correct? now, if, yeah, correct. And if there is bony defect, we have to pass that point defect also lovely. So the first answer to everyone is when I use a stem is when I want to. Whenever I go up and constraint, I will use the stem.
Then you want to verbalize this concept to moment that say the reason stems are used is that you tell the examiner that by using any stem either on a rotating hinge or a semi constrained knee or on a normal need to be play, I increased my surface area of the construct. Happy to use that phrase moment. I have increased my surface area of the construct and say the reason I want to increase my surface area construct is by doing that, it dissipates.
The correct word is dissipates the forces on the bone implant interface. Happy with that. Yeah, Yeah. So the increased surface area of your construct dissipates or takes away the forces from your bone implant interface and prevents loosening. Yeah so that's the reason you use it and say therefore, the conditions I'm worried about is when there's bone is not of the best quality.
So you can say, and that's weaker. So whenever you use a high constraint bone definitively are not large enough for the next step of which I'll come to full bone quality and I do it. I as a knee surgeon, which I take on complex needs. I do it for all those tibial fractures or at moment, happy with that. Yeah, Yeah. And next, and I'll finish with this is.
Now you see this knee, you agree it's very deformed every one moment you agree deforming. Do you believe it's going to walk through your door? Do you agree it's going to be a severe deformity? Yes most of the time and I asked my registrars and Fellows their first line would be, oh, this is a severe deformity. I'll need something. It'll need the first answer. They gave it a very severely constrained knee or something.
No, it might. I'm not saying don't keep it in your background of your theater, but the first, you can't judge that because this issue is due to bone loss. You agree moment. Yes now, do you agree just putting a stem here will not help that bone loss? You agree. Yes, you need something else.
The word I want you to use and I want the audience to use you will use two words I for the last 10 years, use something called up. What? I use my artificial sleep. Yeah so see this here. This is a simple artificial sleeve. Or you can use the word I will use augments which come in the world of steps or.
Ledges OK. Yeah so when you want to recreate or you want bone loss to be better. Don't say if it's mild, you just use a stem correct moment like you said, yeah, yeah, if it's severe, you will use the word tibial metaphysical sleeve. Or you will use a step or augment, augment, but all I think we as knee surgeons have gone a little away from that chin from Mikhail Jean.
He wanted to clarify the rotational element on the femur with, you know, indirectly, I think, just to convey his message clearly rather than be passing it on to talk. Yeah OK. So you mentioned, can you hear me? Mr yeah, thank you. Very well. Yes, we can hear.
Yeah, OK. Yeah you mentioned about the dialing of the external rotation on the femoral component, which is based on the inherent virus of the tibial plateau. Correct Yeah. Yeah so my I don't quite understand that about a slight deformity of the tibial plateau is an angulation deformity. How you can compensate that by correcting the rotation component on the other aspect, or whether it's based on the anatomy of the femoral contents, which is why you need the axilo rotation.
It's a good, good. Yeah, good. You answered that. The reason is this is all comes down to traditional knee replacement philosophy. Now if we have to accept that a normal virgin. tibia of anyone right is in 3 degree of areas, do you accept that at least mikael? Yes yeah, Yeah.
Now that means your collaterals, right, aren't inherently at a different tightness in you because your, you know your variances of three degrees, right? You know? OK Yeah. Now, when we do knee replacements, we want to balance our extension and flexion gaps, right? Yeah now your flexion gap, right? Your flexion gap depends on what do you agree of flexion?
Gap depends on your posterior femoral condyles how much you got and where you cut. You agree with that. Yes right. So now imagine if you don't cut now. Now the next point, therefore, to clarify your point is when you do your tibia cut, you agree that we cut the tibia, not in 3 degrees, because most people don't x-rays what we want to do at 90 degrees, even though it's not the Virgin tibia, because that's we surgeons cannot be so good to cut at three degrees.
You agree with that point. Yeah, we got it. We cut it perpendicular to the egawa test. Yeah, and that is three degrees away away from what the normal human nature has given us. Correct? Yeah. So therefore, in flexion, the only way to balance that part is to cut your distal femoral epicondyle in a different amount.
You agree what you've got because now you've got a 90 instead of 3. So those people who propagate this new concept called, you know, anatomical knee replacements, which which is, you know, they say will cut out. You know, it doesn't matter. You can cut your tibia, you're in there. The answer is that we don't have the skills. Yes, with robotics coming in, we may be able to.
But as a surgeon, I've done thousands and even my colleagues have done even more than me. They can say they'll never cut to 3 degrees. You see what I'm trying to say. So if we are cutting, you're 90, we need to recreate that. So Thanks for asking this question and I hope I have clarified it to everyone in this manner. OK Yeah. OK, thank you.
Yes, thank you. That was very clear. Thank you for your question. Question that came in from Rajan. He's asked, what's the difference between a sleeve and a cone? Yeah, I would say I leave this to who's asked this. Rajan, yeah, Rajan, I would say, Rajan, thank you for asking this.
If you ask at the FRC board level, there are some questions which are we need to know, and there are some questions, which I call fellowship level questions now for us may agree with me that truly saying, knowing and knowing the difference between cones and sleeves is something which I know as a surgeon because I do it in complex surgery. The difference is that the metaphysical sleeve incorporates the entire metaphysics.
All right, and the stability and in growth happens because of this metaphyseal fixation throughout the metaphysics and the cone will be used within that area, but it can be used as a semicolon or trabecular metal, which can also incorporate to make up bone issues, not necessarily only in the metaphysics. All right. But I don't think I mean, I'm answering this as a knee surgeon, but Faraz will agree that as a concept for FRC sort, it's not an important concept.
All you know is a cone can be used interchangeably, but it can be used also for only parts of bone which need to be looked into. Yeah, but I only use a tibial material slip if I have to remind everyone. When you go for their first case exam, you test it at day one consultant level and they one consultant is unlikely to be asked to put them to do a knee replacement with cones and sleeves and things like that.
But you're expected to know the principles, obviously, and you say exactly supplement this or with the bones of steel. So I wouldn't expect that to be drilled into this any further. Yeah, that's why I don't want to take it more now for everyone, for us, you know, just as a concept, it's done for bone loss, and I think that's a good enough answer. If there's one more question from Norman, he said, I think you went through this in your presentation, but he wanted clarification on how do you define constraint?
How do you define constraint, what is exactly constraint and there stability given by the implants, the inherent stability given by the implants irrespective or dependent on the soft tissue envelope? All right. Is that? Yeah and therefore, for that, I would say need to know that the levels of constraint.
And you can say after the posterior cruciate retaining and your substituting knee replacement, which are the standard knee replacements in the world, the next level up for constraint is a partial various well constrained knee where the constraint is higher. And that is an the next level up would be a hinged knee. Yeah, I think other questions here are towards revision because it's difficult concepts.
But again, if you get in the exam, if you get to that, that's fine. You definitely pass the question. Mm-hmm And we worry too much about that, so next, we have another question about the tibial slope and how important it is that someone is going, you want to be clear, clarified whether increased tibial slope increases the flexion is it? How much is it recommended 0 or 3 or seven degrees?
Good question. Can I who ask? That is a very good question and I can answer. I mean about. So no. Thank you for that. Let's start first by because the target audience of this is farces and passing. But obviously it's very important good concept to have as surgeons because whatever we talk about is in real life.
The answer for this slope right is, first of all, you have to say that if you're using a posterior cruciate substituting knee cruciate substituting knee, you do not have to give a slope because the post and the Cam. Meet together at a particular flexion and you get a reliable or reproducible flexion, OK, in a posture most requested retaining knee.
Yes, there's a degree of slope needed to recreate your flexion. Now I am a true or straight cruciate substituting knee surgeon and all of us in Harlow, all because of all-irelands and our philosophy of posture because of a knee. Only now the reason why we don't give slope in a knee and you don't need a slope knee is that you agree that when you're cutting your tibia, you put your jig on the front of the tibia.
You agree. Yes Yeah. Now, if you know where the true front of the tibia is, then when you cut your proximal tibia, you get a perfect cut, which is not in Vegas or various right, but in real life. When you put your jig onto that front of your tibia, you agree your patella tendon, your tibial tuberosity. Everything is biasing you, not on the front.
True front of the tibia, it's biasing you more immediately. Yes Yeah. And therefore, when if you put slope right, and then you cut, you are propagating or making your values where it's got worse, so you choose your two Devils. You want to have your values where it's got worse. No, because posture, your lack or posture immediately if you have a slope that becomes worse. So therefore, I don't go for a particular slope, but make sure that we don't have any upslope.
OK, so the answer to your question is it makes a difference in the two knees you're using in a posterior cruciate substituting knee. You don't necessarily need a slope. And the reason why that could be advantages is that you're cutting in the front of the tibia, but you do want to cut and give you a values fairness issue with your gut. But in a posterior cruciate retaining knee, yes, there's a degree of slope required, but I'm telling you as a practical knee surgeon, reducing slopes, you know, saying three degrees, seven degrees is a lot of you have to use some slope.
But getting it exactly how much is not reproducible unless you're using robotics or computer typekit. That's my practical answer to you. I said, that's enough. No, sir. Yeah, thank you. Thank you very much. I can. The clarification?
You ok? Yes lovely. Yes, Yes. Thank you. Thank you. Thank you. So we have next question from ative and it is a reasonable question. I think he wanted to make sure he's using the right terminology.
When he answers, he wanted to know the difference between constraint and conformity that obviously completed two different aspects. I think he wanted them clarified. Conforming is a very important word. I didn't want to introduce it here because I've not that too many concepts for, but that would come under the heading of Austria cruciate substituting versus retaining knee.
Now in that, you know that there are two types of polley's which are different in the retaining and the substitution you agree in the retaining, you do not have a Cam and post, right? Yes and in. Yeah correct. You don't have a command post in your retaining now in your regaining knees when originally 30 years ago, 20 years ago, that design was called a flat design.
You agree with it? Yes Yeah. And we realize that flat designs did cause more wear, especially especially in the CR knees. Right? so over years, the new poly is called a conforming poly, right? So at the word conforming is a word you use when the police is given to you in your hands.
Or when you as a practicing surgeon, I do know so you can say modern polyethylene are conforming. So you can save and pick it up, you can say this is a modern poly. I know it's conforming while the old ones would have been flat on flat designs, which were not good. So that's where I would like you to say. So the message would be conforming is a word for polyethylene.
All modern new systems have a conforming poly. Vote for us as well as c.r, but is more important for your Sr. part of it because in the old days, the flat cars were way more. That would be my answer. Thank you. Happy with that. Thank you.
That's lovely, thank you very much, I think we have Abhishek who wanted to ask a question about the longevity of the constraint implants. I'm not sure exactly what he wants to know about it and how relevant it is for, I think I think for us, it's relevant to a degree that, let's suppose examination your exam an X-ray with, you know, that it's a constraining plant, right?
You see it or he gives you a polyethylene or implant, which, as a constraint. He may ask you that why does this not last in studies as long as your normal knee? Yeah, that would be a basic science level. And therefore, you can say that as the constraint goes up. The problem happens is that the same words are used before that the forces on the metal bone interface become worse.
And I need to dissipate those forces. And therefore, if I'm using constraint, I need longer stems to dissipate those forces. And therefore I do know that the long term survival of them may not be as much as your primary knees, but with modern knee techniques with more than knee metallurgy. We are hoping we'll get that, so that will be a fellowship level. But what he was asking for?
You need to know that the higher the constraint, the more you have forces on your correct word metal bone interface or cement, bone interface, whatever you want. Thank you. How many ask questions about anterior and posterior referencing? He wanted this also clarified, and that was the difference between India and Brazil referencing. OK that the first thing to tell someone and once again, ferrous and fall.
You'll agree that no one is going to ask this question directly at the physics level, right? I mean, it's a more practical knee surgeons rather than a concept. But I think it's important to know because all of your audience are going to be doing knee replacement. I mean, you teach good concepts. So the first thing to say is anterior and posterior, referencing both of them reference off the jig.
Right? this is your jig. Both of them sit on your posterior femoral condyle. So that's the first message I want to give everyone which everyone gets confused. So the lugs of this will sit on your condyles happy with that. Everyone that you sit there. Yes is that the outrigger? You know, the front part will fall on the front of the femur. Yeah, that's on your anterior cortex.
Now, the issue of entry and postural reference only becomes an issue if you're between sizes. So if you're a straightforward three, it doesn't really matter whether you've done a posterior referencing or anterior person. All right, because you're going to be using a three implant and with modern systems with more and more sizes coming in, this issue of anterior and posterior reference is becoming less of an issue.
So that's the fundamental message. OK but at the but still in posterior up referencing what we are saying is when your outrigger falls on the front, you see that it falls in the front of the femur. I'm sorry, it wasn't part of my talk. That's why I don't have it to show you, but it folds here. Where it falls gives you a number. Let's say it falls here and it says it's a two.
It's not an issue, but what happens when you're between sizes? That's when you have to decide whether you want to violate your. Back of your knee, that's a posterior part of me or the front of me. So with a down referencing with a down referencing, you're telling yourself that you will never notch the fever. All right, so I can repeat again with people who use an A down referencing.
You're telling yourself you will never notch the FEMA if you're a posterior up province in which I am, that's why Zubin works with me, picked it up that we in Harlow, everything is standardized. We only use apostrophes up. We are telling ourselves we'll never violate the flexion gap. All right. So the two concepts. And I think I'll stop there.
I don't want to make it too complicated because I don't have slides to show you. Is that a.? Posture referencing only are important if you're between sizes. If you're a down referencing, you're saying you will never violate or never notch the femur. If you're a posterior presence. You're saying you will never go into or violate the flexion gap.
And these are the three messages, but I would say is important for this. One more question from Norman he's ask about in. Christian sacrificing knee replacements. He said there are two types a stabilized and posterior stabilized. Is that a concept that we need to worry about for the first year or that you need if you're sacrificing your posterior cruciate, then you will use the correct word is a posterior cruciate stabilized knee where you use a box?
Yeah, and a can. But there are some surgeons, and I don't know whether this is what he's asking for, the sacrifice, the. PCL, right, but they don't necessarily use a posterior cruciate knee. They use a CRT with a different type of a insert, which gives this degree of conformity instability.
Now I'm very clear all the 1,000 needs we do in Harlow, we have standardized, we get fantastic results. We stick to 1 knee, so we lose only post-trade with substitute winning. But I think this is what he was asking about. But once again, for the audience, I don't want to confuse it by going in doing anything more. And one more question is, is congruence see the same as conformity as far as knee replacement surgery?
To a certain degree, you can use them interchangeably. But for the polyethylene, let's use the word conformity of the. And, OK, you wouldn't use congruent, see design. It's a correct you can use it as interior, but it's a design. Philosophy is congruent. And the polyethylene will be. Yeah thank you, Mr Mike Zavala. You know, you spent all this time considering all these questions and answered them very nicely and carefully.
Everyone who's attended a very appreciative of your efforts. Thank you. You got a couple of case discussions, isn't it? Yeah and then after that, we'll put that to use, yeah, sure, sure. And I hope for the audience, I think all the questions for us were very relevant and I think I hope I didn't. I think for the people giving the example, having the concepts, I think these were important we touched upon.
But all what I gave in my talk is what you need to have your delivery on your verbalization. So that's the message I would like to give. It's perfectly level 4 pitch for the level of the exam. So just before we start again, I would like to encourage you guys to make the best of this opportunity of having a private practice with the experienced examiners we have. So anyone interested in have in being asked questions being put in a hot seat, please raise the hand symbol.
You are interested. No one is judged and and as you say, it's everyone is welcome. So for four, the first case, we have armored. Um, yeah, so he he's kind of discussing this case with yourself, your reconstruction people, not your basic science on it. Can you hear me? Yeah, I can. Yeah and tell me these are the X-rays which and you agreed.
It's a common scenario. You'll be shown difficult hip x-rays, difficult knee X-rays. So my rate of what we're doing now is just to tell you how to talk about a complex need X-ray shown to you. Yeah, that's what I want to show you. So tell me what you see here. Yeah, so. So this is a plain radiograph of a knee. The there's lots of.
The most obvious abnormality is the severe osteoarthritis with a significant bone loss. What seems to be to me on the femur component, specifically on the lateral femur combined? Yeah OK, so that's on your AP, right? Yeah, that's right. So stick to your app and just tell me once again, I didn't hear you too well.
So on the app view, the most important abnormally start with that is sorry, significant arthritis. And there is a significant wear and bone loss on the lateral thumb as well. But yeah, yeah, this is what you mean. OK and do you think there's any bone loss on the medial tibia? Uh, yeah, I mean, it's difficult to get it, but there is some degree of effect, so that's the correct answer.
So you say this is that would you commend the degree on whether it's a very sort of elegance? Again, it's a deformed knee. It's the correct word, would be it subluxation laterally is that you are happy with that phrase so laterally, but to a certain degree, it comes in the realms of a variation. Do you agree?
That's right. Yeah, Yeah. So this is where you get confused, sometimes with gross changes. So let's have a let's have a plan for you and for everyone. So actually shown, do you always start with the app? Don't go jumping from app to a lateral? That's the message. OK, so even in a hip?
Don't jump from your app hip to the lateral hip. All right. So are you going to finish one X-ray and then move to the other one? Happy with that. I have it. Yeah so on an app, you'll say this is an app radiograph new green. Is it a short leg film or is a long leg view?
Well, we have a short view, should we have any, so the correct word is a short leg view, so I want you to always know for low limb as well as upper limb, every X-ray got a terminology, which is correct. Please use that it automatically gives you a four or five. So if it was a hip, you say it's a pelvis or both hips or it's a pelvis, you say it's a pelvis. If the shoulder you see, it's this view that view, right? So this is an AP view, which is a short leg view.
The most common abnormality and speak, you know, a severe significant degenerative changes. Happy with that. Then say from what I see on the tibial side, there is a definite tibial cellblocks, correct? Yes and there is a degree of varus deformity. Yeah radiology can then say my areas of suspected bone loss use these words is that I'm not sure, but there may be some loss on the medial side, but I feel there may be some loss on your bilateral framework on that.
Happy with that. So that's all you say and then say without having a history of any previous fracture above and below, I need that clarification or I need long leg films. Just you have to say that what I mean, because you can't not know what's happening above and below these five statements for this. Yeah and then you go to the lateral the lateral.
Just speak to me about the lateral. Yeah so again, it's a severe degenerative changes with what seems to be a loss of bone loss as well. Again, so when you say a bone loss, what can you say bone loss on your lateral, you normally see bone loss and lateral. Not not in this. No, not really. Laterally, no.
So what do you what do you see for one, you see whether they are posterior fights, correct? Yeah so you agree there is a huge posterior spider. That's right. Yeah so you can see that you agree that there's a significant patellofemoral arthritis. Yeah and you think you can see the joints, you think there's a joint where there's no joint, but it's difficult to see on this view, but it's very clearly a stiffening.
And I'm telling you, when this patient comes, it's zero, maybe 0 to 5 degrees. Yeah, Yeah. So so that's what you have to pick up. Yeah so there is going to be an issue of it's not a few joints. There's a degree of ankylosing, there's a significant posterior device. Yeah now if you have to approach this dynamic, so now I'm going to ask you fine.
Thank you very much. You've clearly passed on this now. How will you What do you do next? So as you highlighted earlier, sir, I would want to know if this patient had any previous fractures to the proximal female or the distal tibia. I want to know the detailed history and examination history.
I want to know the severity of pain, the level of mobility to know if he has passed medical history to the vets for that. You're telling me this, but I would just tell you, just because I'm trying to distill all the teaching rather than your avivah, if you don't mind, is use a phrase that, assuming this patient, I take a complete history examination and all quantitative measures have been exhausted and this patient does not have any definite contraindications to joint replacement surgery.
My feeling is that this patient is a candidate for that, but I do agree it comes under the realms of complex surgery. So, yeah, so rather than saying otherwise, two or three minutes goes away and saying, I'll take this to you, I'll do this. I'll do that. Just use this phrase. Assuming all exhausted and exhausted, I've taken a history, examine them and there are no contraindication to join in brain surgery.
This patient is a candidate for that because that's what we are doing. Thank you. Carry on. So what are we going to next summit? So I want to examine him, so assess the how stiff his knee would be in terms of exposure, what difficulty I'd be facing. So tell me all your problems.
So exposure? Yes, carry on. Thank you. Carry on. So exposure in terms of laxity and the medial and lateral collateral ligament may be assessed preoperatively. But I think what will make a big difference is when you do a intraoperatively in this case. Fantastic very good answer.
Thank you for that, Gary on. In terms of any previous cause, the patient may had, Yeah. OK, so now tell me the only exposure is going to be an issue. And that could be due to previous cause or the fact that it's, you know, you've got this bony type of issue of a 0 to 5. So you agree the exposure is going to be an issue. Don't you go in?
Tell me about your what are you going to next from your bony point of view? So let's go in and you don't have an issue on your femoral site. Let's say the femur canal is fine, right? Correct that's fine, I say. If so, once assessed the exposure. My next thing is assess the bone loss. Steve, we've highlighted that there is a bone loss on the tibial side, on the medial side.
Do you think it's going to be huge? You're going to be it's going to be as bad as the earlier X-ray I showed you or not as bad. As Dexter has previously shown. Yeah, I would have thought it's. And you agree this is much more in very dramatic compared to this potential. And yeah, so in your gut feeling is yes, you're worried about it, but you know that it may not be as bad as, yeah, so remember and I talk, what?
What are you going to use if you have to use something? If we are worried about bone loss, we're going to use an implant with a stem and sleep stem. Yeah so first start with the stem because small amounts of bone loss, you agree, can be tackled by just stemming an implant. Right that's right. Now you are very right and actually you picked it up, which I probably yeah, I thought of it, but I didn't think too much of it agree on the female as well.
If there's not too much, we requires a sleep. What are you going to use? As a again, I'm going to stand anyway, right? So the issue with difficult needs is a talk about where the bone losses. We talk about your lateral, then divide your problem into four parts. A is exposure. Is it going to be difficult or not?
So this is going to be a difficult exposure. So say that be make sure that you don't missing a microfracture or a deformity above and below. Happy with that. I might like you said C is look into the bone loss, where and when, how to tackle. And for. After I tackle that, I will check the integrity of my soft tissue envelope.
And if I feel I do not need a higher constraint, I will not need a higher constraint. I'm happy with that. Yeah, that's right. Is your gut feeling that you lead been screened for this or not? Well, I think the fact that is stiff and enclosed is unlikely. Yeah and let that be an issue. OK, let this issue that once you re-created your bone loss.
Have you got to align me without any issue of the laxity? Yeah, Yeah. OK, so this is what I've done. So all what you said is correct. You agree now. I put a stem on because I was a little concerned, like you, about my integrity of my bone, on the femur. You agree on my tibia. I put a stem on why, because I was a little worried about my integrity.
You see that there? Yes but do you agree it would have been overkill to put a sleeve, right? Yeah and you agree. Once I put all everything in, I did my integrity for my collaterals. It was perfect. Did I need any higher constraint? No, no, I didn't.
So that's how I will say, OK, I bet. So I think you answered it very well for us. You agree he would have definitely passed with a good answer. It was very good answer. And also your feedback was excellent and highlighted the main positive aspects, as well as how to improve the answer. And I had a question for the boss with the amount of subluxation, the constraint when you went inside, what is the state of the collaterals and how did you tackle that?
You see, the sub blocks will be there. The issue of blocks, it's there visually as well because of bone loss. All right. Correct yeah, it's there due to tightness and most people feel and once again, whereas with your permission, this is a true fellowship answer. Yeah, it's not going to be tackled at the seesawed level, but I'll answer it for you.
Is that at the true when you see lateral sub blocks, but in a various type of me? Yeah, those are the ones where I actually divide or do something to the popular discontent. So most people feel that when you're doing a company standard is tackled in the value need. My feeling is most of the time I've done it in my complex, various knees. All right.
So that's one question. And my question of integrity of collateral is very clear. I build up. I cut where I want. I build up my bone to make my tibia and my femur, where it should be without excessive bone loss. So I'll never use or insert more than 10 12, et cetera once I do my trial, I check my integrity, and if the collateral are fine, that is fine.
It does not need higher constraint. I agree. But when you went in this particular place, how is the collateral? Was it? I mean, was, I'm sure, with these knees as collateral? Well, if you ask my opinion, it was, it was fine. The issue with his knee was due to the significant cost of fights.
So nowadays, collateral, you know, lengthening collateral releases all that we've stopped doing because we have now working very much on Oscar capsule, getting implants at the correct level, you know, not proximal. It's not digitalizing. This is where it is. But the answer is they were fine. Good question.
Even I was I have my back up always. But in Harlow, because of Paul Allen's legacy with Depuy in mind, we have everything on the ship. So so everything of DP is on the shelf for us, you know? So we have it. Thank you so much. That sounds wonderful, I think. I think we just, if you don't mind, we'll put on the excuse now for the first question.
Patella resurfacing offers clear advantages for taking our outcomes in evidence based studies and 91% of you. And said its answer number three. Yes, there is no clear evidence to support resurfacing or not. And next question stems by their own are used in total replacement to provide stability and collateral ligament incompetency, 72% says it's false.
And that's the correct answer. Uh, question number three, low viscosity cement is routinely used in total knee replacement practice, and 89% said falls. And that's the correct answer, so well that everyone who answered correctly, you'll be listening. Thank you, everyone. I hope that was clear. Any questions you want, I can come back to your later if you want.
And I just want to end with very glad to say one of the epimysium in the second edition is just starting today. Got published. So this is a book which covers everything all the senior authors have contributed. It's amazing. And a route very kindly, because, like I said, she is passionate about her role in the UK for providing courses, and she's put this up as challenging cases, it's on the website and which anybody can go in.
The contributors have given these challenging cases give your input and then later on to the surgeons who have given their input will give the answer. So this is there on the website now. There are these books which have been traditional books already available from your UK who they support. And lastly, really as a unit or as an entity, you UK does everything for non-profit making and this is the donations are routed.
Kindly said you could just put these up for her and I'm very happy to do so and thank you very much, Ruth, and for us for this excellent day. Thank you. Lovely, thank you, Mr Mike Zavala. I was a wonderful session. Was very, very nicely comprehensively covered the total concepts of total knee replacements, a buzzword to use how to answer questions perfectly well.
We have all used your methods of answering these questions, and they worked very well for us. So I encourage everyone to try to use the same approach to answering questions related to tenotomy replacement. We have certainly learned a lot from you today. Thank you. The one who participated for all the questions that we very good, sensible questions and they're all relevant. I would encourage participation and interaction during these sessions.
Thank you so much. Thank you both. So thank you. Thank you, everyone now.
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