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The Rotator Cuff for Orthopaedic Exams
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The Rotator Cuff for Orthopaedic Exams
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Language: EN.
Segment:0 .
Welcome, everyone. Thanks for attending this FRC teaching session with the fancy splinter group. And the presenter tonight is Ranjit Isaac. He's a surgeon from Leicester, he recently passed, yes, and he was going to talk tonight about rotator cuff tears and relevant points to consider for the examination.
Also, we have other ministers in attendance here, babu and Mohammad imam, I was an orphan upper limb surgeon and they will be here to give a supporting hand to Ranjit and answer any questions you have. I'm sure I'll be moderating the session, please ask any questions in the chat box or raise the hand symbol next to your name. If you would like to talk directly to the presenter or any of the mentors at the end, there will be one vyver question Apple related five a question at the end of this teaching session.
So if anyone is interested, please make sure you raise your hand to be the candidate. And just a reminder that. Anyone who would like to have a CPD certificate. One credit from the Royal College is encouraged to get in touch with me to ensure everyone we get a case and this teaching will be published later on.
Channel the YouTube channel called dfacs mentor. So thank you, everyone, and I will leave you now with Ranjit. Hello, everyone. Hi I want to present of. It's purely for the forces, so it's not for a daily day to day practice of yoga practice or it's just purely what you need to know for the exam. And for what one.
Essentially, it's the insidious and part two. It's basically for the practical and the viewers. So I talk about it as we go through it. So rotator cuff tears. The anatomy. Just the basic anatomy. You know that actually with a subscapularis attached to the lesser tuberosity supplied by the ulnar claw subscapularis nose, then you got the surprise.
When it is in pain, it is materials when attached onto the tuberosity so bas status and bas status by the subscapularis nose. So that's essentially the anatomy when no one is going to ask. That was its undergraduate level. And what they saying is that hot favorite for the MSCI because it comes time and time again. So in fact, it's a triangular region which is bound anteriorly by.
It is bound separately by the anterior border of the supraspinatus niches in Philly, by the superior border of the subscapularis and the base formed by the coracoid and the contents of the rotating table. That's the most important part for the nccu, and the contents are the long hair, the biceps tendon, the ligament, the superior ligament and the rotating travel capsule, and that it's rotating, which you lease in the arthroscopy surgery for the same capabilities.
So in part a for the afarensis, it's usually to give you a scenario and then they won't ask you what is the content of a rotating table? The question would be like a clinical picture, for instance, to see a capsule like this or a frozen shoulder, an arthroscopy surgery being done, going to release a structure, then they're going to ask you, what are the contents of that region?
So it's going to be in direct question with regards to internal and the contents of it. So that's a favorite in situ. And speaking of the rotator christened, it's a thin present shape sheet of rotator cuff comprising the distal portions of the supress managers and the spine by is insertions. So if you can see my cursor there, so this area, which is adjacent to the great tuberosity where they suppress wages and in frustration, just insert.
This is called the rotator Crescent and just proximal to rotate across. And you got something a lot of data cable, which is a thick bundle of fibers, which are 2 to 2.5 times thicker than the rotator cuff. And so it's a thick cable, which is just proximal to the rotator cuff. And the combination of the rotator cuff. And the rotator cable is what you call the shoulder suspension bridge.
So shoulder suspension bridges bond with the rotator cuff. And the rotated cable. I think in autoblog, they got a picture of this area and they're going to erode towards the cable asking for structure. So essentially the same basic cable interconnection. And then the rotator cuff is a dynamic stabilizer. It balances the force couples because it balances the force couples form and surely by the subscapularis, clearly by the suppressed by energies and possibly by the bas status AM.
And it causes concavity compression. So the buzzword for the exam is concavity compression. So whenever you in the situation of the practicals, they usually get a picture of card property where the human letters migrated approximately. The next question would be, why is it so? Then the bus? What are they looking for? Would be the concavity.
Compression is lost because of the helicopter, and that's the bus word which needs to be said in the exam. So the blood supply means that it's essentially of the rotator cuff is by the subscapularis, subscapularis and femoral arteries. The boysen side is more muscular than the articular side. The other side is considered to be hypo vascular, and the zone of critical hyper muscularity is adjacent to the most lateral portion of the insertion.
So that's the sort of political egawa security where you can get a lot of theories. And of course, if someone asks you the causes you can, it's always better to classify whatever you say, especially when it comes to courses so you can classify broadly as traumatic and traumatic and traumatic, classically follows a fall or dislocation. And there is this best VOA patient care pathway, which says that any patient about 4 to five years with a loss of shoulder function after shoulder dislocation of more than four weeks of shoulder dysfunction after a shoulder injury, should undergo an MRI scanner ultrasound scan to investigate for a possible acute rotator cuff tear.
So in essence, if you go to more than 40 years a patient with a shoulder dislocation, then you need to look for a rotator cuff there. And if it's a patient basically looking for a bongarts lesion? And again, the course is like initially was traumatic and traumatic, and the other causes can be classified as intrinsic muscles or intrinsic muscles. The intrinsic muscles can be related to the age degenerative diabetes mellitus, inflammatory process and rarely connective tissue disorders like Marfan syndrome and extrinsic causes would be like impingement, and the cause of impingement can be again inflammatory causes and osteoarthritis the economic life killer joint calcification of the cortical ligament or cyber-criminals.
Someone asks the course of a leg up. There's always good to classify them. So that it gives us time to answer the question. Also, like examiners like it when you've got a system to answer it. And classification, you got the Coffield classification. I was just describing 1982 as pathetic of terrorists in small, medium, large and massive small towns are when it's less than 1 centimeter size.
Medium is when it's 1 to three centimeters largest, when it's 3 to 5 centimeters and massive. It's when it's more than 5 centimeters or some people say it's two or more tendons, which are done. It's a massive they're. And the classification can also be based upon the cuff there, the shape of the cuff tear, so it can be a prism shape.
So a prison shape their means. Can you see the cursor? OK, so. Yeah a Crescent shaped means if you see it here, you can see that this is the median actual length. And that's the and width. So the medial and lateral length will be less than the opposed to width and then it's called a Crescent shape and.
And the don't end proximal will be mobile in a multilateral direction that you can hold the proximity tone and then bring it back onto the footprint. So then you call it a Crescent shaped care, and the treatment for that would be a direct tendon to bone repair. As you can see there, on the right side, the next type of cuff they're based upon shape would be a longitudinal tear.
And it acts the opposite, so it's typically mobile in the anterior to posterior direction. So you can see the medial lateral length would be more than the anterior posterior bit. So it will be very difficult to hold the proximal end and bring it on to the footprint. So what do you do initially is you do something called a margin convergence and that's the buzzword in the longitudinal care.
You do margin convergence by a margin convergence. What do you mean? Is you suture the tear? We just don't care like this. You suture it end to end and then, if possible, you bring it on to the footprint. So this is essentially what you call margin convergence or margin convergence is the buzzword that you need to know, and launch letters can be u-shaped and shape.
So as the name suggests, this would be a u-shaped one and this would be an l-shaped one. So in both instances, whatever you decide to repair and that's called a margin convergence and if possibly bring it back onto the footprint, the third type of care is going to massive and immobile type of stairs where you do an interval slide, where you do a lot of releases and then you bring it on. So that's the interval slide in mattress sutures.
And of course, there are shelters. Classification with a partial terrace would be an articulate site there or a person site there. So that's another way of classifying these stairs and the clinical features. The classical history would be an acute pain pain, typically with overhead activities and weakness. So in an exam situation, so you'd most probably it would be a short case.
So when you walk into of the cubicle, the examiner would be taking you and asking you to examine the patient's shoulder. Or sometimes the examiner would directly tell you, like exam the patient's rotator cuff more properly, the patient. I mean, the exam would be saying that examination shoulder. So when you do the inspection, so you ask the patient, the patient might be sitting down, you ask the patient to stand up if possible, ask the patient to stand up.
In a short case, the patient might be kept undressed. If it's not undressed, you ask the patient to undress his shoulders. You see both shoulders together. You stand in front of the patient. He started the inspection, so you see that on inspection. I see that there's a loss of control there is wasting. They'll ask you, examine the patient's right shoulder or left shoulder the way you bilateral findings.
But if they ask you to examine the right shoulder, stick onto the right shoulder so that any of the right shoulder there is a loss of control there is wasting. You need to see exactly what the waste thing is, for instance, the wasting of the area of the major, the deltoid. And then you go behind the patient, you stand and go around the patient, go behind the patient and say that there is wasting of the subscapularis slap and there's wasting waiting for us.
And we can add on. That was Mason so indicative of a supraspinatus industry wasting or in front of InfraWorks waste. And then if there are scars, say that there is a scar of a topical approach or there's a scar scar suggesting after the procedure. And then that end up inspection, you go back to the friend and onto the side and now do the palpation. So in palpation, what you essentially palpation, you look for tenderness.
You look for tenderness of the joint along the clavicle. The AC joint. Then the cyber-criminals base. And you speak as you go along and then you go into the movement. Always, you start over with that Timmermans. You ask the patient to keep both the arms in front the elbow straight, try to move it forward as smooth as possible, both elbows at the same time.
And then you can ask the patient, does it say the patient has got this manufacturing in motion? And once the patient sees that, OK, I can do it only until this much, you pull it and try to get some passive range so you never get a cuff tear unless we can protect our property. This is that if your rotator cuff tear, you will get some more passive range of motion. And then as you do that, you say, OK, I get more passive range of motion.
And if you get more passive range of motion, you don't need to bring it up until 180 degrees because you've got the information that it's for the passive range of motion. So that's not a frozen shoulder. You've got one hand over the patient's shoulder, you don't get any credit. So now you know that it's not a rotator cuff properly, it's not osteoarthritis.
So all these you, you verbalize as you go along. And then the examiner knows that OK is thinking as you're examining the patient and then you go into the abduction observation to give you that. And again, the patient doesn't actively. And then after the patient is finished doing an activity, you do it passively to see how much more you can get it. And as I mentioned, you'll need to get it on 180 degrees because you get the information you get after doing a bit more of passive movement already goes straight away, especially test you start off with.
The suppressed pain does, in fact, not the subscapularis slap Las Vegas empty desk. We just need to do one test each for all in each of the rotator cuff. So so you do the empty can test. You say that, OK, this patient has got a week. I'm doing the American test that's go. It's we. So they test is positive.
Professor bas status there after that, you go on to being frustrated is being frustrated as you test with the axilo degrees of reduction, you ask to external data shown in the picture here. And then you do both sides simultaneously and you say, OK, the acceleration is weak. So I think that's in bas status also tone. So after that, you go to your subscapularis subscapularis. There are three classical tests and it's many films egawa exam egawa breath test, where you ask the patient to hold both hands.
In fact, you keep both hands in front of the belly. Ask the patient to bring the elbow forward. You hold the elbow from friend and try to push it back. And that's how you do the belly breath test. And then you can say that OK, patient is weak on the side. Must be having a subscapularis there. That's it. You don't need to do further tests like the lift off test or the bear hug test.
So for the purpose, you need to know the lift off test, the global lift off test because is again, the hand goes behind because in a lot of this pathology, the patient will be having a lot of internal rotation problems and patient would be having trouble going onto the back. And also, like, you waste a lot of time doing that. Basically, try to do it. You you waste a lot of valuable time and work tested, something which is also being prescribed.
You never do it, but it's better to know that they bring it on to the top of your shoulder. Try to press down and you resist and the patient is weak. So now you're done with the rotator cuff test. Well, in fact, the minor is also there. And that's mainly for the MCU because you don't test the theories minor for the practical exam, because it's very hard to do isolate the actual materials minor and you don't do anything about it.
But for the example they use, it's a very interesting way something called the lawyers bond loci where you ask the patient to emit up to 90 degrees and 90 degrees, and you ask the patient to call it there after some time. If the patient still is minus stone, the hand goes in front and that's on both sides. And after you're done the special test, you go on to the axilo.
It's very important you test for actually, Neal. So when you're testing what you of two components, you test for the regimental bacteria, the sensations number one, and also you look for the deltoid you need to look for both. And then you screen the cervical spine because that's important part of the exam because that's a safety issue in it. So that has to be the moment you say, I'm going to screen cervical spine and say, OK, that's fine.
It's normal, but it's important for you to tick that box by saying that I'm going to examine the cervical spine. So essentially, when you do, you reach until there. So in examination, you could reach until this point by the three, 3 and 1/2 minute mark. So whether you scored a six or seven depends upon how much penis you reach until this level and whether you're being able to detect a diagnosis by as you go along with the examination.
So once you reach a diagnosis, you're definitely reached the 6 and 1/2 mark the day. And now examination examiners will ask you, what? What do you want to know next? I mean, to say that get radiographs. AP axillary Oklahoma is usually not done, but you can, if needed against it, to ask to assess the protein. So the X-ray radiographic features of pathology.
None of these signs are highly specific, but these are signs which are indicative of a pathology like sign, which is shown here that you find sclerosis, undiagnosed Kessler chromium and cystic changes in the greater tuberosity Kessler suture epicondylitis, a type III acromion which would be a chromium. So all these are the extra features which you can see in there and in helicopters, you can get proximal migration of the humeral head and then you get a break in the children's line and a proximal migration of the human head, which which can be quantified when they are chromosomal distances less than 7 millimeters.
So when you say an investigation, the next question would definitely be, what do you expect to see? So it's always good to know what to expect to see rather than just saying that and take it off. KPIX review you need to know what do you expect to see? They show the X-ray. Then they'll ask you what?
What next? I also want to take an MRI scan. MRI scans the diagnostic standard, so obviously next question would be, in fact, it's better for you to say, I want to take an MRI scan to know these things rather than wasting a few seconds asking why? Why? so the MRI scan is basically to assess the terraces to know if it's a full thickness or partial thickness to the shape and degree of retraction.
So if you reach the seven mark level, then they might go into something the classification shall become in a short time later. And the second purpose of doing MRI scan would be to assess the muscle quality. There is a multilayer classification. If you answer all those, you are definitely under the. And yeah, so and then in good classification is basically based on the fatty infiltration of the cuff in an MRI.
And then you also looking for the medial biceps tendon subluxation, which is indicative of a subscapularis tear that's also names you can get it either way is that then you can get an MCU describing like what? Biceps and subluxation? Medially, what? What would that be? Then it would be subscapularis all the way around, like a picture of a subscapularis there.
What else do you see then that it wouldn't be a middle biceps slap lesion? And then there is this sport point. It's better not to say that, but in case someone drops, you can say that because it's too much theoretical, there's something of a tangent sine you can see here in the picture that normal a tangent along the superior border of the scapular spine. So you get a portion of the spine is crossing it, whereas when you get an iconic day, so you can see that when you draw a line in tangent along the gap left by the MRI, the brain is just not crossed it.
So and then I'm coming on to the packet classification, so if it's a show that you get, you can get this goes from here to a shoulder surgeon, obviously, but it's good to know that. So the classification is based upon the amount of success when the standard retraction in a complete day. So a stage one is when the tendon is near the insertion, the greater tuberosity. Stage two is when the tendon retracted to the level of the humeral head.
And stage 3 is when the tendon has reached the level of the glenoid or approximately. And coming onto the quarterly classification and MRI based classification. Where is it? Zero zero? When you get normal muscle and grade 1 and when you get some fatty streaks in the muscle grade two, you get more muscle than fat.
Three, you get equal amounts of muscle and fat and for me to get more fat than muscle. Essentially, the good classification is for looking on to the fatty infiltration of the muscle, which shows the quantity of the there, the quality of the tear, especially in the context of a chronic, protracted tear. And then if you want to consider that are other options would be to do an ultrasound examination.
The use of doing an ultrasound is it's a dynamic assessment. And what the problem is, it can all break independent and it's similar sensitivity, specificity and accuracy when compared to an MRI scan. So if you go to a patient, it's better to take an MRI, for example, because I would say go for an MRI scan because I can see for the infiltration, I can see for the muscles, all those bits you can see. And also you can say ultrasound can be obturator dependent, but there's no harm in saying that they can go for an ultrasound.
If someone ask you what the risk factors were to their progression, you can say that age more than 60 years and then the tendency will be for the full thickness there. Then the chance of their progression is there is higher the size of there and it's the medium size. There is more chance of progression than is a small place. They're smoking a lot of other instances, irrespective of their progression and dominance in the dominant and more chance fatty infiltration, families and family history is considered a risk factor for their function.
So once you've gone through the MRI scan, so next, what are you going to do for the patient? These are the bones essentially surgical treatment. That is to reduce pain and disability to reduce the risk of their progression. And number three, to reduce risk of their property. So whenever you answer a question from for treatment, it's a good strategy to say that the goals of treatment are less.
And as you always you start off with conservation measures. You say that a private equity line of management initially and then it would include it includes what it shouldn't be. For example, you say that what are the conservative measures they want to do? So both physiotherapy, which is the first line of physiotherapy, will be to strengthen the muscles based on the shoulder to improve the posture and the biomechanical axis of the shoulder steroid injections.
Second line and you can also be in a series they use in the short term for pain relief, but there is no functional improvement. And the last point that a subscapularis blocker ablation so that can be kept as part of the material because in the end stage of disease on our property, where the patient is not fit for surgery or patient decline surgery, that is an option for a super blocker ablation. So that's also part you shouldn't say that I'm going to go for block ablation.
The first thing is confidence building measures one, two and three then keep that, according to the scenario. Speaking with surgery, Philip open muscular peel-back surgery, the u-curve trial published in media day in 2017. So it's good to know that. Because if you speak about that, you're going on to the nearly eight territory.
So open was supposed to take off repair in patients more than 50 years with a degenerative tear. So they found that there's no difference in clinical outcome at two years, but the rate of tear the retail rate was high in both open and arthroscopy groups for all sizes of tiers and ages. And this adversely affects the outcome. So in essence, the u-curve trial showed that open bas status both are good results, but the rate is high in both instances.
And of course, this retail adversely affects the outcome. And now in the thick of it, can we get off without a decompression? So there is limited evidence that performing the sober decompression, along with the rotator cuff repair, will significantly improve patient patient outcomes. So that's something to know, though we keep on doing it. And then again, a similar versus a double role or a suture bridge technique, no one is going to ask it to go into that level because if someone asked about that means that you're scoring really, really high.
Because when it's good to know that in general, it seems to perform better in the current literature due to a lesser reiterate, the largest area of contact input biomechanical strength due to multiple points of fixation. So in fact, I know this is a very controversial area. But if their policy is, or even if this comes up in the way you want, you won't go beyond this level. And then this important thing, the massive, retractable buildup there is, because obviously if you get a patient like that, I like it to get that, you need to know the treatment options, so you need to be able to list the treatment options.
Number one would be physiotherapy like dental rehabilitation. No deal would be a partial repair, plus someone is the bridesmaid number three would be tendon transfers, so you can do a lot of damage transfer for a massive structural helicopter, but that needs an intact subscapularis function and you can do a major transfer in a chronic subscapularis there.
So that's an issue that in subscapularis, what's the type of tenderness medial epicondylitis needed? That's and then there are the other options are a synthetic patch like golf jacket, where it's essentially denatured, demonized human skin that uses a synthetic patch, so it's helping muscle. You do it when the patient a helping muscle, but tendon quality options would be a superior Kessler reconstruction.
The principle of a separate capsule reconstruction is it restores the normal anatomic restraint of the humeral head graft for four, restoring the superior strength of the human head, and it relies on the deltoid for architecture. It essentially prevents the humeral head from migrating, approximately. Then you go to inspace balloon, which essentially is you. If you place an inflatable balloon, which is a deflated balloon which is inflated with normal saline in the slap space.
And the principle of that is depresses the female head. And by doing that, it enables the patient to exercise and allows other muscles to take over function of the cuff. So that's an option to speak about. You don't need to know in detail about all this, just need to know what the options are and how each one would help. And then, of course, they're all short on capacity, something that you want to do as a last resort when there's a patient painful or insufficient and non-functioning shoulder in an older patient.
So it's very important to mention these are the options that go forward for conservative management, for physiotherapy, for dental rehabilitation by surgical options would be a partial repair treatment, then transfer synthetic patches to break up the reconstruction in space balloon. If everything fails, it's not nonfunctional children. All the patients will suffer, and probably that will be end of where the very ends.
And also, I doubt it will go beyond this, even for four in the clinical cases, because by that time, the five minute mark will be done. So this is essentially what you need to know for the FRC is exempt. And if you go until this level, then you'll probably scoring until the 70s and 80s and how you reach the six or seven, as I mentioned, is how well you go along the examination.
Then you explain verbalized vocalized examination examinations and get the diagnosis as you go along confidently. The way you examine should seem like you've done this a lot of times. Thank you. I'd be happy to take it. Think it was an excellent presentation? It's very nice to hear this from you as you recently passed the exam.
You've taken us through the journey of rotator cuff problems from. Theory part two, Viva and clinical. And I think. You pitched your presentation at the right level for the Air Force exam, talked and he advises all participants to focus on being systematic in your answer.
And have clear classification systems. You don't need to go in a lot of depth clearly, but you have to have a system to follow. And it just happened to look like you are a smart candidate to the examiner, have the right approach. You will be unlucky that you have a shoulder examiner, but you could be.
But if a non shoulder examiner, if you follow this nice approach, Ranjit explained in this presentation, you will really impress them. You'll even impress a shoulder specialist, some specialty surgeon, so it always helps. So that's. Thank you. I think this covers the whole aspects of our case that all three parts of the exam, I think this presentation could be a reference, really, to all future candidates.
If you don't mind. Yeah you mentioned in your. Treatment options using synthetic graft and lifejacket, what can you tell us a bit more mean examiners might say what is life jacket. Or what is this? I mean, is it synthetic or is it It's a little graft or whatever graft is it?
So essentially, the graph jacket has its miniature human skin. Once again, it's the nature of human skin is in its human skin may just be nature, so it's essentially a sort of an allograft, which is good. So it's not. Would it still be synthetic? But this can mean it's allograft and the various options in of this you got. Because I think in the mean to say that it's a cool idea, it's the nature of human skin, which has been demonized and all that.
OK thank you. Yes, ma'am. We would like to hear from you your comments overall about rotator cuffs. Any comments you have, please? Yes, it's just a very good presentation. Ranjeet and I really enjoyed it. As for us, I think that's good to have on the website because it is very educational.
Just one thing, you know, gruff jacket is a commercial name for the allograft used by right Medica. So I won't use the term gruff jacket. And we've written a meta analysis on different scaffolds used in biological threat components like for augment and so. And there are three types you can just use say, allograft or autograft autograft with the original one described by a toy by mhatre, 3 from Japan.
And there is a look like I like that jacket, and it's also manufactured by Arthrex as well. Also, there is and it is in this and in other. Studies now they proved that this is associated with superior outcomes, but still controversial. Also last question. Graph jacket is a brand name. It's not absolutely the right medical.
So what do you suggest we should use for the exam? Candidates should use, but I would say augmented that, you know, like patches would be enough. And then they can ask you further. You could explain what the patch is composed of unless he's the examiner is a shoulder surgeon. I don't think they would go in depth, but you can also say that recent evidence supports it is associated, you know, doing augmented repairs and those patients with bad quality tendons are associated with improved outcomes.
Recently, and that's one of the moment, yeah, I mean, it dropped typekit is something you shouldn't be putting there. I think it's my mistake because it's a strict no not to come up with a commercial name. My apologies for putting that there. It's always good, you know? So, you know, if you want to use the word traject, you can just say acellular human dermal matrix augmentation because that's all dermal matrix augmentation or thermal patches.
I think that if you want to use a term supported the use of graft check. It was published in 2012. It is an oddity. So it's really a very well conducted. The thing also there is also I think it's a nice guidance now that can be only done as part of a trial nowadays because there isn't enough evidence validating it, although many surgeons are using it everywhere.
But it is now suggested that you can only use superior capsule reconstruction as part of a clinical trial. So I would. So if it is a repairable cuff, you can consider options like superior capsule reconstruction as mentioned or tendon transfers either lower, you know, lower transfer or led to site transfer for superior and repairable cuff tears or even velocity, which would be easier to discuss in detail.
So just choose something you're confident talking about. Thank you very much. It's true of all the dead men described describe boycott, and essentially what boycott did was essentially the angle in which the suture anchor is inserted into the footprint. So it's I mean, 45 degrees, 90 90 degrees, what was being described in the language? Essentially, the 45 degrees, which is recommended by Walcott.
So that's essentially. Thank you very much, I think they're very good, I think. Thank you very much. Ranjit and thank Mohammad for your input. I was a fantastic presentation. I've learned a lot and I am going to have the pleasure of revisiting this to edit it and put it on the YouTube channel for everyone to see for, especially for those people who didn't have the opportunity to attend today.
I just want to remind people you will be entitled to have a CPD certificate one credit from Royal College of Surgeons. Please get in touch with me via the telegram group or Facebook, if you like to have one. I think we are reaching 8 o'clock now, so we probably will finish the session. Mentors need to rest now.
So thank you very much, everyone, for attending. Thank you. Thank you. Thank you for inviting us. We had 45 participants this evening to thank you to every one of you, and I hope you all learned something useful, for example, from this session. And good NIPE.
Bye bye. Thanks Thanks. Thank you. Thank you. Thank you. Thank you.
Segment:0 .
Welcome, everyone. Thanks for attending this FRC teaching session with the fancy splinter group. And the presenter tonight is Ranjit Isaac. He's a surgeon from Leicester, he recently passed, yes, and he was going to talk tonight about rotator cuff tears and relevant points to consider for the examination.
Also, we have other ministers in attendance here, babu and Mohammad imam, I was an orphan upper limb surgeon and they will be here to give a supporting hand to Ranjit and answer any questions you have. I'm sure I'll be moderating the session, please ask any questions in the chat box or raise the hand symbol next to your name. If you would like to talk directly to the presenter or any of the mentors at the end, there will be one vyver question Apple related five a question at the end of this teaching session.
So if anyone is interested, please make sure you raise your hand to be the candidate. And just a reminder that. Anyone who would like to have a CPD certificate. One credit from the Royal College is encouraged to get in touch with me to ensure everyone we get a case and this teaching will be published later on.
Channel the YouTube channel called dfacs mentor. So thank you, everyone, and I will leave you now with Ranjit. Hello, everyone. Hi I want to present of. It's purely for the forces, so it's not for a daily day to day practice of yoga practice or it's just purely what you need to know for the exam. And for what one.
Essentially, it's the insidious and part two. It's basically for the practical and the viewers. So I talk about it as we go through it. So rotator cuff tears. The anatomy. Just the basic anatomy. You know that actually with a subscapularis attached to the lesser tuberosity supplied by the ulnar claw subscapularis nose, then you got the surprise.
When it is in pain, it is materials when attached onto the tuberosity so bas status and bas status by the subscapularis nose. So that's essentially the anatomy when no one is going to ask. That was its undergraduate level. And what they saying is that hot favorite for the MSCI because it comes time and time again. So in fact, it's a triangular region which is bound anteriorly by.
It is bound separately by the anterior border of the supraspinatus niches in Philly, by the superior border of the subscapularis and the base formed by the coracoid and the contents of the rotating table. That's the most important part for the nccu, and the contents are the long hair, the biceps tendon, the ligament, the superior ligament and the rotating travel capsule, and that it's rotating, which you lease in the arthroscopy surgery for the same capabilities.
So in part a for the afarensis, it's usually to give you a scenario and then they won't ask you what is the content of a rotating table? The question would be like a clinical picture, for instance, to see a capsule like this or a frozen shoulder, an arthroscopy surgery being done, going to release a structure, then they're going to ask you, what are the contents of that region?
So it's going to be in direct question with regards to internal and the contents of it. So that's a favorite in situ. And speaking of the rotator christened, it's a thin present shape sheet of rotator cuff comprising the distal portions of the supress managers and the spine by is insertions. So if you can see my cursor there, so this area, which is adjacent to the great tuberosity where they suppress wages and in frustration, just insert.
This is called the rotator Crescent and just proximal to rotate across. And you got something a lot of data cable, which is a thick bundle of fibers, which are 2 to 2.5 times thicker than the rotator cuff. And so it's a thick cable, which is just proximal to the rotator cuff. And the combination of the rotator cuff. And the rotator cable is what you call the shoulder suspension bridge.
So shoulder suspension bridges bond with the rotator cuff. And the rotated cable. I think in autoblog, they got a picture of this area and they're going to erode towards the cable asking for structure. So essentially the same basic cable interconnection. And then the rotator cuff is a dynamic stabilizer. It balances the force couples because it balances the force couples form and surely by the subscapularis, clearly by the suppressed by energies and possibly by the bas status AM.
And it causes concavity compression. So the buzzword for the exam is concavity compression. So whenever you in the situation of the practicals, they usually get a picture of card property where the human letters migrated approximately. The next question would be, why is it so? Then the bus? What are they looking for? Would be the concavity.
Compression is lost because of the helicopter, and that's the bus word which needs to be said in the exam. So the blood supply means that it's essentially of the rotator cuff is by the subscapularis, subscapularis and femoral arteries. The boysen side is more muscular than the articular side. The other side is considered to be hypo vascular, and the zone of critical hyper muscularity is adjacent to the most lateral portion of the insertion.
So that's the sort of political egawa security where you can get a lot of theories. And of course, if someone asks you the causes you can, it's always better to classify whatever you say, especially when it comes to courses so you can classify broadly as traumatic and traumatic and traumatic, classically follows a fall or dislocation. And there is this best VOA patient care pathway, which says that any patient about 4 to five years with a loss of shoulder function after shoulder dislocation of more than four weeks of shoulder dysfunction after a shoulder injury, should undergo an MRI scanner ultrasound scan to investigate for a possible acute rotator cuff tear.
So in essence, if you go to more than 40 years a patient with a shoulder dislocation, then you need to look for a rotator cuff there. And if it's a patient basically looking for a bongarts lesion? And again, the course is like initially was traumatic and traumatic, and the other causes can be classified as intrinsic muscles or intrinsic muscles. The intrinsic muscles can be related to the age degenerative diabetes mellitus, inflammatory process and rarely connective tissue disorders like Marfan syndrome and extrinsic causes would be like impingement, and the cause of impingement can be again inflammatory causes and osteoarthritis the economic life killer joint calcification of the cortical ligament or cyber-criminals.
Someone asks the course of a leg up. There's always good to classify them. So that it gives us time to answer the question. Also, like examiners like it when you've got a system to answer it. And classification, you got the Coffield classification. I was just describing 1982 as pathetic of terrorists in small, medium, large and massive small towns are when it's less than 1 centimeter size.
Medium is when it's 1 to three centimeters largest, when it's 3 to 5 centimeters and massive. It's when it's more than 5 centimeters or some people say it's two or more tendons, which are done. It's a massive they're. And the classification can also be based upon the cuff there, the shape of the cuff tear, so it can be a prism shape.
So a prison shape their means. Can you see the cursor? OK, so. Yeah a Crescent shaped means if you see it here, you can see that this is the median actual length. And that's the and width. So the medial and lateral length will be less than the opposed to width and then it's called a Crescent shape and.
And the don't end proximal will be mobile in a multilateral direction that you can hold the proximity tone and then bring it back onto the footprint. So then you call it a Crescent shaped care, and the treatment for that would be a direct tendon to bone repair. As you can see there, on the right side, the next type of cuff they're based upon shape would be a longitudinal tear.
And it acts the opposite, so it's typically mobile in the anterior to posterior direction. So you can see the medial lateral length would be more than the anterior posterior bit. So it will be very difficult to hold the proximal end and bring it on to the footprint. So what do you do initially is you do something called a margin convergence and that's the buzzword in the longitudinal care.
You do margin convergence by a margin convergence. What do you mean? Is you suture the tear? We just don't care like this. You suture it end to end and then, if possible, you bring it on to the footprint. So this is essentially what you call margin convergence or margin convergence is the buzzword that you need to know, and launch letters can be u-shaped and shape.
So as the name suggests, this would be a u-shaped one and this would be an l-shaped one. So in both instances, whatever you decide to repair and that's called a margin convergence and if possibly bring it back onto the footprint, the third type of care is going to massive and immobile type of stairs where you do an interval slide, where you do a lot of releases and then you bring it on. So that's the interval slide in mattress sutures.
And of course, there are shelters. Classification with a partial terrace would be an articulate site there or a person site there. So that's another way of classifying these stairs and the clinical features. The classical history would be an acute pain pain, typically with overhead activities and weakness. So in an exam situation, so you'd most probably it would be a short case.
So when you walk into of the cubicle, the examiner would be taking you and asking you to examine the patient's shoulder. Or sometimes the examiner would directly tell you, like exam the patient's rotator cuff more properly, the patient. I mean, the exam would be saying that examination shoulder. So when you do the inspection, so you ask the patient, the patient might be sitting down, you ask the patient to stand up if possible, ask the patient to stand up.
In a short case, the patient might be kept undressed. If it's not undressed, you ask the patient to undress his shoulders. You see both shoulders together. You stand in front of the patient. He started the inspection, so you see that on inspection. I see that there's a loss of control there is wasting. They'll ask you, examine the patient's right shoulder or left shoulder the way you bilateral findings.
But if they ask you to examine the right shoulder, stick onto the right shoulder so that any of the right shoulder there is a loss of control there is wasting. You need to see exactly what the waste thing is, for instance, the wasting of the area of the major, the deltoid. And then you go behind the patient, you stand and go around the patient, go behind the patient and say that there is wasting of the subscapularis slap and there's wasting waiting for us.
And we can add on. That was Mason so indicative of a supraspinatus industry wasting or in front of InfraWorks waste. And then if there are scars, say that there is a scar of a topical approach or there's a scar scar suggesting after the procedure. And then that end up inspection, you go back to the friend and onto the side and now do the palpation. So in palpation, what you essentially palpation, you look for tenderness.
You look for tenderness of the joint along the clavicle. The AC joint. Then the cyber-criminals base. And you speak as you go along and then you go into the movement. Always, you start over with that Timmermans. You ask the patient to keep both the arms in front the elbow straight, try to move it forward as smooth as possible, both elbows at the same time.
And then you can ask the patient, does it say the patient has got this manufacturing in motion? And once the patient sees that, OK, I can do it only until this much, you pull it and try to get some passive range so you never get a cuff tear unless we can protect our property. This is that if your rotator cuff tear, you will get some more passive range of motion. And then as you do that, you say, OK, I get more passive range of motion.
And if you get more passive range of motion, you don't need to bring it up until 180 degrees because you've got the information that it's for the passive range of motion. So that's not a frozen shoulder. You've got one hand over the patient's shoulder, you don't get any credit. So now you know that it's not a rotator cuff properly, it's not osteoarthritis.
So all these you, you verbalize as you go along. And then the examiner knows that OK is thinking as you're examining the patient and then you go into the abduction observation to give you that. And again, the patient doesn't actively. And then after the patient is finished doing an activity, you do it passively to see how much more you can get it. And as I mentioned, you'll need to get it on 180 degrees because you get the information you get after doing a bit more of passive movement already goes straight away, especially test you start off with.
The suppressed pain does, in fact, not the subscapularis slap Las Vegas empty desk. We just need to do one test each for all in each of the rotator cuff. So so you do the empty can test. You say that, OK, this patient has got a week. I'm doing the American test that's go. It's we. So they test is positive.
Professor bas status there after that, you go on to being frustrated is being frustrated as you test with the axilo degrees of reduction, you ask to external data shown in the picture here. And then you do both sides simultaneously and you say, OK, the acceleration is weak. So I think that's in bas status also tone. So after that, you go to your subscapularis subscapularis. There are three classical tests and it's many films egawa exam egawa breath test, where you ask the patient to hold both hands.
In fact, you keep both hands in front of the belly. Ask the patient to bring the elbow forward. You hold the elbow from friend and try to push it back. And that's how you do the belly breath test. And then you can say that OK, patient is weak on the side. Must be having a subscapularis there. That's it. You don't need to do further tests like the lift off test or the bear hug test.
So for the purpose, you need to know the lift off test, the global lift off test because is again, the hand goes behind because in a lot of this pathology, the patient will be having a lot of internal rotation problems and patient would be having trouble going onto the back. And also, like, you waste a lot of time doing that. Basically, try to do it. You you waste a lot of valuable time and work tested, something which is also being prescribed.
You never do it, but it's better to know that they bring it on to the top of your shoulder. Try to press down and you resist and the patient is weak. So now you're done with the rotator cuff test. Well, in fact, the minor is also there. And that's mainly for the MCU because you don't test the theories minor for the practical exam, because it's very hard to do isolate the actual materials minor and you don't do anything about it.
But for the example they use, it's a very interesting way something called the lawyers bond loci where you ask the patient to emit up to 90 degrees and 90 degrees, and you ask the patient to call it there after some time. If the patient still is minus stone, the hand goes in front and that's on both sides. And after you're done the special test, you go on to the axilo.
It's very important you test for actually, Neal. So when you're testing what you of two components, you test for the regimental bacteria, the sensations number one, and also you look for the deltoid you need to look for both. And then you screen the cervical spine because that's important part of the exam because that's a safety issue in it. So that has to be the moment you say, I'm going to screen cervical spine and say, OK, that's fine.
It's normal, but it's important for you to tick that box by saying that I'm going to examine the cervical spine. So essentially, when you do, you reach until there. So in examination, you could reach until this point by the three, 3 and 1/2 minute mark. So whether you scored a six or seven depends upon how much penis you reach until this level and whether you're being able to detect a diagnosis by as you go along with the examination.
So once you reach a diagnosis, you're definitely reached the 6 and 1/2 mark the day. And now examination examiners will ask you, what? What do you want to know next? I mean, to say that get radiographs. AP axillary Oklahoma is usually not done, but you can, if needed against it, to ask to assess the protein. So the X-ray radiographic features of pathology.
None of these signs are highly specific, but these are signs which are indicative of a pathology like sign, which is shown here that you find sclerosis, undiagnosed Kessler chromium and cystic changes in the greater tuberosity Kessler suture epicondylitis, a type III acromion which would be a chromium. So all these are the extra features which you can see in there and in helicopters, you can get proximal migration of the humeral head and then you get a break in the children's line and a proximal migration of the human head, which which can be quantified when they are chromosomal distances less than 7 millimeters.
So when you say an investigation, the next question would definitely be, what do you expect to see? So it's always good to know what to expect to see rather than just saying that and take it off. KPIX review you need to know what do you expect to see? They show the X-ray. Then they'll ask you what?
What next? I also want to take an MRI scan. MRI scans the diagnostic standard, so obviously next question would be, in fact, it's better for you to say, I want to take an MRI scan to know these things rather than wasting a few seconds asking why? Why? so the MRI scan is basically to assess the terraces to know if it's a full thickness or partial thickness to the shape and degree of retraction.
So if you reach the seven mark level, then they might go into something the classification shall become in a short time later. And the second purpose of doing MRI scan would be to assess the muscle quality. There is a multilayer classification. If you answer all those, you are definitely under the. And yeah, so and then in good classification is basically based on the fatty infiltration of the cuff in an MRI.
And then you also looking for the medial biceps tendon subluxation, which is indicative of a subscapularis tear that's also names you can get it either way is that then you can get an MCU describing like what? Biceps and subluxation? Medially, what? What would that be? Then it would be subscapularis all the way around, like a picture of a subscapularis there.
What else do you see then that it wouldn't be a middle biceps slap lesion? And then there is this sport point. It's better not to say that, but in case someone drops, you can say that because it's too much theoretical, there's something of a tangent sine you can see here in the picture that normal a tangent along the superior border of the scapular spine. So you get a portion of the spine is crossing it, whereas when you get an iconic day, so you can see that when you draw a line in tangent along the gap left by the MRI, the brain is just not crossed it.
So and then I'm coming on to the packet classification, so if it's a show that you get, you can get this goes from here to a shoulder surgeon, obviously, but it's good to know that. So the classification is based upon the amount of success when the standard retraction in a complete day. So a stage one is when the tendon is near the insertion, the greater tuberosity. Stage two is when the tendon retracted to the level of the humeral head.
And stage 3 is when the tendon has reached the level of the glenoid or approximately. And coming onto the quarterly classification and MRI based classification. Where is it? Zero zero? When you get normal muscle and grade 1 and when you get some fatty streaks in the muscle grade two, you get more muscle than fat.
Three, you get equal amounts of muscle and fat and for me to get more fat than muscle. Essentially, the good classification is for looking on to the fatty infiltration of the muscle, which shows the quantity of the there, the quality of the tear, especially in the context of a chronic, protracted tear. And then if you want to consider that are other options would be to do an ultrasound examination.
The use of doing an ultrasound is it's a dynamic assessment. And what the problem is, it can all break independent and it's similar sensitivity, specificity and accuracy when compared to an MRI scan. So if you go to a patient, it's better to take an MRI, for example, because I would say go for an MRI scan because I can see for the infiltration, I can see for the muscles, all those bits you can see. And also you can say ultrasound can be obturator dependent, but there's no harm in saying that they can go for an ultrasound.
If someone ask you what the risk factors were to their progression, you can say that age more than 60 years and then the tendency will be for the full thickness there. Then the chance of their progression is there is higher the size of there and it's the medium size. There is more chance of progression than is a small place. They're smoking a lot of other instances, irrespective of their progression and dominance in the dominant and more chance fatty infiltration, families and family history is considered a risk factor for their function.
So once you've gone through the MRI scan, so next, what are you going to do for the patient? These are the bones essentially surgical treatment. That is to reduce pain and disability to reduce the risk of their progression. And number three, to reduce risk of their property. So whenever you answer a question from for treatment, it's a good strategy to say that the goals of treatment are less.
And as you always you start off with conservation measures. You say that a private equity line of management initially and then it would include it includes what it shouldn't be. For example, you say that what are the conservative measures they want to do? So both physiotherapy, which is the first line of physiotherapy, will be to strengthen the muscles based on the shoulder to improve the posture and the biomechanical axis of the shoulder steroid injections.
Second line and you can also be in a series they use in the short term for pain relief, but there is no functional improvement. And the last point that a subscapularis blocker ablation so that can be kept as part of the material because in the end stage of disease on our property, where the patient is not fit for surgery or patient decline surgery, that is an option for a super blocker ablation. So that's also part you shouldn't say that I'm going to go for block ablation.
The first thing is confidence building measures one, two and three then keep that, according to the scenario. Speaking with surgery, Philip open muscular peel-back surgery, the u-curve trial published in media day in 2017. So it's good to know that. Because if you speak about that, you're going on to the nearly eight territory.
So open was supposed to take off repair in patients more than 50 years with a degenerative tear. So they found that there's no difference in clinical outcome at two years, but the rate of tear the retail rate was high in both open and arthroscopy groups for all sizes of tiers and ages. And this adversely affects the outcome. So in essence, the u-curve trial showed that open bas status both are good results, but the rate is high in both instances.
And of course, this retail adversely affects the outcome. And now in the thick of it, can we get off without a decompression? So there is limited evidence that performing the sober decompression, along with the rotator cuff repair, will significantly improve patient patient outcomes. So that's something to know, though we keep on doing it. And then again, a similar versus a double role or a suture bridge technique, no one is going to ask it to go into that level because if someone asked about that means that you're scoring really, really high.
Because when it's good to know that in general, it seems to perform better in the current literature due to a lesser reiterate, the largest area of contact input biomechanical strength due to multiple points of fixation. So in fact, I know this is a very controversial area. But if their policy is, or even if this comes up in the way you want, you won't go beyond this level. And then this important thing, the massive, retractable buildup there is, because obviously if you get a patient like that, I like it to get that, you need to know the treatment options, so you need to be able to list the treatment options.
Number one would be physiotherapy like dental rehabilitation. No deal would be a partial repair, plus someone is the bridesmaid number three would be tendon transfers, so you can do a lot of damage transfer for a massive structural helicopter, but that needs an intact subscapularis function and you can do a major transfer in a chronic subscapularis there.
So that's an issue that in subscapularis, what's the type of tenderness medial epicondylitis needed? That's and then there are the other options are a synthetic patch like golf jacket, where it's essentially denatured, demonized human skin that uses a synthetic patch, so it's helping muscle. You do it when the patient a helping muscle, but tendon quality options would be a superior Kessler reconstruction.
The principle of a separate capsule reconstruction is it restores the normal anatomic restraint of the humeral head graft for four, restoring the superior strength of the human head, and it relies on the deltoid for architecture. It essentially prevents the humeral head from migrating, approximately. Then you go to inspace balloon, which essentially is you. If you place an inflatable balloon, which is a deflated balloon which is inflated with normal saline in the slap space.
And the principle of that is depresses the female head. And by doing that, it enables the patient to exercise and allows other muscles to take over function of the cuff. So that's an option to speak about. You don't need to know in detail about all this, just need to know what the options are and how each one would help. And then, of course, they're all short on capacity, something that you want to do as a last resort when there's a patient painful or insufficient and non-functioning shoulder in an older patient.
So it's very important to mention these are the options that go forward for conservative management, for physiotherapy, for dental rehabilitation by surgical options would be a partial repair treatment, then transfer synthetic patches to break up the reconstruction in space balloon. If everything fails, it's not nonfunctional children. All the patients will suffer, and probably that will be end of where the very ends.
And also, I doubt it will go beyond this, even for four in the clinical cases, because by that time, the five minute mark will be done. So this is essentially what you need to know for the FRC is exempt. And if you go until this level, then you'll probably scoring until the 70s and 80s and how you reach the six or seven, as I mentioned, is how well you go along the examination.
Then you explain verbalized vocalized examination examinations and get the diagnosis as you go along confidently. The way you examine should seem like you've done this a lot of times. Thank you. I'd be happy to take it. Think it was an excellent presentation? It's very nice to hear this from you as you recently passed the exam.
You've taken us through the journey of rotator cuff problems from. Theory part two, Viva and clinical. And I think. You pitched your presentation at the right level for the Air Force exam, talked and he advises all participants to focus on being systematic in your answer.
And have clear classification systems. You don't need to go in a lot of depth clearly, but you have to have a system to follow. And it just happened to look like you are a smart candidate to the examiner, have the right approach. You will be unlucky that you have a shoulder examiner, but you could be.
But if a non shoulder examiner, if you follow this nice approach, Ranjit explained in this presentation, you will really impress them. You'll even impress a shoulder specialist, some specialty surgeon, so it always helps. So that's. Thank you. I think this covers the whole aspects of our case that all three parts of the exam, I think this presentation could be a reference, really, to all future candidates.
If you don't mind. Yeah you mentioned in your. Treatment options using synthetic graft and lifejacket, what can you tell us a bit more mean examiners might say what is life jacket. Or what is this? I mean, is it synthetic or is it It's a little graft or whatever graft is it?
So essentially, the graph jacket has its miniature human skin. Once again, it's the nature of human skin is in its human skin may just be nature, so it's essentially a sort of an allograft, which is good. So it's not. Would it still be synthetic? But this can mean it's allograft and the various options in of this you got. Because I think in the mean to say that it's a cool idea, it's the nature of human skin, which has been demonized and all that.
OK thank you. Yes, ma'am. We would like to hear from you your comments overall about rotator cuffs. Any comments you have, please? Yes, it's just a very good presentation. Ranjeet and I really enjoyed it. As for us, I think that's good to have on the website because it is very educational.
Just one thing, you know, gruff jacket is a commercial name for the allograft used by right Medica. So I won't use the term gruff jacket. And we've written a meta analysis on different scaffolds used in biological threat components like for augment and so. And there are three types you can just use say, allograft or autograft autograft with the original one described by a toy by mhatre, 3 from Japan.
And there is a look like I like that jacket, and it's also manufactured by Arthrex as well. Also, there is and it is in this and in other. Studies now they proved that this is associated with superior outcomes, but still controversial. Also last question. Graph jacket is a brand name. It's not absolutely the right medical.
So what do you suggest we should use for the exam? Candidates should use, but I would say augmented that, you know, like patches would be enough. And then they can ask you further. You could explain what the patch is composed of unless he's the examiner is a shoulder surgeon. I don't think they would go in depth, but you can also say that recent evidence supports it is associated, you know, doing augmented repairs and those patients with bad quality tendons are associated with improved outcomes.
Recently, and that's one of the moment, yeah, I mean, it dropped typekit is something you shouldn't be putting there. I think it's my mistake because it's a strict no not to come up with a commercial name. My apologies for putting that there. It's always good, you know? So, you know, if you want to use the word traject, you can just say acellular human dermal matrix augmentation because that's all dermal matrix augmentation or thermal patches.
I think that if you want to use a term supported the use of graft check. It was published in 2012. It is an oddity. So it's really a very well conducted. The thing also there is also I think it's a nice guidance now that can be only done as part of a trial nowadays because there isn't enough evidence validating it, although many surgeons are using it everywhere.
But it is now suggested that you can only use superior capsule reconstruction as part of a clinical trial. So I would. So if it is a repairable cuff, you can consider options like superior capsule reconstruction as mentioned or tendon transfers either lower, you know, lower transfer or led to site transfer for superior and repairable cuff tears or even velocity, which would be easier to discuss in detail.
So just choose something you're confident talking about. Thank you very much. It's true of all the dead men described describe boycott, and essentially what boycott did was essentially the angle in which the suture anchor is inserted into the footprint. So it's I mean, 45 degrees, 90 90 degrees, what was being described in the language? Essentially, the 45 degrees, which is recommended by Walcott.
So that's essentially. Thank you very much, I think they're very good, I think. Thank you very much. Ranjit and thank Mohammad for your input. I was a fantastic presentation. I've learned a lot and I am going to have the pleasure of revisiting this to edit it and put it on the YouTube channel for everyone to see for, especially for those people who didn't have the opportunity to attend today.
I just want to remind people you will be entitled to have a CPD certificate one credit from Royal College of Surgeons. Please get in touch with me via the telegram group or Facebook, if you like to have one. I think we are reaching 8 o'clock now, so we probably will finish the session. Mentors need to rest now.
So thank you very much, everyone, for attending. Thank you. Thank you. Thank you for inviting us. We had 45 participants this evening to thank you to every one of you, and I hope you all learned something useful, for example, from this session. And good NIPE.
Bye bye. Thanks Thanks. Thank you. Thank you. Thank you. Thank you.
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Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode