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Online FRCS Course - Basic Sciences for Orthopaedic FRCS Exams (2)
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Online FRCS Course - Basic Sciences for Orthopaedic FRCS Exams (2)
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Segment:0 .
OK guys, so welcome to this case, discussions for the first case exam, the course today involves seven stations covering all aspects of the exam from the rival stations.
Five other stations pediatrics, hands, pathology, trauma and basic sciences, and two clinical stations, upper limit and lower limb clinics. The course is intense. It is tiring. We will be going through about almost 50 cases today. We have to stick to time. Yeah, we have to keep moving every 10 minutes because if you just spent 10 minutes per case, that's eight hours.
So and it will be guys exhausted at the end, so we just have to stick to time. And so excuse us if we move on between the Kessler, this is what we're covering and the faculty today, they call coming and joining later on their time slots. Top faculty who has been educating for FARC for a long time, they handpicked really for their skills in specifically in coaching and mentoring FARC as candidates.
So I said we'll have 10, 10 minutes per participant. And it is a case based, case based discussion course, when we go through the cases with you, we ask you questions and see how we respond. We try to give you feedback and we will be focusing only not on your knowledge in orthopedics, but more modeling how to techniques for the exams, how you answer your question, how can you score higher?
What are buzzwords to use? How can you be focused in your answer? Yeah so we will try to avoid, you know, going into great depth into any topics, anything beyond a farke's level. We will not go. Yeah, our aim is to keep it there for this level and try to help you guys get it 7 and 8 in the exams. Yeah so we will not teach you.
None of us is top expert today, for example, you know, I might be discussing things that I might never done in my life. So none of us is an expert or expert in any of the topics we are discussing. We're not here to teach you. We are here to guide you. OK you got the knowledge. You passed your exams.
You've done your trainings. If everything what you need now is exam mentality, exam focus and just to nail it in the day. So I just say, guy, just during the day to day, just try to when you're not talking, you just mute yourself. Uh, you know, I know you all probably sitting comfortably in your homes and there could be some times distractions and stuff and noises.
Just try to mute yourselves when you're not talking, just to reduce any distractions. Um, that's great. And just to obviously allow a person who was in the hot spot to. And are full time, please. OK, so what are we giving feedback to you learn from your performance, but also you learn from your colleagues performance.
So make sure you guys you write down the questions, you write down the feedback that's given, ok? Because today will be intense, so you can go back to these notes later on, maybe tomorrow and reflect more. Well, unfortunately, we would not be able to share the slides, so if any of you was, you know, want to take any notes you can, you can take photo shots of any slides you want.
And just stay in touch with us, and there are also other courses I want to ask you. Time now on those, but might share them with you if you're interested later on. Encore? yeah, for the last many years. So you get the same questions, sometimes they are new twists on the questions and new evidence to add new changes, but they tend to be the same topics.
And when I ask the people in the February exam what you've been asked, I find they are exactly the same. Nothing weird. Wonderful so that's how it is. So I can tell you the basic sciences, we a lot of us just general guidance, a lot of us are apprehensive about it. But in the exam, it's probably if you know your stuff, it's all about basic sciences is more All about knowledge.
If you know your stuff, you score high. No doubt about it. You know, no tricks. There's nothing. Questions are always straightforward. In fact, if you're good at your topic, if you prepared well, you could spend the whole five minutes in the exam. Just giving the examiners a tutorial. It has happened.
I've seen it happening and we heard a lot about. We were always in touch with candidates and. You could just spend the whole five minutes just taking the exam, and then I will just sit back and listen, enjoy the talk. That's that's very possible. So, you know, again, try to, you know, you don't need to go because I know there are, you know, sometimes some courses I used to attend and some books.
I used to see, they go into great depth that you feel you feel completely lost. You don't need to go into great depth at all. You need to, you know, you need to. You need to fall. You need to. They don't look into great detail. They're not biomedical engineers. They're they are.
They're not histopathology. They don't want to create. They want to know what exactly is relevant to our day to day practice. And that's what the examiners know. So you don't need to go into a great depth in any of your answers. That will be my advice to you. Stay broad and superficial.
And if you're scoring very high or if you are, you know, very expert in particular topic and you want to shine, you can OK, but you have to know how to play that tactfully in the exam. Is there a quite difficult to draw on this platform, but in the exam, please practice drawing and practice talking while drawing and make your drawing big to the examiners can see it and they will always be papers and pen in front of you on the desk.
So as I said, all the questions today, I've been asking the exam, so we'll move on quickly now. Good OK. So now tell me what you can see. So this is a limited AP radiograph of the right hip showing a cemented total hip replacement with a metal stamp metal head and a liner lovely cemented hip replacement.
So tell me what is cement? It's a composite biomaterial which has which acts as a Grout, essentially in total hip replacements. It has got liquid and solid phases. Solid phase is the PMMA powder mixed with an initiator and an activator. The liquid phase has a tile may missile mono acetate.
Sorry, I can't remember, and it's got the inhibitor which prevents polymerization within the liquid itself when these are mixed together. So that's fine. Well, so tell me, why do we use cement? So aid as it acts as a crowd, so essentially acts as a space filler between the stem and the shaft.
Yeah, Yeah. But generally in orthopedics, why do we use cement? Is it just a joint replacement? Do you use it for anything? Other indications you can use it as a space filler, especially in proximity to be a fractures when you have bone defects? Yeah, it can be used as a carrier for antibiotics. Yeah yeah, that's good, that's good.
Yeah, that's good, so that could be part of if your answer of why we use cement. Yeah and when you ask about what is cement? Yeah what is cement? We probably before jumping into that, what components of the cement are monomer and polymer and fluids stuff? You could start with just generally, what is cement definition, as you said, you know, just a simple thing.
Do we use cement? Yeah, OK. And I can tell you in the exam, you're not scoring is still not scoring anything. These are just warming up questions just to make sure you know what there is, what you're seeing. You know, what there is something called cement. And you you're not a former candidate. You can the examiner can move you on, so you're not scoring anything on this opening question.
Yeah, they need to waste too much time on it. Yeah so, yeah, so obviously you can use it in cases when you need to improve various forms of fixations, such as in joint replacements, avoid filler and provide mechanical stability as well, like in vertical plastics and also void filler in tumors. Masculine techniques? OK so that's what it is, yeah, so fixation, load, transfer, filler and mechanical stability.
OK, so for general uses of cement? OK so not just only in joint replacement, so because you remember this question, the opening questions here. Yes, we have put a joint replacement, but we're not talking about the. We're talking about cement. So just get to think all the examiner's thinking, OK. So tell me now in your joint replacement surgery, what type of cement do you use and why?
Which cement you use when you are a consultant, what cement you're going to use and why? We use high viscosity cement, which is a trademark, of course. Yeah, it's called vancomycin and gentamicin in it. Yeah which our antibiotics? Which help reduce the incidence of infection. Funso, so you said you use bellicose.
Yeah, because if it is high viscosity, yeah, OK, so tell me now, so you've taken this question into the viscosity direction? Yeah you decided, which is fine. So tell me about viscosity. What do you know about cement viscosity and why you choosing a high viscosity cement? Rather than medium or low.
A high viscosity cement gives you. More working time. Yeah which allows us time for application to implants and cementing them in place versus the low viscosity cement which is used in water propensities. OK OK. Yes it's more fluid and can be injected into low volume areas. Yes that's so.
So tell me, tell me now about this. A, you know, pellicle segment of yours. Tell me more about it. It's got a powder and a liquid face, yeah, the powder phase is PMMA powder. It has got a radio opaque barium sulfate. Scott chlorophyll as a color. And I think.
Initiator, which is. Benzoyl peroxide. OK this powder phase and the liquid phase is me, which is the monomer, and it has got an inhibitor which avoids auto polymerization in the liquid phase. OK sure, sure. Are you bellicose? Why not anything else?
So there's good evidence to say that antibiotic loaded cement prevents infection and joint replacements. Yeah, that's fine, that's fine. That's good. So anything else, evidence to support the use of bellicose at all over any other type of cement?
Sorry, can I write replacement surgery? So sorry, I cannot think of any evidence. No, that's fine, that's fine, it's good. So, yeah, I mean, I agree with you. I mean, you know, I would use bellicose, but I'm not, you know, the timing for this. You could use anything you like. You just support it. Yeah, that's what the examiners want to know.
So when they're throwing this question to you, what type of cement you use? Yeah, it's just an opening question just to show your knowledge about cement. They don't care what cement you use. No one, you know, examiners will not care what type of cement you use. You practicing in the UK, you're going to be using a certified type of cement.
You are going to be using anything dodgy. So they want to know is, is is, you know, about cement. So when you ask about this, you could take these questions into three directions to justify your answer. You could talk about the components of cement because I like the cement. Because it has the colorants, for example. So it allow me to differentiate between the cement and the bone.
Yeah, it has the radio, opaque materials, the barium to allow me to see it on the x-rays. Do you know what I mean? You just that's what's higher order thinking in the exam. They want you showing that you just showing your knowledge, but in how you use it in your daily practice. So when you asked about cement? Uh, what type of cement you use?
I advise you the way I advise you to go is go through the components of your cement. The viscosity properties of your cement and the anger in the air, we know from a jar that publicos has lower risk of revision in 10 years for septic and septic. So the ingredients of cement. Yeah, as you said, powder and liquid, and I've stolen this mnemonic from Nike, some of you guys might like mnemonic to help you to remember.
I think the stress of the exam will probably become handy. So powder, you know, polymer is the powder. So PFLP and IBC, so I is the initiator. B is the barrier. And see, is the chlorophyll, so pib, if you like. But what the higher order thinking that you owe they always been referred to in the exam is, is how you justify. So you say there is a polymer that gives the structures structural strength in cement.
Yeah, that's how you answer the question. So you just define your answer. You want the 24 examiners to ask you, OK, why you care about. There is a barrier. Yeah, just not say just there is a barrier is explained, just justify why there is a barrier and why I like the cement that has barrier in it. Yeah you know, what does the initiator do? What does the antibiotics do?
Yeah, and why there is antibiotics? So so so we've talking about antibiotic antibiotics, for example. The next question we could be from the examiner is which antibiotics with you at your cement or which antibiotic add is added to your preferred cement. Vancomycin and gentamicin. OK, and why these antibiotics? So you.
I so here. What do you give your answer in the exam? Don't say Mason because everyone knows the gentamicin, yet you now you you want to impress the exam and tell them we're using gentamicin examiners doesn't want just to know that you have to because they can open the packet and they can. Anyone can see this gentamicin, but they want more justification from you.
That's the higher order thinking. That's you actually in a. And explaining to them, why gentamicin? Yeah, but examiners can ask you, but then you will if I ask you as examiners, they'll probably scoring six, but if you say it by yourself, it's why gentamicin is used. That's when you're scaring 7 and 8. Yeah so why gentamicin? Why not the penicillin?
It's got a broad spectrum of activity. It has heat stable. So during the mixing phase, which is an exothermic reaction, the antibiotic doesn't get inactivated. OK um, anything else? So it is broad spectrum, as you said, it's heat stable. Yeah it has long Ellucian time and it has the minimal disruption to the mechanical properties only adds what is the disadvantage of adding antibiotic is that makes the cement a little bit more brittle.
OK and that's one of the disadvantages of cement or poor quality, but it adds to that. So that's why there is a limit on how much antibiotics you can add. OK and then you got the liquid. Yeah, so you got the powder and you got the liquid. Which has the monomer and accelerator and inhibitor in it. Yeah OK.
So, you know, all about the cement, isn't it? You just need to be able. To use that knowledge as quickly as possible, because you remember in the real exam, there's a time limit. Yeah and you know, time is your asset in the exam, you know, you're scoring, the more time you have, the more you can score. So you need just to get on with it. But it's a good start and a good start here.
Lovely, lovely. I think now. Now I move on to Simon. Sorry, fellas. Can I ask you something? Yeah, you made a statement statement from Ngo. Bellicose has high risk of revision in what? What did you say? I just know lower, lower risk of.
Now, yeah, but that's a lower risk of revision with bellicose cement compared to any other cement for septic and aseptic loosening. OK, thank you. Well, that's know, that's how you know, you justify one of the justifications of using bellicose thus higher order thing is just defy your answer as an independent consultant. Yeah, you've been sitting on board.
You'll be asked why bellicose? Why we are purchasing power costs and not purchasing other cement. You could use other cement as long as you convinced of its qualities. But now we're doing just exam practice, so you just advising you what to say in the exam? Lovely so, Simon.
Good morning, Simon. And so I think your exam is also in April, isn't it? Yeah November, November. OK, well done, then early preparation. I think that's definitely a good thing. Lovely, Sam. I so you've seen we're talking about cement. OK, so we carry on with the same subject. I'm going to want to see because Hammond touched on the viscosity of cement.
Yeah, for you for joint replacements, what type of cement would you prefer in terms of viscosity? And what the different viscosity of cement of. And as far as I'm aware. Once you've covered what cement is made up of. My my use of.
Of cement is the same, I want a high viscosity cement for the use of my arthroplasty. I want it to kind of Interdigital it and give me a good fixation in my arthroplasty. So I would use Pentecost as well. Lovely, lovely. So obviously, cement in Durban has got viscosity catalogs and there are low, medium and high viscosity cement. Yeah and we don't need to know, go to a lot of depth exactly what you said.
There's no need to really go into depth into what the viscosity is of the mains and diverse. But what we know, what we need to know as orthopedic surgeons is what each one provide us. So the low viscosity cement, it has a low, doughy phase and a short working time. OK, so it's not really ideal if you're doing joint replacement surgery. And joint replacement surgery.
You want a high viscosity cement that gets that has a longest working phase. OK, so it allow us to work more. That's what we want. So that's really why we use a high viscosity cement. OK there are evidence that there are more for giving, and that's why they are the most commonly used, predominantly used cement in the United Kingdom. So and that could be part of our answer as well.
You know, when we're saying justifying what type of cement we use because high viscosity cement is allowing us, it's more forgiving a lower small working time. And that's why it's most commonly in practice in the United Kingdom. Yeah and that's what you want to say in the exam. We want to say what's come on the practice? We want to be out. We don't want to be outliers.
You don't want to be. You don't want to look different in the exam and be safe and boring. Absolutely you want the examiners to forget about you when you leave the table, you don't want them to remember you unless you're outstanding. That's fine. I mean, obviously, the top scoring people they will remember, they won't forget these people, obviously, because, you know, they know everything.
They all know all the evidence. They've done all the PhDs and relevant stuff, so they will know. But otherwise, for the majority of us, we just want to be bold and boring, as you said. Simon, so. So if it is, this cement is the common use, that will be our answer in the exam. Exeter, Exeter yeah, that's it.
So obviously, when are you talking about cement also just explain the examiner, the rate of setting of the cement depends on the environmental factors, as you know, guys like temperature and the humidity in the storing areas, as well as in the operating theaters. Yes so we have to be aware of that during our work. OK, good.
So I'm afraid Simon is next question is, tell us about the cement setting stages. So after you've after you've mixed your. Setting it it's divided into four phases. The first phase is the kind of curing phase, and then it goes Mixon.
Sticky working and hardening. Are mixing is, as it sounds, it's when they're mixing it normally under vacuum. Sticky is as it sounds, and it's when you get a little bit out at the end of the tube and you often put it in between your fingers and it's kind of tacky. Yeah working is where you're doing. The work of inserting the implant and hardening is, as it sounds, where it's setting.
For me, I like to implant relatively early, but as soon as that sticky phase becomes the working phase, I like to implant early because I'd rather have time to get my implant exactly where I want to do some fine tuning than be caught short, and no one wants to do it on table revision. The sticky phase is when it's still quite low viscosity. It kind of is going everywhere. You know, if you put it on the drapes, it kind of puddles, whereas the the, Uh, the working phase, it's a bit firmer and you can start to kind of shape it and roll it into a ball.
Again, I'm always mindful of things like fair to temperature, because if the theater's warm, if it's summer or the air has worked, your working phase can be a matter of minutes. And for most cement, I guess they Harden. My experience has been somewhere between 10 and 15 minutes, which is why I always wait 11, just to be sure. And that's all I know, really.
So the positive things there, Simon, you demonstrated you are a safe surgeon. That's very important. Now you it's like doing a driving test. You have to show the examiner, you have to demonstrate to them you. So you have to show them are a safe surgeon. As you say, I'm starting at the early as early as possible in the working phase to optimize the working time.
So because I don't want to get short time and doing table revision, as you said, and that's exactly what they want. They want safe surgery. They don't want you to know everything about cement ingredients and things they want to know. You're a safe surgeon. You know how to use cement. And when you said about your mindful of the temperature in theater stuff, that's an extra safety feature you put in your answer.
And that's exactly what they want. Honestly, that will be music to the examiners. Yes, they will just love to hear that. And for those examiners, for those candidates who might be struggling with their answer, if you throw these safety words, you at least you're guaranteed you passing this question. Yeah, if you're not scoring higher, obviously, but at least you know you, they know they are your sensible, you know, they are safe surgeon who knows the qualities of the cement.
And that's it. They are happy for you to come and do your independent list or arthroplasty list in their hospital. So, so, yeah, so these are the phases now there are a lot of slight controversies about the terms used, but I don't think it matters because you explain that how and exactly what it is. So there is the mixing phase when you mix it, it's about 30 seconds and the doorway or the sticky sticky phase.
Yeah obviously, you don't want to be handling the cement during this time because anything could stick. Stick on it. Blood debris, bone debris, whatever sticks to it. You don't want that. OK, you want to wait until you're out of the sticky or doughy phase. They are the same, though, if it's exactly the same as the phase.
No difference between them. Some references, for instance, this that did exactly the same. And then you move into your working phase, that's when you really have to be 100% focused on the job, no distractions at all. Yeah, and no music, whatever. No, not no distractions in theaters at all, you're focusing, you got this 5 minutes to execute the job. You know, that could be 5 to seven minutes.
Obviously depends on many factors. And then you got the working phase and then you got the hardening phase phase, obviously, and then the total set. Yeah, the hardening phase of the cement and the hardening phase of cement. Simon, how long that can be the final hardening to, you know, I mean, the my understanding is the final hardening can actually be up to 24 hours.
Yes but the one that matters, the one that matters is kind of 10 minutes. But I guess that would fit in with the idea of even though it only reaches its ultimate strength at 24 hours because we get the weight bearing it, that will probably have implications on things like a little bit of creep and that sort of stuff as well. Absolutely, and that's what we're going to talk about next.
Oh, good, that's good. Yeah so yes, absolutely so. How about 24 hours? And that is when the cement has its some of this biomechanical properties? Yeah and in the setting time, obviously, Uh, it's all dependent on many factors. But yeah, these are mainly mixing, though we working on hardening hardening phases.
And that's how it is. And this is from what book consists of. That's what an exam please draw. Draw this timeline and just show to the examiners what each phase is and what you're talking about, and it's really very it can be simple. I know sometimes it gets more complicated than that sometimes, and some references make it more complex. And I played a lot of these books and struggled sometimes.
Um, until I reach this simple, simple timeline of cement, really, and I don't think you need to know any more as an orthopedic surgeon or as for the exam. So so, Simon, what do you tell me about the biomechanical biomechanical properties of cement, please?
Yeah so one of the reasons we use cement is that it has a very similar, um, not a similar Young's modulus to court on counsellor's bone, but it sits between cortical and cancellous bone. Yes, it is strongest in compression and it undergoes creep, which is where you get deformation under a continuous load over time.
And it's all of these in combination that are why we use it, because it's behaviors are close enough to. Bone that it works well in weight bearing. Yeah, I think I like that what you said about it's the modulus of elasticity is between it sits between the bone and the implant. So it's like it's just transitional medium for the load.
So and you can start your answer here. I think it's a very elastic material. Who the cement is an Invesco elastic material, Yeah. So now then would be the question is which you touched on. What Invesco elastic properties does the cement have? You did mention already one of them, which has greater stiffness, higher strain. Yes exactly.
Yeah, but you did say about when you talk about the elastic properties in particular, you mentioned about creep. Mm-hmm Yeah. So tell us more. What does that mean and. What does that mean, exactly? Creep is the reason we put the little plastic doohickey on the end of the stem of our femoral implant, so what you get is progressive deformation in a response to a constant force over an extended period of time.
So in reality, what that means is as the patient wait Bears on their implant, whatever that might be. Slowly but surely, that implant causes the cement to creep it. It deforms progressively over time. Ergo, the implant sits down a little bit as the cement deformed outwards. But it's also again how you get that press fit as the implant sinks into it.
Brilliant yes, that's very good. I like what I like about your answer, Simon justifying the answer. Yeah, and that's what they want. It irritates the examiner when a candidate sees an answer and then told me, OK, why? Yeah so you're giving the answer and you're also justifying it using this, this because of that. So that's perfect.
So so basically, it's a very elastic material. So there are these elastic properties, three viscoelastic properties. Yeah, cream stress, relaxation and hysteresis. Yeah, but not every elastic material has to have the three properties. OK, so the cement has to risk elastic properties, creep and under stress, relaxation. Yeah and I think it only has these properties only during the setting time.
Until it's fully hard, until 24 hours after that, it doesn't have it doesn't deform over time after that period of time, it's only until it's hard. Yeah, and that's what you mentioned about. It's how it's subsidized, how the cement, how the stem. The Exeter stem is designed to subside into the cement within the first 24 hours. After that doesn't subside anymore, it's only the first 24 hours while it's fully getting hard and set so creep, as you guys know, is that information over time.
You won't score anything. If the different definition of creep in the exam, you only score if you know what, how it applies to you, the question you've been asked and how it applies to the material you discussing about. OK, but in the exam, you could stay, you could just give them this simple drawing of creep in the exam, just kill them. This is the strain.
The strain is the deformation is the same thing. Strain is deformation as far as the fastest exam is concerned. So you could see a old load applied here. There's more deformation over time, and obviously it doesn't continue to deform forever. It stops at some point. Unless the load is excessive, obviously. So what's the other property we said about what other viscoelastic property does it have?
Simon, you mentioned stress load relaxation. Yeah which is where? You get. You get. Under constant strain you get. Decrease stress. Correct correct. Confusing, isn't it?
I got to think about it so much. I know I want to be a hand surgeon. This stuff makes me cry. I know. I can't believe how many times you're not the only one. And believe me, even the examiners will know this. The examiners at the end of the day, they are normal. Or suppose that we see every day they themselves have opened the day the book on the morning of this.
Of of the Viva to revise what is creep and what stress relaxation is. So they know. They it's very it's very tricky, but they won't. That's why they won't expect much from any of us. They want simple definition what it is and exactly what, what it means. And that's it. And they will.
As far as I'm concerned, that's all I want you to know. You know, you know, that's just this relaxation and that's one other properties. So here is you get the stress out, you know, it goes higher when you first put the implant in. But over time. Over time, over time, under the same load, which is put in, you cemented implant in and that's it, you let go. So there is no more load going on, but over time there will be reduced stresses.
OK, and that's exactly why the cement behaves well because they will reduce the stresses on the implant cement bone interface. And you touched about when you put in your cemented implant that it's subsidized, It subsides more. So there is a concept here of. Of hoop stresses, Yeah. And that's what you can also touch on in your answer to get just the score a little bit higher.
That's when you the cement, when you're putting your implant, the cement around the implant produces the houthis, hope stresses that enhances the fixation and the stability of the stem. So I wanted to talk about huge stresses. But I realized that beyond knowing that they're a thing, and it basically means that everything pushes outwards. I couldn't really talk about it. With in any detail, right?
As the storm sinks down, you get whooped stresses, and that's good. Is it worth saying something where you don't know much about it or are you better to? That's a very good note, not dig yourself a hole because I was going to say, yeah, it increases, hoop stresses, which means you get less loosening, which is good. But then I realized if you ask me any more questions about it, I would go, I don't know.
Now that's very, very valid question. And they get asked a lot by the I candidates is how to avoid digging yourself a hole, as you said. Yeah, and I think my for you, you won't dig yourself a hole at all. You will dig yourself hole only if you mentioned something that's funny, that's out of the ordinary, that's something, you know, waking up the examiner and then the examiner or something completely irrelevant to the topic.
But if you could just simply say the cement, the tapert, which polished implant when inserted into a cement, the construct produces hoop stresses that enhances the implant stability. That's wonderful. And the examiner, if they want to ask you more about hoop stresses, I guarantee you they don't know more. But if they want to ask you more, you could just simply sorry.
That's all I know. Just just that's the I know. This is the Exeter principals, and I know that it works well. And that's it. That's all I know. Yeah, I think that's absolutely fine. You don't need it. There there will be a stage when you wouldn't. You can't go any further.
There will be, you know, and that's fine. You know, you know, you can in, you know, we all have. A certain memory span, you won't remember anything, but I remember from my exam, I used to remember there are papers discussing this and that, but I've never been able to quote the paper I was. But they never actually didn't feel too much to mind that at all. I just told them, I know there is evidence.
There are some, some paper recently discussing this, this and it showed this and that they were happy. And I mentioned that almost in every single answer. There's the literature that explains this without actually quoting the exact paper or in digging much into it. You don't have to. Honestly, you don't have to. I think that's my take on this.
But I think only you dig yourself a hole if you Mason something weird and wonderful or something out of context. And they you, you, you, you, you, they. They like a humble, simple surgeon as well who knows their limitations. Yeah, they might actually be irritated to find a candidate, you know, spend all their training days just studying books about biomechanics.
They want to know that you just understand the clinical implications. And that's my take on it. But I think, yeah, lovely. Good, good. So well done, Simon. So we'll move on now to the next candidate, who is aj?
AJ Hello. Good, good. Right so, jay, tell me what you see here. So on this x-ray, I can see AP and a lateral view of the cervical spine with an obvious finding of a postsurgical plate and screws in the cervical spine, which is on the. Five, five, six level with a spacer or probably a craft.
So I and the plate and screws that I a so I'm thinking patient had an of procedure done. And honorably slap lesion perfect start, perfect start straight to the point explaining exactly we are in the base. Remember you are in the basic sciences station, not the trauma station, you're not an adult pathology station.
So what do you think the next question is going to be? So describe probably the implant used and could be, yeah, or Uh, depending on the degenerative spine. Could be or it could be. What approach has been used to do this procedure? OK, so usually for the act, it would be an Imperial approach, which is usually from the left side.
Yeah Yeah. It has to be it's called a Yeah see, the F is here for a So it has to be a Yeah yeah, that's fine. So so tell me about, Uh, about this approach and you told me from the left side. So I hopefully within your answer, you can explain to me why on the left side, so so so a approach to the cervical spine would be adequately consented and position patient under general anesthetic and skin.
Landmark would be midline incision or we can do a transverse incision, which is more. More cosmetic incision, but on the skin and subcutaneous tissue, you would divide the plasma and then you would see the initial investing layer of cervical fascia, which you would divide longitudinally to see the slap muscles, which are retracted on both sides.
You would try to find the plane between the carotid. Utterly and and slap muscles. And then the next layer would be the deep layer of the cervical fascia, which on incision you would reach the required level of the intervertebral space you want to operate. There are few structures you need to be careful when you dissect the brain structure to look for would be the recurrent branch of the a recurrent laryngeal nerve.
And also, sometimes you have to be careful about the esophagus and trachea when you do deep dissection on the left side. There will also be the thoracic duct, which you need to be careful about in the proximal part of your approach. And depending on the vertebral level, which you had chose to operate, then you find your vertebral level.
And the first thing would be to get clearance of the bony to and then do a this to me up to the level of the posterior longitudinal ligament. Sometimes if there is a joint property and if there is thinking of the ligament on flavor, you carefully remove the hypertrophic labrum as well as the joint capsule and taking care that you don't cause damage to the dura.
And once you get the intervertebral disk space cleared, then you can. Then you can stabilize your decompression by using either a ring, a try cortical drug or a ring construct with autologous graft to. And then you can add, add the stability by using anterior plates and screws.
Brilliant, brilliant. Very good. Very good answer. You say I was very quiet and that's what a purpose is. That's I think that's how that if they ask about approaches in the exam, that's how it should be. You take the examiner through the whole journey. It's like you're telling them story.
Yeah, it's like you telling them a story showing them and they will not ask you any approach in the exam that you're not expected to have at least seen, at least, if not done. Yeah so there's no excuses, unfortunately, with approaches to say, I've never seen it. You know, if you have never seen it, you could say it, but they won't ask you an approach they would not expect you to see.
At least see if not done personally. So, yeah, and that's how they approach the question in the exam. What approach should go? So generally for the approaches, they will get asked about an approach at least once in the exam, probably twice it could come a trauma. could come in pathology in the pathology section. Even any section really can't come most commonly in the basic sciences, but have a system.
Yeah, for answering any common question in the exam. One of them is the surgical approaches. So as you said, inappropriately, Ma consented and who checked listed patient. Uh, you've got to say this, I know it's boring, just say it. You've got to show the examiners you are safe. Always remember you positioned how you position the patient. Yeah, and you didn't talk much about positioning the patient, as you know.
Yeah, that's very important. You don't start the operation. With that appropriate positioning. Yeah, obviously it is not only Cahill, but always remember that you inappropriate approaches. You talk about the tourniquet and you talk about the CRM. Did you talk about the crm? No, no, no. It's part of this procedure.
Yeah, Yeah. And it's part of most of our procedures, even for us. I'm sorry. I'm sorry for the interruption. Yes, the link takes me to your meeting. Is that right, wine? Or shall I? Yeah now you're right. One year.
Well, thank you. Thank you. So sorry about that, so yeah, so. A CRM, so CRM was used in many of our operations, so. So always have it, even if you don't know you need it to say this procedure, I don't need the CRM, but at least the examiner will you're considering everything you preparing, ok?
And you're just not concerned about holding the knife and starting your incision. You have done adequate preparation. So here? Remember, in your answer, you have to say the position. Yeah Yeah. You preparing for adequate exposure? Yeah yeah, Yeah. This might be boring words, but the examiner won't want to hear those words.
They want to know you are safe said. You don't want to know after you are after you prepared everything. That's the preparation. The drapes are in the way of your incision and then landmark. You were not very clear about the landmark where, you know, I was initially thought midline incision, but then usually go more cosmetic transverse incision.
So I don't know how to answer this incision between both or mastoid. Yeah, but you got to mention this until this examiners. Yeah, we are all here just to prepare for exam. I'm not a spinal surgeon, you know, apart from watching, doing one in 10 years ago, I now know nothing about this approach. But the examiners want to hear some buzzwords from they not hear the word landmarks.
Yeah, and then they go to sleep again. Yeah, they sleep there. Then you mentioned incision. They wake up again. That's OK. They go sleep. So landmarks, they want to hear this world. You have to mention if there are no landmarks, say it. They want my landmarks are.
That's yet to be here about it. My incision is this from here to there, my entire nervous plane. You have to say these buzz words. Yeah nick, Yeah. So what is your internet service plane, you have to say this words, my internet explain, is this and that in this approach and a lot of approaches, that is superficial dissection and dissection.
And you did mention my superficial reaction and deep dissection. And you did say that and you were mentioning your structure at risk. Yeah you were so. So just be a bit more clear with the words you're using the structures addressed in my superficial dissection of this. The structures at risk are that in this section of that, ok?
Yeah, so just be so when you mentioning other approaches, you say any approach. You say, what are the indications for it? Yeah which you mentioned, as I said, the positioning of the patient. Yeah very important. Are you going to how you position the patient in those various ways, you could position patients for various procedures.
However, you know, this is the main things I want. Obviously, they have to be in slight extension, and that's what higher order thinking is, you say the snake is in slight extension, and that's not how the examiner will know you have seen this. You have actually, with your hands, positioned the patient on the table. Yeah, Yeah. And you tell them when you say words like but not in my allopathy patient, the examiner will be ecstatic.
He will be. They will know you completely safe. You know when how to position your patient, depending on their condition. Yes Yeah. You're turning the head away and and you're getting the X-rays to identify your correct level. That's medically, legally, very important. If you don't say it in the exam.
I probably find it difficult to pursue. That's a medical legal aspect, is getting your correct level. Yeah, and you need an X-ray. Yeah OK, so these are safety, safety come first in the exam you got demonstrate you are a safe surgeon. You're not going to bring litigation to your department. Yeah then we talked about approaches and really approach from the right or from the left.
Yeah, Yeah. So which what you need your preference and why? So I would prefer to approach from the left because on the right side, there is higher risk of recurrent laryngeal nerve injury. And on the left side, the course of the current laryngeal nerve is more defined. And so it becomes much easier to protect us from damage. So the left side is longer.
A longer and more predictable course on the left side. Yes OK. And that's why would you approach it from left side? Yes OK, fine. There's nothing wrong with that answer. But but there are the literature tell us there is no difference in injuries to recurrent laryngeal nerve with the approach from right or from left.
OK, so you do the approach. If you are right handed you, you'll find it easier to approach. From the right, and there is no increased incidence of it's like, you know, it's like, you know, you need to know your anatomy and that's why you know, there is more incidence of sciatic nerve injury with posterior hip approach, but that doesn't mean they cannot do posterior.
Yes, you just need to know where the nerve is. Yeah it doesn't mean that you have to do and always multilateral approach because of that. So so yeah, there's no difference in that. In fact, there could be more risk. If you go the left side because you've got the thoracic duct in the way, in addition to everything else. Yeah, but that's fine. That's a reasonable answer.
But you, I to justify your answer. I think this is about long course ulnar nerve and stuff like this. It's all theoretical. I don't think there's anything evidence to back it up. And then you describe your incision from midline to border of the mastoid muscle, and he's describing a superficial dissection and your deep dissection.
You describe that very well. You described your superficial dissection of dissection. This part of the answer was perfect. I described your approach dissection. You describe the structures at risk is very good. You went through that very well. And then you got the deep dissection. Honestly, I won't bore you want to disguise the same books is nothing invented, anything new, and this is about obviously as you described the left-click recurrent laryngeal nerve has got a longer course here, so it's probably more amenable to be moved.
Theoretically, I don't know. Practically, I don't think that's been confirmed. I think the next question would be here is that OK, you accidentally injured the Ranger nerve? What are the implications of that on the patient? So the patient would have a hoarse voice after the recurrent laryngeal nerve injury because it supplies the vocal cord and the structures controlling it, so preoperatively would discuss the patient about the risk of original injury and potential for the correct.
Hoarseness of voice after the surgery. Now what can you do now, patients come to your clinic six weeks after and they still have hoarseness, a voice, so. The one thing would be it would, Uh, be either in Europe or Asia or iatrogenic injury. So even after six weeks, it is not resolving and patients having crossed a soft voice then would have to evaluate for the weather if it is injured or not.
Would also discuss him with the colleagues in int department to see to evaluate the work of God and to see whether there can be any, any. We have a possibility for that. Yeah, that's a tragedy. That's well, that's I wanted to know again, safety, you're going to acknowledge the problem. You can refer it to the US specialists. Yeah, yeah, that's what they want to know.
Complications can happen. Yeah, you're not going to say, oh, this is going to better observe the patient. That's it, observer in six weeks. They know better. Are you going to do something about it, which is refer the patient to your EMT colleagues for further evaluation? There are things they can inject, apparently Teflon or whatever, and which can improve the situation.
But that's not for us, it's for them. We see you referred to your colleagues and then it structures at risk obviously has to be, as I said, part of your approaches. Answers to approaches. Yeah so structure at risk. I think you went to that. I think guys, if you want to maybe take a photo shot of this, you just have a system, I think.
Say these buzzwords and just fill the gaps, just fill the gaps with ethnic, you know, they know you're not expert in anterior cervical approaches that you just don't know the principles. They're wonderful, very good. Now other things that give you back here in your answer say you were saying generally you talking like you could do, you could do just it's your patient. Yeah, Yeah.
Imagine every patient in the exam is your patient. So I would take charge of the situation. You are a consultant in charge of this patient. Yeah, you've been asked your opinion. That's how it is. You've been asked your opinion, your expert opinion, and you're giving it. So I would take this patient to theater. I would position them like this.
I would get the X-rays. I would do the incision. I would consent. I would. I would. Yeah, yeah, you. It's all about you. Your opinion is what matters at this time. Yeah well, then again, thank you.
So we got to move on, guys. Now I think, Uh, next candidate is one, I think. Yeah so I think after this question will probably should move on. I've got two more questions which I could go through later on, but I think after this, next one will probably go to the hands station. So what are you with us?
Yeah, Hello. Ready? Yeah. So first, I want to see an example. I'm getting it in June, June. Lovely, lovely international one Yeah. Yes, Yes. All the best. What that way is that Dubai, you mason?
Yes, exactly. Exactly that's nice. OK, lovely. What do you see here? Oh, actually, I can see a photograph on the left side. I think it is a photograph of a demon born metrics and on the right side. I think these are the most liked pieces of being less bone matrix mixed with blood.
OK, so tell me. Do you decide this bone graft, Yeah. Yes, it was a bone drug substitute, actually. So tell me what is bone graft and why do we use it? Always the answer. Always these guys just has advise you whenever they ask, what is something? Give a definition and why we use it.
What are the indications within the same answer? Generally speaking? Bone graft is a bone broth is bone broth can be autochthonous or allergenic, so it can be a synthetic. Now what do you know? What is it all about is a substance like which can be of different types, which is used in special situations where like nonunion of microfracture or to fill a gap which is damaged by a tumor or we can use in backing grafting like in total hip hop for bas status, where you are doing a revision setting and it has a lot of uses and it comes in handy in different scenarios as to induce a bone osteogenesis.
OK, that's fine, I think you touched on the main principles of the answers here. As I said, it's a material used to support bone healing, where it's either the mechanical properties or biological properties or both. Yeah, provide structural stability and structure healing. That's really only that all you need to say in your answer. And so one of the thing we are here today is to improve your score and optimize how you use your time in theater.
You got 5 minutes and they will go within, you know, very quickly. You know, you blink. They're gone five minutes. They go very fast. And you got the score. You prepared for this exam for so long, you got so much knowledge. To impart.
And what happens, most cannot leave a stage, I think, oh, I knew a lot more. And I did not say it. I knew a lot more. And you think, oh, this examiners must think of I'm an idiot because I only was talking about the basics. And the reason of that is that you don't have enough time. The goal about to show all of your knowledge, so.
So you spent more than a minute just going through the same thing. And again again, all you need to do is you couldn't answer that. This is the opening question. You're not scoring anything still and you don't want to spend more than 30 seconds on your opening question. You're not scoring anything, this is just to assure the examiners that what the bone graft is.
Or you see, you know what it is. They proceed with the question. So tell me now about what you know about what different classification systems we have for bone graft. And they believe this is a very boring question. But believe me, I picked it because it was asked in February's exam. They keep asking the same questions again and again. Both groups can be classified as to their whether they are all still in the field or they're also conducted.
That that is what the mechanism of how they are. They are supposed to be used. Otherwise, when it comes to the varieties of gun drugs, it can be classified as autographs, all of drugs and synthetic bone matters. Fair enough. Now how would you ask that this is you're going to classify? You say classified bone graft. According to qualities.
Or, according to ET's source. That's how ideally I would love to answer to start and then I must examiner. Can tell you, OK, well, tell me about the sources of grafts, different sources of. Well, I can tell you, OK, tell me about different qualities. Yeah OK, so, so tell me now about the different qualities of bone graft that of.
You did mention that correctly, you will start. You are absolutely on the right spot there. Is the Austrian conductor so sorry? There are two different sides, ultimately, those two people. And one no one is Austrian conductor. When you are, when you're mentioning the word Austrian India, we are, we are. We are, think about a situation where there is no bone healing happening and we need to induce bone healing mechanism or that happens when we have viable bone cells and which can which which has bone mineral Martinek proteins and that induces the healing of potential.
And it is like we were put in a situation where there is no healing at all these function in the best way. And when need to also conductive, not as such a structural bond where we have this needs to function as a feeling between the bone loss and as well as it can be used as a.
OK, so Paul, on again. Uh, same thing. You you could just use the simple buzzwords in your answers. Yeah in the exam, so you can just simply the examiner. There's also conductive bone graft. Which act as three dimensional scaffold?
That's it. Osteo inductive. Which has biological factors to stimulate bone growth and healing. That's it. And then you got the osteogenic bone graft that has live cells. Yeah live mesenchymal cells, this is osteogenic bone graft, which you did not talk about, and that's it.
Yeah, you could answer this whole question in 3 simple sentences very clear to the examiner. That's what they want to hear. Yeah, you did answer correctly, by the way. Yeah but just to the time and I am as examining, I had to really focus with you to see exactly what you're talking about. You mentioning the meakin keywords? OK, which is fine.
You still pass. Yeah, you still pass. But you, you take a long time. That a lot of concentration from the examiner and long time, that's the day not going to find time not to take you to the higher questions to 7 and 8 questions. Yeah so but that's good. So you classifying according to the qualities of your conductive post, inductive and osteogenic?
Yeah fine. So as I said, conductive is a scaffold inductive has the biological factors, and estrogenic has life mesenchymal cells. OK in addition to the biological factors, obviously. Or you can classified, according to. Thoughts? Yeah. You can classify, according to qualities, according to source, so tell me about the source.
The source? Yes sources of drops be it can be ordnance bone-dry, one is harder from the same person body and used who we are to use the bone grafts can and rocks. And there are in the book about xenograft been born at different times.
OK, that's very good answer, you see. Brilliant you got already better for. You already got better in your technique, not your knowledge, your knowledge, is there fine? Absolutely because now you allowed me You showed me immediately within a few seconds that you understand the origins of bone grafts. Now I can expand further as I want as an examiner.
If I want to ask you about the autograph to me more about the advantages, disadvantages, different structural properties, cortical considers, cortical cancers I could ask you showed me the basic stuff, but you forgot to talk about bone substitute. Yeah, which is another source of bone graft. Very important source, which can create a lot of discussion. Yeah so.
So, yeah, so classification, according to a source autographed. Yeah these are all from the books. I'm not going to bore you guys. I'm not nothing. They're invented. You guys take a photo shot if you like it. But, you know, autographed advantages. Disadvantages umm, allograft, as you said, and then we can talk more about allograft that could be in itself, that's the topic of question, you know, for a lot of time that we could go then and what is different types of allograft, fresh frozen, freeze dried and then rice?
What might taste and what are the differences between them? And the bone substitute, obviously, which are synthetic, that's why you have to use it. It's part of the answer. You did not mention it. You've got to mention it. Here is a synthetic material. It's bone substitute.
So that's good, that's good point. Are you happy? Well, so now now you've done very well. I'm going to throw the last question at you is what's the ideal bone substitute or bone graft for whatever? Oh, I bought. That's what you want to get to your answer very well previously.
You go quickly through the exam. Do you want to get to this question? This is a question. You know, if you get this question, you are getting close to eight. Open muscular, on the Eve of you breaking up for one, I think some connection problem, I can't hear you properly breaking up, but I think we've got to move on now to the hand station.
So so basically, these are the main principles of the ideal bone graph that you got to mention. Your exam has to be biocompatible. It has to go after these properties. It has to be resolvable as obviously bone substitute. You don't want to be staying there as a foreign body forever. It has to be easily molded, which you can put in the defect that you want.
Um, obviously, it has to be sterilized, but. A regular sense it doesn't get in the way of assessing your fixations or. And it has to have a really, you know, reasonable cost and be available in the market license and everything and has a reasonable cost, so it could. I would probably view this question as a high level kind of. The cherry on the cake kind of question.
OK, guys, so I love, so I think now we spent long enough on basic answers and I will move on to the hand station now.
Segment:0 .
OK guys, so welcome to this case, discussions for the first case exam, the course today involves seven stations covering all aspects of the exam from the rival stations.
Five other stations pediatrics, hands, pathology, trauma and basic sciences, and two clinical stations, upper limit and lower limb clinics. The course is intense. It is tiring. We will be going through about almost 50 cases today. We have to stick to time. Yeah, we have to keep moving every 10 minutes because if you just spent 10 minutes per case, that's eight hours.
So and it will be guys exhausted at the end, so we just have to stick to time. And so excuse us if we move on between the Kessler, this is what we're covering and the faculty today, they call coming and joining later on their time slots. Top faculty who has been educating for FARC for a long time, they handpicked really for their skills in specifically in coaching and mentoring FARC as candidates.
So I said we'll have 10, 10 minutes per participant. And it is a case based, case based discussion course, when we go through the cases with you, we ask you questions and see how we respond. We try to give you feedback and we will be focusing only not on your knowledge in orthopedics, but more modeling how to techniques for the exams, how you answer your question, how can you score higher?
What are buzzwords to use? How can you be focused in your answer? Yeah so we will try to avoid, you know, going into great depth into any topics, anything beyond a farke's level. We will not go. Yeah, our aim is to keep it there for this level and try to help you guys get it 7 and 8 in the exams. Yeah so we will not teach you.
None of us is top expert today, for example, you know, I might be discussing things that I might never done in my life. So none of us is an expert or expert in any of the topics we are discussing. We're not here to teach you. We are here to guide you. OK you got the knowledge. You passed your exams.
You've done your trainings. If everything what you need now is exam mentality, exam focus and just to nail it in the day. So I just say, guy, just during the day to day, just try to when you're not talking, you just mute yourself. Uh, you know, I know you all probably sitting comfortably in your homes and there could be some times distractions and stuff and noises.
Just try to mute yourselves when you're not talking, just to reduce any distractions. Um, that's great. And just to obviously allow a person who was in the hot spot to. And are full time, please. OK, so what are we giving feedback to you learn from your performance, but also you learn from your colleagues performance.
So make sure you guys you write down the questions, you write down the feedback that's given, ok? Because today will be intense, so you can go back to these notes later on, maybe tomorrow and reflect more. Well, unfortunately, we would not be able to share the slides, so if any of you was, you know, want to take any notes you can, you can take photo shots of any slides you want.
And just stay in touch with us, and there are also other courses I want to ask you. Time now on those, but might share them with you if you're interested later on. Encore? yeah, for the last many years. So you get the same questions, sometimes they are new twists on the questions and new evidence to add new changes, but they tend to be the same topics.
And when I ask the people in the February exam what you've been asked, I find they are exactly the same. Nothing weird. Wonderful so that's how it is. So I can tell you the basic sciences, we a lot of us just general guidance, a lot of us are apprehensive about it. But in the exam, it's probably if you know your stuff, it's all about basic sciences is more All about knowledge.
If you know your stuff, you score high. No doubt about it. You know, no tricks. There's nothing. Questions are always straightforward. In fact, if you're good at your topic, if you prepared well, you could spend the whole five minutes in the exam. Just giving the examiners a tutorial. It has happened.
I've seen it happening and we heard a lot about. We were always in touch with candidates and. You could just spend the whole five minutes just taking the exam, and then I will just sit back and listen, enjoy the talk. That's that's very possible. So, you know, again, try to, you know, you don't need to go because I know there are, you know, sometimes some courses I used to attend and some books.
I used to see, they go into great depth that you feel you feel completely lost. You don't need to go into great depth at all. You need to, you know, you need to. You need to fall. You need to. They don't look into great detail. They're not biomedical engineers. They're they are.
They're not histopathology. They don't want to create. They want to know what exactly is relevant to our day to day practice. And that's what the examiners know. So you don't need to go into a great depth in any of your answers. That will be my advice to you. Stay broad and superficial.
And if you're scoring very high or if you are, you know, very expert in particular topic and you want to shine, you can OK, but you have to know how to play that tactfully in the exam. Is there a quite difficult to draw on this platform, but in the exam, please practice drawing and practice talking while drawing and make your drawing big to the examiners can see it and they will always be papers and pen in front of you on the desk.
So as I said, all the questions today, I've been asking the exam, so we'll move on quickly now. Good OK. So now tell me what you can see. So this is a limited AP radiograph of the right hip showing a cemented total hip replacement with a metal stamp metal head and a liner lovely cemented hip replacement.
So tell me what is cement? It's a composite biomaterial which has which acts as a Grout, essentially in total hip replacements. It has got liquid and solid phases. Solid phase is the PMMA powder mixed with an initiator and an activator. The liquid phase has a tile may missile mono acetate.
Sorry, I can't remember, and it's got the inhibitor which prevents polymerization within the liquid itself when these are mixed together. So that's fine. Well, so tell me, why do we use cement? So aid as it acts as a crowd, so essentially acts as a space filler between the stem and the shaft.
Yeah, Yeah. But generally in orthopedics, why do we use cement? Is it just a joint replacement? Do you use it for anything? Other indications you can use it as a space filler, especially in proximity to be a fractures when you have bone defects? Yeah, it can be used as a carrier for antibiotics. Yeah yeah, that's good, that's good.
Yeah, that's good, so that could be part of if your answer of why we use cement. Yeah and when you ask about what is cement? Yeah what is cement? We probably before jumping into that, what components of the cement are monomer and polymer and fluids stuff? You could start with just generally, what is cement definition, as you said, you know, just a simple thing.
Do we use cement? Yeah, OK. And I can tell you in the exam, you're not scoring is still not scoring anything. These are just warming up questions just to make sure you know what there is, what you're seeing. You know, what there is something called cement. And you you're not a former candidate. You can the examiner can move you on, so you're not scoring anything on this opening question.
Yeah, they need to waste too much time on it. Yeah so, yeah, so obviously you can use it in cases when you need to improve various forms of fixations, such as in joint replacements, avoid filler and provide mechanical stability as well, like in vertical plastics and also void filler in tumors. Masculine techniques? OK so that's what it is, yeah, so fixation, load, transfer, filler and mechanical stability.
OK, so for general uses of cement? OK so not just only in joint replacement, so because you remember this question, the opening questions here. Yes, we have put a joint replacement, but we're not talking about the. We're talking about cement. So just get to think all the examiner's thinking, OK. So tell me now in your joint replacement surgery, what type of cement do you use and why?
Which cement you use when you are a consultant, what cement you're going to use and why? We use high viscosity cement, which is a trademark, of course. Yeah, it's called vancomycin and gentamicin in it. Yeah which our antibiotics? Which help reduce the incidence of infection. Funso, so you said you use bellicose.
Yeah, because if it is high viscosity, yeah, OK, so tell me now, so you've taken this question into the viscosity direction? Yeah you decided, which is fine. So tell me about viscosity. What do you know about cement viscosity and why you choosing a high viscosity cement? Rather than medium or low.
A high viscosity cement gives you. More working time. Yeah which allows us time for application to implants and cementing them in place versus the low viscosity cement which is used in water propensities. OK OK. Yes it's more fluid and can be injected into low volume areas. Yes that's so.
So tell me, tell me now about this. A, you know, pellicle segment of yours. Tell me more about it. It's got a powder and a liquid face, yeah, the powder phase is PMMA powder. It has got a radio opaque barium sulfate. Scott chlorophyll as a color. And I think.
Initiator, which is. Benzoyl peroxide. OK this powder phase and the liquid phase is me, which is the monomer, and it has got an inhibitor which avoids auto polymerization in the liquid phase. OK sure, sure. Are you bellicose? Why not anything else?
So there's good evidence to say that antibiotic loaded cement prevents infection and joint replacements. Yeah, that's fine, that's fine. That's good. So anything else, evidence to support the use of bellicose at all over any other type of cement?
Sorry, can I write replacement surgery? So sorry, I cannot think of any evidence. No, that's fine, that's fine, it's good. So, yeah, I mean, I agree with you. I mean, you know, I would use bellicose, but I'm not, you know, the timing for this. You could use anything you like. You just support it. Yeah, that's what the examiners want to know.
So when they're throwing this question to you, what type of cement you use? Yeah, it's just an opening question just to show your knowledge about cement. They don't care what cement you use. No one, you know, examiners will not care what type of cement you use. You practicing in the UK, you're going to be using a certified type of cement.
You are going to be using anything dodgy. So they want to know is, is is, you know, about cement. So when you ask about this, you could take these questions into three directions to justify your answer. You could talk about the components of cement because I like the cement. Because it has the colorants, for example. So it allow me to differentiate between the cement and the bone.
Yeah, it has the radio, opaque materials, the barium to allow me to see it on the x-rays. Do you know what I mean? You just that's what's higher order thinking in the exam. They want you showing that you just showing your knowledge, but in how you use it in your daily practice. So when you asked about cement? Uh, what type of cement you use?
I advise you the way I advise you to go is go through the components of your cement. The viscosity properties of your cement and the anger in the air, we know from a jar that publicos has lower risk of revision in 10 years for septic and septic. So the ingredients of cement. Yeah, as you said, powder and liquid, and I've stolen this mnemonic from Nike, some of you guys might like mnemonic to help you to remember.
I think the stress of the exam will probably become handy. So powder, you know, polymer is the powder. So PFLP and IBC, so I is the initiator. B is the barrier. And see, is the chlorophyll, so pib, if you like. But what the higher order thinking that you owe they always been referred to in the exam is, is how you justify. So you say there is a polymer that gives the structures structural strength in cement.
Yeah, that's how you answer the question. So you just define your answer. You want the 24 examiners to ask you, OK, why you care about. There is a barrier. Yeah, just not say just there is a barrier is explained, just justify why there is a barrier and why I like the cement that has barrier in it. Yeah you know, what does the initiator do? What does the antibiotics do?
Yeah, and why there is antibiotics? So so so we've talking about antibiotic antibiotics, for example. The next question we could be from the examiner is which antibiotics with you at your cement or which antibiotic add is added to your preferred cement. Vancomycin and gentamicin. OK, and why these antibiotics? So you.
I so here. What do you give your answer in the exam? Don't say Mason because everyone knows the gentamicin, yet you now you you want to impress the exam and tell them we're using gentamicin examiners doesn't want just to know that you have to because they can open the packet and they can. Anyone can see this gentamicin, but they want more justification from you.
That's the higher order thinking. That's you actually in a. And explaining to them, why gentamicin? Yeah, but examiners can ask you, but then you will if I ask you as examiners, they'll probably scoring six, but if you say it by yourself, it's why gentamicin is used. That's when you're scaring 7 and 8. Yeah so why gentamicin? Why not the penicillin?
It's got a broad spectrum of activity. It has heat stable. So during the mixing phase, which is an exothermic reaction, the antibiotic doesn't get inactivated. OK um, anything else? So it is broad spectrum, as you said, it's heat stable. Yeah it has long Ellucian time and it has the minimal disruption to the mechanical properties only adds what is the disadvantage of adding antibiotic is that makes the cement a little bit more brittle.
OK and that's one of the disadvantages of cement or poor quality, but it adds to that. So that's why there is a limit on how much antibiotics you can add. OK and then you got the liquid. Yeah, so you got the powder and you got the liquid. Which has the monomer and accelerator and inhibitor in it. Yeah OK.
So, you know, all about the cement, isn't it? You just need to be able. To use that knowledge as quickly as possible, because you remember in the real exam, there's a time limit. Yeah and you know, time is your asset in the exam, you know, you're scoring, the more time you have, the more you can score. So you need just to get on with it. But it's a good start and a good start here.
Lovely, lovely. I think now. Now I move on to Simon. Sorry, fellas. Can I ask you something? Yeah, you made a statement statement from Ngo. Bellicose has high risk of revision in what? What did you say? I just know lower, lower risk of.
Now, yeah, but that's a lower risk of revision with bellicose cement compared to any other cement for septic and aseptic loosening. OK, thank you. Well, that's know, that's how you know, you justify one of the justifications of using bellicose thus higher order thing is just defy your answer as an independent consultant. Yeah, you've been sitting on board.
You'll be asked why bellicose? Why we are purchasing power costs and not purchasing other cement. You could use other cement as long as you convinced of its qualities. But now we're doing just exam practice, so you just advising you what to say in the exam? Lovely so, Simon.
Good morning, Simon. And so I think your exam is also in April, isn't it? Yeah November, November. OK, well done, then early preparation. I think that's definitely a good thing. Lovely, Sam. I so you've seen we're talking about cement. OK, so we carry on with the same subject. I'm going to want to see because Hammond touched on the viscosity of cement.
Yeah, for you for joint replacements, what type of cement would you prefer in terms of viscosity? And what the different viscosity of cement of. And as far as I'm aware. Once you've covered what cement is made up of. My my use of.
Of cement is the same, I want a high viscosity cement for the use of my arthroplasty. I want it to kind of Interdigital it and give me a good fixation in my arthroplasty. So I would use Pentecost as well. Lovely, lovely. So obviously, cement in Durban has got viscosity catalogs and there are low, medium and high viscosity cement. Yeah and we don't need to know, go to a lot of depth exactly what you said.
There's no need to really go into depth into what the viscosity is of the mains and diverse. But what we know, what we need to know as orthopedic surgeons is what each one provide us. So the low viscosity cement, it has a low, doughy phase and a short working time. OK, so it's not really ideal if you're doing joint replacement surgery. And joint replacement surgery.
You want a high viscosity cement that gets that has a longest working phase. OK, so it allow us to work more. That's what we want. So that's really why we use a high viscosity cement. OK there are evidence that there are more for giving, and that's why they are the most commonly used, predominantly used cement in the United Kingdom. So and that could be part of our answer as well.
You know, when we're saying justifying what type of cement we use because high viscosity cement is allowing us, it's more forgiving a lower small working time. And that's why it's most commonly in practice in the United Kingdom. Yeah and that's what you want to say in the exam. We want to say what's come on the practice? We want to be out. We don't want to be outliers.
You don't want to be. You don't want to look different in the exam and be safe and boring. Absolutely you want the examiners to forget about you when you leave the table, you don't want them to remember you unless you're outstanding. That's fine. I mean, obviously, the top scoring people they will remember, they won't forget these people, obviously, because, you know, they know everything.
They all know all the evidence. They've done all the PhDs and relevant stuff, so they will know. But otherwise, for the majority of us, we just want to be bold and boring, as you said. Simon, so. So if it is, this cement is the common use, that will be our answer in the exam. Exeter, Exeter yeah, that's it.
So obviously, when are you talking about cement also just explain the examiner, the rate of setting of the cement depends on the environmental factors, as you know, guys like temperature and the humidity in the storing areas, as well as in the operating theaters. Yes so we have to be aware of that during our work. OK, good.
So I'm afraid Simon is next question is, tell us about the cement setting stages. So after you've after you've mixed your. Setting it it's divided into four phases. The first phase is the kind of curing phase, and then it goes Mixon.
Sticky working and hardening. Are mixing is, as it sounds, it's when they're mixing it normally under vacuum. Sticky is as it sounds, and it's when you get a little bit out at the end of the tube and you often put it in between your fingers and it's kind of tacky. Yeah working is where you're doing. The work of inserting the implant and hardening is, as it sounds, where it's setting.
For me, I like to implant relatively early, but as soon as that sticky phase becomes the working phase, I like to implant early because I'd rather have time to get my implant exactly where I want to do some fine tuning than be caught short, and no one wants to do it on table revision. The sticky phase is when it's still quite low viscosity. It kind of is going everywhere. You know, if you put it on the drapes, it kind of puddles, whereas the the, Uh, the working phase, it's a bit firmer and you can start to kind of shape it and roll it into a ball.
Again, I'm always mindful of things like fair to temperature, because if the theater's warm, if it's summer or the air has worked, your working phase can be a matter of minutes. And for most cement, I guess they Harden. My experience has been somewhere between 10 and 15 minutes, which is why I always wait 11, just to be sure. And that's all I know, really.
So the positive things there, Simon, you demonstrated you are a safe surgeon. That's very important. Now you it's like doing a driving test. You have to show the examiner, you have to demonstrate to them you. So you have to show them are a safe surgeon. As you say, I'm starting at the early as early as possible in the working phase to optimize the working time.
So because I don't want to get short time and doing table revision, as you said, and that's exactly what they want. They want safe surgery. They don't want you to know everything about cement ingredients and things they want to know. You're a safe surgeon. You know how to use cement. And when you said about your mindful of the temperature in theater stuff, that's an extra safety feature you put in your answer.
And that's exactly what they want. Honestly, that will be music to the examiners. Yes, they will just love to hear that. And for those examiners, for those candidates who might be struggling with their answer, if you throw these safety words, you at least you're guaranteed you passing this question. Yeah, if you're not scoring higher, obviously, but at least you know you, they know they are your sensible, you know, they are safe surgeon who knows the qualities of the cement.
And that's it. They are happy for you to come and do your independent list or arthroplasty list in their hospital. So, so, yeah, so these are the phases now there are a lot of slight controversies about the terms used, but I don't think it matters because you explain that how and exactly what it is. So there is the mixing phase when you mix it, it's about 30 seconds and the doorway or the sticky sticky phase.
Yeah obviously, you don't want to be handling the cement during this time because anything could stick. Stick on it. Blood debris, bone debris, whatever sticks to it. You don't want that. OK, you want to wait until you're out of the sticky or doughy phase. They are the same, though, if it's exactly the same as the phase.
No difference between them. Some references, for instance, this that did exactly the same. And then you move into your working phase, that's when you really have to be 100% focused on the job, no distractions at all. Yeah, and no music, whatever. No, not no distractions in theaters at all, you're focusing, you got this 5 minutes to execute the job. You know, that could be 5 to seven minutes.
Obviously depends on many factors. And then you got the working phase and then you got the hardening phase phase, obviously, and then the total set. Yeah, the hardening phase of the cement and the hardening phase of cement. Simon, how long that can be the final hardening to, you know, I mean, the my understanding is the final hardening can actually be up to 24 hours.
Yes but the one that matters, the one that matters is kind of 10 minutes. But I guess that would fit in with the idea of even though it only reaches its ultimate strength at 24 hours because we get the weight bearing it, that will probably have implications on things like a little bit of creep and that sort of stuff as well. Absolutely, and that's what we're going to talk about next.
Oh, good, that's good. Yeah so yes, absolutely so. How about 24 hours? And that is when the cement has its some of this biomechanical properties? Yeah and in the setting time, obviously, Uh, it's all dependent on many factors. But yeah, these are mainly mixing, though we working on hardening hardening phases.
And that's how it is. And this is from what book consists of. That's what an exam please draw. Draw this timeline and just show to the examiners what each phase is and what you're talking about, and it's really very it can be simple. I know sometimes it gets more complicated than that sometimes, and some references make it more complex. And I played a lot of these books and struggled sometimes.
Um, until I reach this simple, simple timeline of cement, really, and I don't think you need to know any more as an orthopedic surgeon or as for the exam. So so, Simon, what do you tell me about the biomechanical biomechanical properties of cement, please?
Yeah so one of the reasons we use cement is that it has a very similar, um, not a similar Young's modulus to court on counsellor's bone, but it sits between cortical and cancellous bone. Yes, it is strongest in compression and it undergoes creep, which is where you get deformation under a continuous load over time.
And it's all of these in combination that are why we use it, because it's behaviors are close enough to. Bone that it works well in weight bearing. Yeah, I think I like that what you said about it's the modulus of elasticity is between it sits between the bone and the implant. So it's like it's just transitional medium for the load.
So and you can start your answer here. I think it's a very elastic material. Who the cement is an Invesco elastic material, Yeah. So now then would be the question is which you touched on. What Invesco elastic properties does the cement have? You did mention already one of them, which has greater stiffness, higher strain. Yes exactly.
Yeah, but you did say about when you talk about the elastic properties in particular, you mentioned about creep. Mm-hmm Yeah. So tell us more. What does that mean and. What does that mean, exactly? Creep is the reason we put the little plastic doohickey on the end of the stem of our femoral implant, so what you get is progressive deformation in a response to a constant force over an extended period of time.
So in reality, what that means is as the patient wait Bears on their implant, whatever that might be. Slowly but surely, that implant causes the cement to creep it. It deforms progressively over time. Ergo, the implant sits down a little bit as the cement deformed outwards. But it's also again how you get that press fit as the implant sinks into it.
Brilliant yes, that's very good. I like what I like about your answer, Simon justifying the answer. Yeah, and that's what they want. It irritates the examiner when a candidate sees an answer and then told me, OK, why? Yeah so you're giving the answer and you're also justifying it using this, this because of that. So that's perfect.
So so basically, it's a very elastic material. So there are these elastic properties, three viscoelastic properties. Yeah, cream stress, relaxation and hysteresis. Yeah, but not every elastic material has to have the three properties. OK, so the cement has to risk elastic properties, creep and under stress, relaxation. Yeah and I think it only has these properties only during the setting time.
Until it's fully hard, until 24 hours after that, it doesn't have it doesn't deform over time after that period of time, it's only until it's hard. Yeah, and that's what you mentioned about. It's how it's subsidized, how the cement, how the stem. The Exeter stem is designed to subside into the cement within the first 24 hours. After that doesn't subside anymore, it's only the first 24 hours while it's fully getting hard and set so creep, as you guys know, is that information over time.
You won't score anything. If the different definition of creep in the exam, you only score if you know what, how it applies to you, the question you've been asked and how it applies to the material you discussing about. OK, but in the exam, you could stay, you could just give them this simple drawing of creep in the exam, just kill them. This is the strain.
The strain is the deformation is the same thing. Strain is deformation as far as the fastest exam is concerned. So you could see a old load applied here. There's more deformation over time, and obviously it doesn't continue to deform forever. It stops at some point. Unless the load is excessive, obviously. So what's the other property we said about what other viscoelastic property does it have?
Simon, you mentioned stress load relaxation. Yeah which is where? You get. You get. Under constant strain you get. Decrease stress. Correct correct. Confusing, isn't it?
I got to think about it so much. I know I want to be a hand surgeon. This stuff makes me cry. I know. I can't believe how many times you're not the only one. And believe me, even the examiners will know this. The examiners at the end of the day, they are normal. Or suppose that we see every day they themselves have opened the day the book on the morning of this.
Of of the Viva to revise what is creep and what stress relaxation is. So they know. They it's very it's very tricky, but they won't. That's why they won't expect much from any of us. They want simple definition what it is and exactly what, what it means. And that's it. And they will.
As far as I'm concerned, that's all I want you to know. You know, you know, that's just this relaxation and that's one other properties. So here is you get the stress out, you know, it goes higher when you first put the implant in. But over time. Over time, over time, under the same load, which is put in, you cemented implant in and that's it, you let go. So there is no more load going on, but over time there will be reduced stresses.
OK, and that's exactly why the cement behaves well because they will reduce the stresses on the implant cement bone interface. And you touched about when you put in your cemented implant that it's subsidized, It subsides more. So there is a concept here of. Of hoop stresses, Yeah. And that's what you can also touch on in your answer to get just the score a little bit higher.
That's when you the cement, when you're putting your implant, the cement around the implant produces the houthis, hope stresses that enhances the fixation and the stability of the stem. So I wanted to talk about huge stresses. But I realized that beyond knowing that they're a thing, and it basically means that everything pushes outwards. I couldn't really talk about it. With in any detail, right?
As the storm sinks down, you get whooped stresses, and that's good. Is it worth saying something where you don't know much about it or are you better to? That's a very good note, not dig yourself a hole because I was going to say, yeah, it increases, hoop stresses, which means you get less loosening, which is good. But then I realized if you ask me any more questions about it, I would go, I don't know.
Now that's very, very valid question. And they get asked a lot by the I candidates is how to avoid digging yourself a hole, as you said. Yeah, and I think my for you, you won't dig yourself a hole at all. You will dig yourself hole only if you mentioned something that's funny, that's out of the ordinary, that's something, you know, waking up the examiner and then the examiner or something completely irrelevant to the topic.
But if you could just simply say the cement, the tapert, which polished implant when inserted into a cement, the construct produces hoop stresses that enhances the implant stability. That's wonderful. And the examiner, if they want to ask you more about hoop stresses, I guarantee you they don't know more. But if they want to ask you more, you could just simply sorry.
That's all I know. Just just that's the I know. This is the Exeter principals, and I know that it works well. And that's it. That's all I know. Yeah, I think that's absolutely fine. You don't need it. There there will be a stage when you wouldn't. You can't go any further.
There will be, you know, and that's fine. You know, you know, you can in, you know, we all have. A certain memory span, you won't remember anything, but I remember from my exam, I used to remember there are papers discussing this and that, but I've never been able to quote the paper I was. But they never actually didn't feel too much to mind that at all. I just told them, I know there is evidence.
There are some, some paper recently discussing this, this and it showed this and that they were happy. And I mentioned that almost in every single answer. There's the literature that explains this without actually quoting the exact paper or in digging much into it. You don't have to. Honestly, you don't have to. I think that's my take on this.
But I think only you dig yourself a hole if you Mason something weird and wonderful or something out of context. And they you, you, you, you, you, they. They like a humble, simple surgeon as well who knows their limitations. Yeah, they might actually be irritated to find a candidate, you know, spend all their training days just studying books about biomechanics.
They want to know that you just understand the clinical implications. And that's my take on it. But I think, yeah, lovely. Good, good. So well done, Simon. So we'll move on now to the next candidate, who is aj?
AJ Hello. Good, good. Right so, jay, tell me what you see here. So on this x-ray, I can see AP and a lateral view of the cervical spine with an obvious finding of a postsurgical plate and screws in the cervical spine, which is on the. Five, five, six level with a spacer or probably a craft.
So I and the plate and screws that I a so I'm thinking patient had an of procedure done. And honorably slap lesion perfect start, perfect start straight to the point explaining exactly we are in the base. Remember you are in the basic sciences station, not the trauma station, you're not an adult pathology station.
So what do you think the next question is going to be? So describe probably the implant used and could be, yeah, or Uh, depending on the degenerative spine. Could be or it could be. What approach has been used to do this procedure? OK, so usually for the act, it would be an Imperial approach, which is usually from the left side.
Yeah Yeah. It has to be it's called a Yeah see, the F is here for a So it has to be a Yeah yeah, that's fine. So so tell me about, Uh, about this approach and you told me from the left side. So I hopefully within your answer, you can explain to me why on the left side, so so so a approach to the cervical spine would be adequately consented and position patient under general anesthetic and skin.
Landmark would be midline incision or we can do a transverse incision, which is more. More cosmetic incision, but on the skin and subcutaneous tissue, you would divide the plasma and then you would see the initial investing layer of cervical fascia, which you would divide longitudinally to see the slap muscles, which are retracted on both sides.
You would try to find the plane between the carotid. Utterly and and slap muscles. And then the next layer would be the deep layer of the cervical fascia, which on incision you would reach the required level of the intervertebral space you want to operate. There are few structures you need to be careful when you dissect the brain structure to look for would be the recurrent branch of the a recurrent laryngeal nerve.
And also, sometimes you have to be careful about the esophagus and trachea when you do deep dissection on the left side. There will also be the thoracic duct, which you need to be careful about in the proximal part of your approach. And depending on the vertebral level, which you had chose to operate, then you find your vertebral level.
And the first thing would be to get clearance of the bony to and then do a this to me up to the level of the posterior longitudinal ligament. Sometimes if there is a joint property and if there is thinking of the ligament on flavor, you carefully remove the hypertrophic labrum as well as the joint capsule and taking care that you don't cause damage to the dura.
And once you get the intervertebral disk space cleared, then you can. Then you can stabilize your decompression by using either a ring, a try cortical drug or a ring construct with autologous graft to. And then you can add, add the stability by using anterior plates and screws.
Brilliant, brilliant. Very good. Very good answer. You say I was very quiet and that's what a purpose is. That's I think that's how that if they ask about approaches in the exam, that's how it should be. You take the examiner through the whole journey. It's like you're telling them story.
Yeah, it's like you telling them a story showing them and they will not ask you any approach in the exam that you're not expected to have at least seen, at least, if not done. Yeah so there's no excuses, unfortunately, with approaches to say, I've never seen it. You know, if you have never seen it, you could say it, but they won't ask you an approach they would not expect you to see.
At least see if not done personally. So, yeah, and that's how they approach the question in the exam. What approach should go? So generally for the approaches, they will get asked about an approach at least once in the exam, probably twice it could come a trauma. could come in pathology in the pathology section. Even any section really can't come most commonly in the basic sciences, but have a system.
Yeah, for answering any common question in the exam. One of them is the surgical approaches. So as you said, inappropriately, Ma consented and who checked listed patient. Uh, you've got to say this, I know it's boring, just say it. You've got to show the examiners you are safe. Always remember you positioned how you position the patient. Yeah, and you didn't talk much about positioning the patient, as you know.
Yeah, that's very important. You don't start the operation. With that appropriate positioning. Yeah, obviously it is not only Cahill, but always remember that you inappropriate approaches. You talk about the tourniquet and you talk about the CRM. Did you talk about the crm? No, no, no. It's part of this procedure.
Yeah, Yeah. And it's part of most of our procedures, even for us. I'm sorry. I'm sorry for the interruption. Yes, the link takes me to your meeting. Is that right, wine? Or shall I? Yeah now you're right. One year.
Well, thank you. Thank you. So sorry about that, so yeah, so. A CRM, so CRM was used in many of our operations, so. So always have it, even if you don't know you need it to say this procedure, I don't need the CRM, but at least the examiner will you're considering everything you preparing, ok?
And you're just not concerned about holding the knife and starting your incision. You have done adequate preparation. So here? Remember, in your answer, you have to say the position. Yeah Yeah. You preparing for adequate exposure? Yeah yeah, Yeah. This might be boring words, but the examiner won't want to hear those words.
They want to know you are safe said. You don't want to know after you are after you prepared everything. That's the preparation. The drapes are in the way of your incision and then landmark. You were not very clear about the landmark where, you know, I was initially thought midline incision, but then usually go more cosmetic transverse incision.
So I don't know how to answer this incision between both or mastoid. Yeah, but you got to mention this until this examiners. Yeah, we are all here just to prepare for exam. I'm not a spinal surgeon, you know, apart from watching, doing one in 10 years ago, I now know nothing about this approach. But the examiners want to hear some buzzwords from they not hear the word landmarks.
Yeah, and then they go to sleep again. Yeah, they sleep there. Then you mentioned incision. They wake up again. That's OK. They go sleep. So landmarks, they want to hear this world. You have to mention if there are no landmarks, say it. They want my landmarks are.
That's yet to be here about it. My incision is this from here to there, my entire nervous plane. You have to say these buzz words. Yeah nick, Yeah. So what is your internet service plane, you have to say this words, my internet explain, is this and that in this approach and a lot of approaches, that is superficial dissection and dissection.
And you did mention my superficial reaction and deep dissection. And you did say that and you were mentioning your structure at risk. Yeah you were so. So just be a bit more clear with the words you're using the structures addressed in my superficial dissection of this. The structures at risk are that in this section of that, ok?
Yeah, so just be so when you mentioning other approaches, you say any approach. You say, what are the indications for it? Yeah which you mentioned, as I said, the positioning of the patient. Yeah very important. Are you going to how you position the patient in those various ways, you could position patients for various procedures.
However, you know, this is the main things I want. Obviously, they have to be in slight extension, and that's what higher order thinking is, you say the snake is in slight extension, and that's not how the examiner will know you have seen this. You have actually, with your hands, positioned the patient on the table. Yeah, Yeah. And you tell them when you say words like but not in my allopathy patient, the examiner will be ecstatic.
He will be. They will know you completely safe. You know when how to position your patient, depending on their condition. Yes Yeah. You're turning the head away and and you're getting the X-rays to identify your correct level. That's medically, legally, very important. If you don't say it in the exam.
I probably find it difficult to pursue. That's a medical legal aspect, is getting your correct level. Yeah, and you need an X-ray. Yeah OK, so these are safety, safety come first in the exam you got demonstrate you are a safe surgeon. You're not going to bring litigation to your department. Yeah then we talked about approaches and really approach from the right or from the left.
Yeah, Yeah. So which what you need your preference and why? So I would prefer to approach from the left because on the right side, there is higher risk of recurrent laryngeal nerve injury. And on the left side, the course of the current laryngeal nerve is more defined. And so it becomes much easier to protect us from damage. So the left side is longer.
A longer and more predictable course on the left side. Yes OK. And that's why would you approach it from left side? Yes OK, fine. There's nothing wrong with that answer. But but there are the literature tell us there is no difference in injuries to recurrent laryngeal nerve with the approach from right or from left.
OK, so you do the approach. If you are right handed you, you'll find it easier to approach. From the right, and there is no increased incidence of it's like, you know, it's like, you know, you need to know your anatomy and that's why you know, there is more incidence of sciatic nerve injury with posterior hip approach, but that doesn't mean they cannot do posterior.
Yes, you just need to know where the nerve is. Yeah it doesn't mean that you have to do and always multilateral approach because of that. So so yeah, there's no difference in that. In fact, there could be more risk. If you go the left side because you've got the thoracic duct in the way, in addition to everything else. Yeah, but that's fine. That's a reasonable answer.
But you, I to justify your answer. I think this is about long course ulnar nerve and stuff like this. It's all theoretical. I don't think there's anything evidence to back it up. And then you describe your incision from midline to border of the mastoid muscle, and he's describing a superficial dissection and your deep dissection.
You describe that very well. You described your superficial dissection of dissection. This part of the answer was perfect. I described your approach dissection. You describe the structures at risk is very good. You went through that very well. And then you got the deep dissection. Honestly, I won't bore you want to disguise the same books is nothing invented, anything new, and this is about obviously as you described the left-click recurrent laryngeal nerve has got a longer course here, so it's probably more amenable to be moved.
Theoretically, I don't know. Practically, I don't think that's been confirmed. I think the next question would be here is that OK, you accidentally injured the Ranger nerve? What are the implications of that on the patient? So the patient would have a hoarse voice after the recurrent laryngeal nerve injury because it supplies the vocal cord and the structures controlling it, so preoperatively would discuss the patient about the risk of original injury and potential for the correct.
Hoarseness of voice after the surgery. Now what can you do now, patients come to your clinic six weeks after and they still have hoarseness, a voice, so. The one thing would be it would, Uh, be either in Europe or Asia or iatrogenic injury. So even after six weeks, it is not resolving and patients having crossed a soft voice then would have to evaluate for the weather if it is injured or not.
Would also discuss him with the colleagues in int department to see to evaluate the work of God and to see whether there can be any, any. We have a possibility for that. Yeah, that's a tragedy. That's well, that's I wanted to know again, safety, you're going to acknowledge the problem. You can refer it to the US specialists. Yeah, yeah, that's what they want to know.
Complications can happen. Yeah, you're not going to say, oh, this is going to better observe the patient. That's it, observer in six weeks. They know better. Are you going to do something about it, which is refer the patient to your EMT colleagues for further evaluation? There are things they can inject, apparently Teflon or whatever, and which can improve the situation.
But that's not for us, it's for them. We see you referred to your colleagues and then it structures at risk obviously has to be, as I said, part of your approaches. Answers to approaches. Yeah so structure at risk. I think you went to that. I think guys, if you want to maybe take a photo shot of this, you just have a system, I think.
Say these buzzwords and just fill the gaps, just fill the gaps with ethnic, you know, they know you're not expert in anterior cervical approaches that you just don't know the principles. They're wonderful, very good. Now other things that give you back here in your answer say you were saying generally you talking like you could do, you could do just it's your patient. Yeah, Yeah.
Imagine every patient in the exam is your patient. So I would take charge of the situation. You are a consultant in charge of this patient. Yeah, you've been asked your opinion. That's how it is. You've been asked your opinion, your expert opinion, and you're giving it. So I would take this patient to theater. I would position them like this.
I would get the X-rays. I would do the incision. I would consent. I would. I would. Yeah, yeah, you. It's all about you. Your opinion is what matters at this time. Yeah well, then again, thank you.
So we got to move on, guys. Now I think, Uh, next candidate is one, I think. Yeah so I think after this question will probably should move on. I've got two more questions which I could go through later on, but I think after this, next one will probably go to the hands station. So what are you with us?
Yeah, Hello. Ready? Yeah. So first, I want to see an example. I'm getting it in June, June. Lovely, lovely international one Yeah. Yes, Yes. All the best. What that way is that Dubai, you mason?
Yes, exactly. Exactly that's nice. OK, lovely. What do you see here? Oh, actually, I can see a photograph on the left side. I think it is a photograph of a demon born metrics and on the right side. I think these are the most liked pieces of being less bone matrix mixed with blood.
OK, so tell me. Do you decide this bone graft, Yeah. Yes, it was a bone drug substitute, actually. So tell me what is bone graft and why do we use it? Always the answer. Always these guys just has advise you whenever they ask, what is something? Give a definition and why we use it.
What are the indications within the same answer? Generally speaking? Bone graft is a bone broth is bone broth can be autochthonous or allergenic, so it can be a synthetic. Now what do you know? What is it all about is a substance like which can be of different types, which is used in special situations where like nonunion of microfracture or to fill a gap which is damaged by a tumor or we can use in backing grafting like in total hip hop for bas status, where you are doing a revision setting and it has a lot of uses and it comes in handy in different scenarios as to induce a bone osteogenesis.
OK, that's fine, I think you touched on the main principles of the answers here. As I said, it's a material used to support bone healing, where it's either the mechanical properties or biological properties or both. Yeah, provide structural stability and structure healing. That's really only that all you need to say in your answer. And so one of the thing we are here today is to improve your score and optimize how you use your time in theater.
You got 5 minutes and they will go within, you know, very quickly. You know, you blink. They're gone five minutes. They go very fast. And you got the score. You prepared for this exam for so long, you got so much knowledge. To impart.
And what happens, most cannot leave a stage, I think, oh, I knew a lot more. And I did not say it. I knew a lot more. And you think, oh, this examiners must think of I'm an idiot because I only was talking about the basics. And the reason of that is that you don't have enough time. The goal about to show all of your knowledge, so.
So you spent more than a minute just going through the same thing. And again again, all you need to do is you couldn't answer that. This is the opening question. You're not scoring anything still and you don't want to spend more than 30 seconds on your opening question. You're not scoring anything, this is just to assure the examiners that what the bone graft is.
Or you see, you know what it is. They proceed with the question. So tell me now about what you know about what different classification systems we have for bone graft. And they believe this is a very boring question. But believe me, I picked it because it was asked in February's exam. They keep asking the same questions again and again. Both groups can be classified as to their whether they are all still in the field or they're also conducted.
That that is what the mechanism of how they are. They are supposed to be used. Otherwise, when it comes to the varieties of gun drugs, it can be classified as autographs, all of drugs and synthetic bone matters. Fair enough. Now how would you ask that this is you're going to classify? You say classified bone graft. According to qualities.
Or, according to ET's source. That's how ideally I would love to answer to start and then I must examiner. Can tell you, OK, well, tell me about the sources of grafts, different sources of. Well, I can tell you, OK, tell me about different qualities. Yeah OK, so, so tell me now about the different qualities of bone graft that of.
You did mention that correctly, you will start. You are absolutely on the right spot there. Is the Austrian conductor so sorry? There are two different sides, ultimately, those two people. And one no one is Austrian conductor. When you are, when you're mentioning the word Austrian India, we are, we are. We are, think about a situation where there is no bone healing happening and we need to induce bone healing mechanism or that happens when we have viable bone cells and which can which which has bone mineral Martinek proteins and that induces the healing of potential.
And it is like we were put in a situation where there is no healing at all these function in the best way. And when need to also conductive, not as such a structural bond where we have this needs to function as a feeling between the bone loss and as well as it can be used as a.
OK, so Paul, on again. Uh, same thing. You you could just use the simple buzzwords in your answers. Yeah in the exam, so you can just simply the examiner. There's also conductive bone graft. Which act as three dimensional scaffold?
That's it. Osteo inductive. Which has biological factors to stimulate bone growth and healing. That's it. And then you got the osteogenic bone graft that has live cells. Yeah live mesenchymal cells, this is osteogenic bone graft, which you did not talk about, and that's it.
Yeah, you could answer this whole question in 3 simple sentences very clear to the examiner. That's what they want to hear. Yeah, you did answer correctly, by the way. Yeah but just to the time and I am as examining, I had to really focus with you to see exactly what you're talking about. You mentioning the meakin keywords? OK, which is fine.
You still pass. Yeah, you still pass. But you, you take a long time. That a lot of concentration from the examiner and long time, that's the day not going to find time not to take you to the higher questions to 7 and 8 questions. Yeah so but that's good. So you classifying according to the qualities of your conductive post, inductive and osteogenic?
Yeah fine. So as I said, conductive is a scaffold inductive has the biological factors, and estrogenic has life mesenchymal cells. OK in addition to the biological factors, obviously. Or you can classified, according to. Thoughts? Yeah. You can classify, according to qualities, according to source, so tell me about the source.
The source? Yes sources of drops be it can be ordnance bone-dry, one is harder from the same person body and used who we are to use the bone grafts can and rocks. And there are in the book about xenograft been born at different times.
OK, that's very good answer, you see. Brilliant you got already better for. You already got better in your technique, not your knowledge, your knowledge, is there fine? Absolutely because now you allowed me You showed me immediately within a few seconds that you understand the origins of bone grafts. Now I can expand further as I want as an examiner.
If I want to ask you about the autograph to me more about the advantages, disadvantages, different structural properties, cortical considers, cortical cancers I could ask you showed me the basic stuff, but you forgot to talk about bone substitute. Yeah, which is another source of bone graft. Very important source, which can create a lot of discussion. Yeah so.
So, yeah, so classification, according to a source autographed. Yeah these are all from the books. I'm not going to bore you guys. I'm not nothing. They're invented. You guys take a photo shot if you like it. But, you know, autographed advantages. Disadvantages umm, allograft, as you said, and then we can talk more about allograft that could be in itself, that's the topic of question, you know, for a lot of time that we could go then and what is different types of allograft, fresh frozen, freeze dried and then rice?
What might taste and what are the differences between them? And the bone substitute, obviously, which are synthetic, that's why you have to use it. It's part of the answer. You did not mention it. You've got to mention it. Here is a synthetic material. It's bone substitute.
So that's good, that's good point. Are you happy? Well, so now now you've done very well. I'm going to throw the last question at you is what's the ideal bone substitute or bone graft for whatever? Oh, I bought. That's what you want to get to your answer very well previously.
You go quickly through the exam. Do you want to get to this question? This is a question. You know, if you get this question, you are getting close to eight. Open muscular, on the Eve of you breaking up for one, I think some connection problem, I can't hear you properly breaking up, but I think we've got to move on now to the hand station.
So so basically, these are the main principles of the ideal bone graph that you got to mention. Your exam has to be biocompatible. It has to go after these properties. It has to be resolvable as obviously bone substitute. You don't want to be staying there as a foreign body forever. It has to be easily molded, which you can put in the defect that you want.
Um, obviously, it has to be sterilized, but. A regular sense it doesn't get in the way of assessing your fixations or. And it has to have a really, you know, reasonable cost and be available in the market license and everything and has a reasonable cost, so it could. I would probably view this question as a high level kind of. The cherry on the cake kind of question.
OK, guys, so I love, so I think now we spent long enough on basic answers and I will move on to the hand station now.
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