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Patello-Femoral Instability for Orthopaedic Exams
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Patello-Femoral Instability for Orthopaedic Exams
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Language: EN.
Segment:0 .
Guys, this is the teaching is very kindly presented by Prof Kader. He's quite well known. It will take me half an hour to introduce him really fully, but just briefly tell you about him. He's a consultant from London. He's worked in the UK for many years. He has many activities, professional activities, but he has a charity activities in the UK and abroad, the Middle East.
He also, if you move on to his academic profile, he has published more than 100 peer reviewed publications. He has edited many books. Some of them are directly, of course, relevant, such as these two books. I think most of you, if not all of these books very well. But, you know, including me, the I've read all the editions. This is the third edition of the postgraduate Orthopedics and I've experienced all editions, excellent books.
The Viva book. There's another book Viva book coming very soon. And also he runs fast courses with very, very well recommended. I think also a lot of people attended. I attended some of these. And the next one, there is one in the UK in October and 1 over also coming in January next year. So these are all recommended.
And so basically a provider is, you know, has a wealth of knowledge. And I think we are very privileged to have him with us tonight. And please make the best of his best of his presence with us and ask you questions, raise your queries and he will do his best. I'm sure to help you guys. Obviously, as you know, if anyone has a question, just raise your hand the hand symbol next to your name, and I will pass on your question to prof.
Kader so over to you. OK, so good evening. You need to show me what to do, though. Yeah, share three now shares screen in the bottom. And so I can still see my. Excellent So good evening, everyone. This hopefully will be one of few seminars I'm going to give you for us. Was very clever by asking me to do this.
I was not sure what I've been signed into. He just asked me to do it and I because I like him, I said Yes. Now I realize there is more into it and just talking to a few people. So never mind, we will continue doing it. And I hope that this talk will be just an introductory. But in the future, this talk is going to be about Patel and stability. Some of it will be exam related.
Majority of it. But there are certain things which you probably benefit for your clinical practice, too. So it is, I wouldn't say, 100% exam focused. The exam questions are so variable. Some centers you get examined, you will find that there are a lot of family related cases. Some others you just find. All of it is metalwork and arthroplasty and things which are just completely different from day to day at work.
So it's very much dependent where you work for where the exam is and what clinical cases are available. But needless to say, this is also an important part of the exam, and it is. It's important for you to know these things. Now I work for a few places as far introduced me, and these are the places at work and I work with the Red Cross in Lebanon and I work with the few charities in Iraq now to tell us stability.
The actual stability of the patella is very much a complex interaction, and it is between soft tissue homeostasis, bone morphology and overall alignment of the leg. Now you can see that in the first 30 degrees of movement, the ability of the people are very much dependent on the sauce. After that, it is dependent on the morphology. Of course, alignment affects that at different levels.
Now, these are the main causes of instability, so of course, in the exam setting, people don't ask you, what are the causes of instability? Because the exam is not there to test your memory. It's there to test the depth of thinking you have and how thorough you are and how analytic you are. So but if you don't know these things, then you have no hope in progressing. You have to keep these things in back of your mind and be able to apply them to clinical practice.
So there are soft reasons for so many reasons. There are alignment and gait. All affect stability of Kessler. Now, I could tell you, this is a controversial thing, and 20 years ago, there was no controversy. Everybody who dislocated their pencil people would put them in a plastic for six weeks. I've done that multiple times when I was in. But nowadays things have moved on and we first if we treat them conservatively, which conservative for a shorter period of time, which is a couple of weeks in a splint just to rest and mobilize as possible.
Of course, there are a subgroup of those people who dislocated their pretending they have a different problem because they have multiple anatomical factors wrong with them. And this group, which is a smaller group, may benefit from the intervention. So if somebody asked you, how would you treat an accurate patella dislocation, you would say it is conservative for a short period of time.
But there are subgroups who may benefit from surgical intervention. That's an answer. Nobody can argue. If, however, somebody dislocated their patella more than once, which is 2 times and above, then it will be reasonable not to prolong conservative treatment and consider surgery early on. So I'll explain why, because Reed dislocation rate after first time dislocation can reach up to 49 or 50% of them may be OK after first time dislocation.
You can see there is a range of dislocation with between 17 or 18, but the 14 million. There are people who are probably younger, who have high mobility or have multiple anatomical factors wrong with them. They will be susceptible to another dislocation while the people who are on the 17th. Those are people who are a bit older and they don't have too many things wrong with them.
They don't have massive cochlear dysplasia or patella outer or I have problems with the overall alignment. So second time dislocation is the serious one when somebody dissipates a second time. Then there is high level up to 2/3 of them would really dislocate. So it will make sense that people who dislocate twice to consider them for surgery patient satisfaction with non operative treatment is very low 40% and the return to premium level after first time dislocation is again, very low.
After first time dislocation, there's 50% chance of positive control, and it has been shown that if you treat those patients conservatively, there is 35% of them who would develop osteoarthritis at a later date. Patella Alta is very high among this group, about 2/3 of them, nearly so is. If you look at the chocolate displays yet again, very high, so some 71% of them could have some sort of chocolate displays.
Not necessarily the type C or d, but they might be just having a shallow chocolate or even a convex one or. TTG is abnormal in 42 of those patients. And I was what some of you might have heard about LGBT and already applied their workplace, but it is the distance between the deepness part of the chocolate and the highest part of the tuberosity, and that is measured by millimeters.
And it is measured superimposing scans on each other so you can measure them from the next three. You have to have either MRI scan or a CT scan and then this measurement from their. And 58% of those patients or people who have a recurrent patella dislocation. There are multiple anatomical factors wrong with them, but these are people who are hyper mobile.
They have a rotational abnormality. There's a problem. They might have a patella outer. So there are multiple things that could dislocation. But it is important, but but in subgroup. Right? who are very young or have a strong family history or had the control and dislocation, moral alignment or rotation, chocolate dysplasia, patella, alt-a, hypermobility.
One has to consider surgery early on so that they don't keep dislocating and they don't keep damaging the articular surface of the telephone. Now the other thing you need to know about the stability that it is, the instability is very difficult to generally quantify. Even with all the tests you do, such as MRI scan and all epicondyle measurement. So I'll explain why.
So these are the anatomical factors we've discussed earlier. I did this rotational profile CTU for eight or nine years, and I measured every single factor that could potentially lead to dislocations or femoral integration, the rotation, external patella and little chocolate and chocolate and other things you get from the teeth we did in a very specific way.
As Paul David, who has been the person who's designed this protocol. So the ephemerality version was measured. The lateral patella tilt was measured, the clear tilt or depth was measured and then rotation such as this. So we measured various things and properly dysplasia.
Of course, I've used Swango for many years, but then I realized yongle is not particularly useful. It's very crude. And I also use TTG for many years, and there are still people who believe that edg, which normally is 2 to 12 millimeters but there are lots of people believe in 20 and above, is an indication to intervene. And when osteotomy or realign the leg, but that is not strictly true.
I am the reason I'm saying because we've done research on this and we have shown that it is the angle if you are both unreliable or to assess in the end in the process of designing and management. No charge, so to speak, or algorithm for instability.
Now the Q&A, as you all know, it is a very crude measure. A lot of people measure it in different ways. Some people measure with standing, certain muscles contract it was relaxed and infection and extension. So therefore it is. We are not talking about the same thing when we are talking, when we are measuring. Merchant, if you know him, is the guy who described the merchant used he has designed gono meters specifically for the Q&A. And for many years after using it for many years.
I believe the Q&A is very, very crude. It's almost useless. But keep it in mind if your mind, for example, you can say I can see the alignment is in or had done that or this will affect the alignment in one way or another. Now the distance is another story. So this the first paper described to TTG was in 1978 and it was in French.
On this paper, had three groups of patients, one of them or were over 65. The second group of health writers, the third group was the only group with this location and the quality of this paper is very poor. It would never pass the stringent review of nowadays, but it has taken off. Now I myself, fortunately or unfortunately, have contributed to the myth of many years ago.
We did the research on this and we suggested that if the TTG is above 15 mm, then one has to implement or use some aggressive surgery to intervene to correct the instability. But I really don't believe that is correct nowadays because logically, if you look at these two guys, you can have a small guy.
And a massive guy. If you move to be able to 5 medially, you would have different impacts or outcomes and those two guys because 5 millimeters on a little bit different impact compared to the big guy. And also, we have the same problem. TTG is measured in different ways. It's measured in flexion and extension, normally very nice.
There is the interest rate reliability of three to 5 millimeter measurement. The difference between the. So it isn't as reliable as people claim for the exact purpose. You can mention, you know, you can q angle, but I wouldn't, you know, think of them and being Allen and all the swear by them. It is one of many investigations that help you in making up your mind, and they are not the most reliable one.
And of course, we've published on this and shown that the US is not a decisive element in establishing therapeutic choices for instability. Now with instability, do we really have to jump on the bandwagon like everybody else and do they do you have to think for yourself what is useful, what's not, what are the exam papers? You just have to have an understanding of what are the main contributing factors in stability and then how to investigate them, how to identify them and generally how to correct them.
If there are different anatomical factors which are abnormal, by the end of this, you would understand how to deal with instability in the exam. Now, I simplify things a lot because I think there's very little point of knowing that not being able to apply clinical. So to me, stability. Again, it is a spectrum.
It's not a continuum. It's a spectrum, so there are people who have a normal. There are others in a five mile typekit that may or may not meet. And then in that group, there something happens that lead them to decompensation, and then some of them may be compensated to an extent to have a recurrent dislocation. And others may have nothing to do with it.
Just be dislocating it all the time. That's what I'm saying. There are a group that is dislocated, though, another group that is dislocated all the time. They simply have two different pathways in the treatments which are available to us and the stability it is. Dislocated patella, so the people are sitting there.
This is all Oh. Each of them would need different treatment. So essentially, the first one would need a simple intervention, such as soft tissue procedures, such as empathetic inspection if the other parameters are not normal. The second one would need to be three four five operations to correct.
What are those things to do? The procedures are. So we have a tendency, as surgeons to apply attrition. We know everybody. And that's what happens with in this situation where people suddenly start doing medical searching and they started doing them and everybody. Yeah so I acknowledge that MPFL is important and it is I've done a lot of research on it personally and before my dissection, and it is well documented in the literature when there is almost 100% chance of being ruptured.
If not, put it up to be partially injured. Now, I also have also published that empathetic instruction is it's a very good procedure. However, there are other procedures which are necessary in certain individuals, and that is trivial to transfer men immediately. And that is because you have abnormality, so you deal with that.
But I will give you an indication. The indications for that in a second. You would also consider a patient who have circular displays that you consider your plastic. And very important operation, which is not very commonly done. It is crystallization of the tibial tubercle for patella Alta. I think I believe patella ulcer is a serious pathology and one of those problems that cannot be corrected by the soft tissue procedure.
You need to do this. Validation and crystallization is a very successful. So the treatment summary is this so you can do a reconstruction in probably 80 or more of the patients and that is on the patients who have had this dislocation NPF rupture. They have a small degree of small degree of dysplasia, white overall hypermobility and muscle alignment and modification, but not severe enough for you to consider legalization or destabilization.
However, if somebody and I in my practice, mainly you have to think about digitalization, primarily if somebody that is more than 1.4, 1.4 and more as you do, you do your measurement. There are different ways of measuring out. You need to know them, for example. There is a Black here, right? There's any question there is a condition that is being used for stability.
So it is one of those things, but it's mainly about digitalization and the indication for it. And I did you hear me when I was talking about different measurements? Yes Yeah. So so if the measurement of any of these indices more than one point two, then you're thinking there's abnormality. And if it is one point four, there is. Where do you think I should be doing this?
Utilization of the tibial tubercle? And if somebody has so clear dysplasia, which is grade C or d, according to law, then that means when it is completely deformed, not just slightly shallow, then one has to talk to your class. Distal femur or body rotation osteotomy are very rare, but occasionally useful if somebody has massive rotation.
Now, this patient of mine had more than one problem, so he was she was dislocated all the time. So in order to put the patella back and keep it on the top of the knee, one has to do release legalization, crystallization added clear plastic and empathetic answer all of them in one go. So that I can control the patella. Simply, people who have a soft tissue problem made painful rupture with some anatomical abnormalities would benefit from ampofo reconstruction, and that is the group which are dislocated both.
However, there are. There are a group of patients who have the patella dislocated all the time. Then that group needs more than one operation altogether to put the patella back on track and then keep it there. Now, the surgical technique for it, I'm not sure how much if you are, if you know that much. I don't think you would probably be asked about technicality of this in the exam, but you know, if you're doing well, then people would ask, so the surgical technique, and for those of you who practice this or see this in theater, it is important that you pick the correct channel placement and not to position your channels.
And I'll show you how it works, I've done a lot of work in the lab on this time of 2012 and all that published in American Journal of Sports Medicine. So the bottom line is previous research, which was done in the same lab by Andrew Amos showed that the MPFL attaches to the medial epicondyle, but that is subsequently have been shown by myself and few people that it is wrong.
It is attached to the. If you look at here, you can see the MPFL is attached to the upper third of the patella and also to the midpoint between adductor tubercle and the medial epicondyle, so it doesn't attach to the medial epicondyle as it was previously believed. Now you can see also where it is attached and it is relation to the shuttle work or the point, which is a lot of people reconstruct their MPFL using the red dot, which is we think not it is not just me.
In fact, today I had some communication from a Japanese soldier who's done a very nice basic science study showing that the attachment is in the green area. Exactly not the right, but there is where it should be the placement. And that point is we call the confluence point, not the cader point with the confluence point. The reason we call it confidence because it is a confluence of things in mind, which is can see where it's coming from and the extension of the line coming from the posterior cortex of the femur.
So those two lines they meet at the point there is where the anatomical point is in the biomechanical study to show that visually and as it happened, that point is in the center of the rotation. And the techniques are to either you do a medial trough or bony tunnel or multiple other ways. You just have to apply the principles of reconstruction.
Now the principles are not to overturn them and fix them the wrong angle. Generally, attention then to New things to 202 or three drums and at a flexion angle of 60 degrees. 30 is acceptable, too, but the reason I'm saying 60 occurs at 60. The Kessler will be constrained by whatever move you have left in the cochlea.
And then you are not going to be over tension in it because it is being buttressed by the top layer at six degrees or. Now, just want to say that the rehab of reconstruction should be just straightforward, just like a Getting them going quickly. No brace for weight bearing as able flex and extend as far as they can.
And of course, you go through different stages. But the reason I'm saying all this, because the tensile strength of Apfel is 218. So essentially, you're really not going to apply massive amount of force to the PFO reconstruction. The epithelial reconstruction is necessary in the first 30 days. Just touch the patella, enter the groove so you put in a graft that is multiple times stronger than the MPFL itself.
So know, the load two failures of a semi and the nurses is much higher. So if we're talking about the poor bundle, which is 4,000 meeting and so a single bundle would be less than that, but still will be much stronger than the reconstruction. Of course, here we have a client who bundle instead of four. So we're probably still about seven or eight times stronger.
And we are reaching the end here, so I personally think, first of all, it is so unnecessary for the reasons I've mentioned earlier and also because they are having uncomfortable skin problems and they have no benefit and they cause muscle weaknesses. Now, so the take-home message here is that an accurate dislocation, consider surgery in a very small subgroup of the treatment of this patient is so conservative and you have to remember that when you dislocated patella first time, there is a 50% chance of redistricting in certain group, not in every individual.
And there are also possibilities of damaging the or 0 control part of. Now, if you have a recurrent dislocation, it is wise not to delay the surgical intervention and not to persevere too long. The more teeth and sending from the freezer because that will lead to a fight.
And you have to also remember, there are multiple anatomical factors that lead to instability. So one has to be mindful of various potential pathology. And we also discussed that is very difficult to quantify and stability, so you really have to use your word or the example of you, of course, for any exam, you need to make sure that you have an understanding of the different types of investigations and the use of them collectively rather than individually.
I wouldn't rely too much on strong go in my clinical practice or for, you know, for theoretical purposes either. Now so it is important to reconstruct anatomically, as I said to the confluence point, rather than to the saddle point. I have to tell you that people do not dislocate after your reconstruction if you use the abnormal tunnel system.
But what they do, they will be tight inspection. The other thing is they will be now tracking for life and probably end up with arthritis. And the other thing is don't apply and for reconstruction to everyone. And remember, we don't need too much force or tension on the NPF every construction and mobilize the early. Thank you very much.
That's our next course in Hyderabad in October. Thanks to everyone. If you have any questions, I'm happy to answer. Thank you. That's amazing. As expected, obviously, clearly I don't have anything to add to it. I thank you very nicely cover the topic. I think this is a summary of years and years of experience, both academically and clinically.
I learned a lot, and I'm going to listen to this lecture again and again to consolidate my knowledge about it. But I liked how. He explained how the TTG is not just a. No, it's actually relative to the patients. You know, so therefore, you know, there's no right answer. It's a 12 the 20s. If we put onto that to the examiners in the exam that it is, it is a relative number and the patient factor.
Body habitats that have told the patient is important that, you know, examiners will then understand that we know we are treating patients rather than treating scans. Or I think if you just take we're not engineers, you know, we didn't with biology and we were dealing with variation and in height, weight and sex and all.
There are multiple factors and can affect all these members. So therefore, we have to just show the maturity of saying, well, I know this is being said 20 is the magic figure, but it is, you know, it can vary because the measurement is not reliable and you could use them for a CT scan or, you know, and there is interactive. The rater reliability of these measurements is very low.
So therefore it just shows you have an analytic mind not repeating what says what is being said in the books. That's what exam is about, isn't it? And so I yeah, I picked up this nice spectrum you put off of the telephone and stability. I don't think I've heard that before, and it's very nice concept. Yeah so I think it's really very interesting.
How you personalize your treatment to depends. It depends on where your patient is in the spectrum. So there is no one right operation, no do two procedure in one patient. You do as you demonstrated multiple procedures or just one. And in this spectrum, I really need to sit down later on and look at that again and. It's very, very interesting concept.
Have any questions. So we have, we have. How is the ttg? Distance is measured and I'm not sure you would they ask this question in the exams or I don't know. They are all sort of weird and wonderful question. And I wouldn't get I wouldn't get too kind of warmed up about anything because people ask all sorts of questions. The thing is the end the exam you, you are.
What what we want to reach is the point that this person is ready to become a consultant by having a depth of analytic brain, I wouldn't say knowledge just because you could have the knowledge that you don't apply properly. So it is the depth of thinking, the analysis, the it is just it isn't about listing 10 causes of death and 12 20 differential diagnosis definitely is not.
And you trying to avoid asking people these direct questions, it is about what would be the situation, how would you handle it? So if I ask you, how would you manage with somebody with instability? Of course, you have to have in the back of your mind all the causes which are causing instability. But then you would say that I would consider if the patient is young or old, hyper mobile, not they have rotational or alignment or not.
And then if they have a femoral intervention, muscle weakness, gait abnormality. So that just shows that you've not just learned about the causes. You can also apply them clinically. And that is a big problem with a lot of people who just know a lot of things can't apply it. And then, you know, what's the point of knowing too much but can be confused with all that traffic in your brain?
So the question was what sort of the question is, how do you measure that? The effect is that you rely on your audiologist to measure it for you? Or do you have to have a first scan? You don't have to have a scan of the as I've shown there of the head and the ankle can be measured by from an MRI scan scan.
But what they do, they align the posterior and then simply measure the distance from the deepest point. I think I have a slide showing that I think, yeah, one of you. Yeah, Yeah. It was a slide show in how to measure it. Yes, you superimposed the two of them. It's not going to work by. So you need a radiologist to work with you to measure them for you.
But if you look at here, they see it anyway. The third image, you see the slide I have, I have. I stopped sharing it. No, no. You are still sharing. We can see. We can see there. There, there are three images. So if you look at the first one, which shows the femur the deepest part, they pick the deepest part of the cochlea, the highest point of the tibial tuberosity.
And these are all controversial because some people say, is this the highest cartilaginous or the highest bone? So if you are a scientist, then you start becoming a bit panicky. Here is the third image here shows that they have been superimposed and that distance is being measured. Yeah OK.
Thank you very much. And is there a difference between doing CT or MRI scan or the equally accurate? No, they're equally inaccurate. Equally inaccurate. That's a profound way to say. And then there is this problem because the cartilage on the top layer and the bone they don't match. So the college may be exaggerating or otherwise the distance.
So both of them have their own problems. Generally, people use ct, but MRI scan could be used. It gives you an idea. I think what you do with a lot of investigations, these are one of them. There are other investigations you do, for example, for infected and arthroplasty. And those investigation, none of them are on its own are useful. But you have to take them all in context.
And in consideration. So then you have this art of. You know, guesstimating this is an infection or not, there is pretty much the same. You have multiple measurements. You just have to decide at the end, which treatment I could use to make a difference. I put it to you that the most important one is the patella Alta.
If you have a high patella, then you're not going to get away with just episodic construction. No further construction is good and probably 80% or more of those patients. But there are people who have abnormalities and primarily the people who are dislocated all the time or people will have to Kessler out. They need more than just for the construction. Thank you.
I think there was one question about when to do soft tissue procedure. I want to do bony procedure, but I think he already answered this. This depends on the etiology of the condition. What's what's behind it? I think I've put it down as a cookbook a La Carte treatment. But yes, you know, in medicine, that doesn't work. I mean, you can.
I think there was. Yeah so you do a reconstruction if you have just soft tissue problem, tibial tubercle, media lines or digitalized if you have a very high TTG. But generally, I don't do. A lot of people don't do medial idealization on their own, and they do just stylization on their own. But when you just alive, you do the operation primarily for the stabilization.
But if I show you as I, if you look at, I can't see it because there are a lot of sequencing. Here you go. So if you look at these, see the image with two screws in the yeah, right. Yes, right. So all right. But at the same time, it has been realized if you look at the gap in the top and it has medium size and the size at the same time.
So that that's why we do crystallization visualization at the same time. But digitalization is the driver here. So to see how different is those kneecaps, you know? So look at the picture here and again, it's been brought down and the work a lot to be uncovered because it is too long. OK Yeah. You have to anchor that, OK, so one more question was about the sign also is that something you would use clinical assessment or you experience?
I think I've mentioned that. Well, I didn't read it, but I don't think I have put in clinical examination. I haven't. No, I haven't. But essentially for the exam, I think you're not going to take that. I don't think I have it for the exam. Yeah, no.
I don't think there is. So in the end, the exam, it is important if you see something, you say that I've made this observation, that is a sign Mason is, you know, it is theoretically, it is supposed to indicate some overall moral alignment. Yeah alignment means in more technical terms that the T2D or the extensor mechanism is not aligned properly.
And it is more naturalized than normal. So that's why the patellar tend to have the reverse J sign when you are. Yeah, well, you mentioned that. But truthfully, I mean, it's not going to change. You just say, well, because they have de sign. I'm going to have to do legalization that doesn't work like that. Some people probably a simpleton and they say that it's OK, but I don't think you can just immediately correlate those to.
But it's something you observe. You mentioned you say theoretically with the suggestion of moral alignment of the extensor mechanism and may be one of those factors which lead you to choose. That really makes sense. It's 21 hours, but it isn't just that you have to remember. Do all the other tests, the clinical ones?
And then so Beaton's what is important for the I'm sorry, I had those slides, but I didn't put them in because I just picked this presentation from ASCO last week. Yeah, Yeah. Score, I think I think one of the things I could say is if a clinical, maybe in a clinical examination situation, anything about instability, shoulder patella, anything? Yeah, straight away.
Check for the bittern. Yeah, of course. Hyper mobility. Yeah first, what is it in the exam? You don't do the apprehension test with enthusiasm, because that could lead to a problem. So it is very important that you don't cause too much pain or plaques test or there are tests you do that causes pain. So you're trying to leave those to the end or ask if it is necessary for you to do them, but for instability purposes, it is, you know, it is just observing certain things, you observing their gait, you are looking at the mobility from for you said something about the gene.
If there is, if there is one, if the patella is pointing or you see them there, work with massive femoral integration, you have to just make a comment on those things. And believe me, none of the things I asked are typical in our exam or in anywhere else. But I think it's just the stress level is too high and people get a bit flustered and confused. Yeah, Yeah.
And we hear that. I mean, it is with time and time again, we remind ourselves and colleagues that these guys are I can speak for the UK exam. It's one of the fairest in the world and I quite important, which you have to be wary about if you are going to answer in the exam when you operate on a first time dislocate or patella dislocation. Yeah prof.
I think I think I've answered that in a way saying that if somebody generally for the exam purposes, you say, I would treat those who treat them conservatively, but there's a subgroup. So it's the subgroup is people who have a strong family history. Had the other side dislocated people who have multiple abnormal anatomical abnormality there, and then there is those who have, for example, a big ostrich control fragments in there on top of these things.
But at least you need to remove that control fragment if you went there and somebody who that a 50% chance of them dislocating, it makes absolute sense to do something about it rather than waiting for them to dislocate again. But it is all dependent on how comfortable you are with treating this condition. So if you are somebody who does that day in, day out and it's fine, you can.
On top of the removing of Austria and then you can do an MPFL reconstruction or even repair or augmentation. But if you are, you know, if you are not comfortable, you can just do the removal of their body and then, you know, leave it somebody else or wait. Yeah and that actually brings up the next question, which is, I'm sorry, but I think it's quite in the exam.
Being prepared for this type of question in pediatrics situations. Is the management the same in these cases? No, I was asked exactly the same question. You know, I have a first time dislocation now at that age group. You can do a medial application. What media application means is you use not five strong bones sutures and you can do it topically or assisted our facility with a small slap over the medial aspect of the patella.
And then you tie all these sutures so that you implicate the medial side and that we make them last for a few years, as you did that adults. After six months, it will all fall apart. They work very well, but I don't think it can withstand the forces of an adult patient. Now the there are times you need to do an MPFL reconstruction with open prices.
There are two different techniques. One of them, you use an eye and then trying to avoid devices. And the other one. Some people try not to make panels in the field, but then they will try to give you something to sling around the adaptive magnet tendon insertion along the tuberosity, because that's one of the techniques that people use that to avoid.
But I have always done the tunnel and I have kept away from it by using this intense file and then the topography. It's important that they know that they have a sound plan for the management of this condition and then some understanding of the causes and the potential factors, then the technicality of things that will take you to more than. OK, you want just for everyone who's about to sit the exam in the summer.
My advice is exactly as prof. Has just said, focus on the management, the principles behind it. Don't get into the acute how you're going to manage the operation itself until you've discussed the basic management in your clinic, in the A&E and long term physical plan and so on. Essentially, develop a walking plan where surgery is your final option and you're not going to discuss the operative technique until you've discussed everything else around it first.
Yeah that you in your talk, you mentioned a few references, and I do recommend that candidates, maybe they should remember this for the exam and the court them if they can. You do you think that's a good idea? Oh, no, no, not necessary. No, I think there's a lot made of it. You know, you need to put this paper, that paper. Yeah, I think it is.
Before that, you need to know your stuff before you stage of putting icing on the cake. So I think first thing first, you have to have an analytic mind and the knowledge to, you know, to just come across as somebody who understands what's going on. And then if you know, papers and you don't have to be very detailed about them, but if you know them, then say, well, this, you know, paper from London or from wherever it shows this.
But it's very important to be a reasonable and neutral and don't be a radical in things that are rubbish in treatment. They stay on the fence. It's not something I would do in also. Is there any guideline broad? No, that no particular test is useful and just, you know, your measurements of the patella, you know, the dysplasia score, you know, a high probability score.
You know that some people have more than one factor. And then you have them all in consideration when you have managing this condition. You also know that MPFL is a very important strain to the patella and ruptures in almost 95% Reconstruction is common. More than 80% of the time you get away with for reconstruction other times.
Thank you, prof. I think that's really amazing. I think, you know, today 51 people attended. That's the most attended event we had so far. You have raised who is really very happy to step in and take the challenge of teaching all of us. We appreciate the time you put it into this presentation, really appreciate that very much and I think a very kind of to offer Viva practice for us on a later day, not today, coming to talk to us, really appreciate what you see and also the general advice for the exam.
It's very useful. We look forward to having you with our group as much as possible. Hey, guys, well, you guys have a nice evening. Thank you very much. Thank you. And thank you everyone for attending and for all the questions have been asked and we will see you again next Wednesday.
All right, guys. Thank you. Thank you very much. Bye bye.
Segment:0 .
Guys, this is the teaching is very kindly presented by Prof Kader. He's quite well known. It will take me half an hour to introduce him really fully, but just briefly tell you about him. He's a consultant from London. He's worked in the UK for many years. He has many activities, professional activities, but he has a charity activities in the UK and abroad, the Middle East.
He also, if you move on to his academic profile, he has published more than 100 peer reviewed publications. He has edited many books. Some of them are directly, of course, relevant, such as these two books. I think most of you, if not all of these books very well. But, you know, including me, the I've read all the editions. This is the third edition of the postgraduate Orthopedics and I've experienced all editions, excellent books.
The Viva book. There's another book Viva book coming very soon. And also he runs fast courses with very, very well recommended. I think also a lot of people attended. I attended some of these. And the next one, there is one in the UK in October and 1 over also coming in January next year. So these are all recommended.
And so basically a provider is, you know, has a wealth of knowledge. And I think we are very privileged to have him with us tonight. And please make the best of his best of his presence with us and ask you questions, raise your queries and he will do his best. I'm sure to help you guys. Obviously, as you know, if anyone has a question, just raise your hand the hand symbol next to your name, and I will pass on your question to prof.
Kader so over to you. OK, so good evening. You need to show me what to do, though. Yeah, share three now shares screen in the bottom. And so I can still see my. Excellent So good evening, everyone. This hopefully will be one of few seminars I'm going to give you for us. Was very clever by asking me to do this.
I was not sure what I've been signed into. He just asked me to do it and I because I like him, I said Yes. Now I realize there is more into it and just talking to a few people. So never mind, we will continue doing it. And I hope that this talk will be just an introductory. But in the future, this talk is going to be about Patel and stability. Some of it will be exam related.
Majority of it. But there are certain things which you probably benefit for your clinical practice, too. So it is, I wouldn't say, 100% exam focused. The exam questions are so variable. Some centers you get examined, you will find that there are a lot of family related cases. Some others you just find. All of it is metalwork and arthroplasty and things which are just completely different from day to day at work.
So it's very much dependent where you work for where the exam is and what clinical cases are available. But needless to say, this is also an important part of the exam, and it is. It's important for you to know these things. Now I work for a few places as far introduced me, and these are the places at work and I work with the Red Cross in Lebanon and I work with the few charities in Iraq now to tell us stability.
The actual stability of the patella is very much a complex interaction, and it is between soft tissue homeostasis, bone morphology and overall alignment of the leg. Now you can see that in the first 30 degrees of movement, the ability of the people are very much dependent on the sauce. After that, it is dependent on the morphology. Of course, alignment affects that at different levels.
Now, these are the main causes of instability, so of course, in the exam setting, people don't ask you, what are the causes of instability? Because the exam is not there to test your memory. It's there to test the depth of thinking you have and how thorough you are and how analytic you are. So but if you don't know these things, then you have no hope in progressing. You have to keep these things in back of your mind and be able to apply them to clinical practice.
So there are soft reasons for so many reasons. There are alignment and gait. All affect stability of Kessler. Now, I could tell you, this is a controversial thing, and 20 years ago, there was no controversy. Everybody who dislocated their pencil people would put them in a plastic for six weeks. I've done that multiple times when I was in. But nowadays things have moved on and we first if we treat them conservatively, which conservative for a shorter period of time, which is a couple of weeks in a splint just to rest and mobilize as possible.
Of course, there are a subgroup of those people who dislocated their pretending they have a different problem because they have multiple anatomical factors wrong with them. And this group, which is a smaller group, may benefit from the intervention. So if somebody asked you, how would you treat an accurate patella dislocation, you would say it is conservative for a short period of time.
But there are subgroups who may benefit from surgical intervention. That's an answer. Nobody can argue. If, however, somebody dislocated their patella more than once, which is 2 times and above, then it will be reasonable not to prolong conservative treatment and consider surgery early on. So I'll explain why, because Reed dislocation rate after first time dislocation can reach up to 49 or 50% of them may be OK after first time dislocation.
You can see there is a range of dislocation with between 17 or 18, but the 14 million. There are people who are probably younger, who have high mobility or have multiple anatomical factors wrong with them. They will be susceptible to another dislocation while the people who are on the 17th. Those are people who are a bit older and they don't have too many things wrong with them.
They don't have massive cochlear dysplasia or patella outer or I have problems with the overall alignment. So second time dislocation is the serious one when somebody dissipates a second time. Then there is high level up to 2/3 of them would really dislocate. So it will make sense that people who dislocate twice to consider them for surgery patient satisfaction with non operative treatment is very low 40% and the return to premium level after first time dislocation is again, very low.
After first time dislocation, there's 50% chance of positive control, and it has been shown that if you treat those patients conservatively, there is 35% of them who would develop osteoarthritis at a later date. Patella Alta is very high among this group, about 2/3 of them, nearly so is. If you look at the chocolate displays yet again, very high, so some 71% of them could have some sort of chocolate displays.
Not necessarily the type C or d, but they might be just having a shallow chocolate or even a convex one or. TTG is abnormal in 42 of those patients. And I was what some of you might have heard about LGBT and already applied their workplace, but it is the distance between the deepness part of the chocolate and the highest part of the tuberosity, and that is measured by millimeters.
And it is measured superimposing scans on each other so you can measure them from the next three. You have to have either MRI scan or a CT scan and then this measurement from their. And 58% of those patients or people who have a recurrent patella dislocation. There are multiple anatomical factors wrong with them, but these are people who are hyper mobile.
They have a rotational abnormality. There's a problem. They might have a patella outer. So there are multiple things that could dislocation. But it is important, but but in subgroup. Right? who are very young or have a strong family history or had the control and dislocation, moral alignment or rotation, chocolate dysplasia, patella, alt-a, hypermobility.
One has to consider surgery early on so that they don't keep dislocating and they don't keep damaging the articular surface of the telephone. Now the other thing you need to know about the stability that it is, the instability is very difficult to generally quantify. Even with all the tests you do, such as MRI scan and all epicondyle measurement. So I'll explain why.
So these are the anatomical factors we've discussed earlier. I did this rotational profile CTU for eight or nine years, and I measured every single factor that could potentially lead to dislocations or femoral integration, the rotation, external patella and little chocolate and chocolate and other things you get from the teeth we did in a very specific way.
As Paul David, who has been the person who's designed this protocol. So the ephemerality version was measured. The lateral patella tilt was measured, the clear tilt or depth was measured and then rotation such as this. So we measured various things and properly dysplasia.
Of course, I've used Swango for many years, but then I realized yongle is not particularly useful. It's very crude. And I also use TTG for many years, and there are still people who believe that edg, which normally is 2 to 12 millimeters but there are lots of people believe in 20 and above, is an indication to intervene. And when osteotomy or realign the leg, but that is not strictly true.
I am the reason I'm saying because we've done research on this and we have shown that it is the angle if you are both unreliable or to assess in the end in the process of designing and management. No charge, so to speak, or algorithm for instability.
Now the Q&A, as you all know, it is a very crude measure. A lot of people measure it in different ways. Some people measure with standing, certain muscles contract it was relaxed and infection and extension. So therefore it is. We are not talking about the same thing when we are talking, when we are measuring. Merchant, if you know him, is the guy who described the merchant used he has designed gono meters specifically for the Q&A. And for many years after using it for many years.
I believe the Q&A is very, very crude. It's almost useless. But keep it in mind if your mind, for example, you can say I can see the alignment is in or had done that or this will affect the alignment in one way or another. Now the distance is another story. So this the first paper described to TTG was in 1978 and it was in French.
On this paper, had three groups of patients, one of them or were over 65. The second group of health writers, the third group was the only group with this location and the quality of this paper is very poor. It would never pass the stringent review of nowadays, but it has taken off. Now I myself, fortunately or unfortunately, have contributed to the myth of many years ago.
We did the research on this and we suggested that if the TTG is above 15 mm, then one has to implement or use some aggressive surgery to intervene to correct the instability. But I really don't believe that is correct nowadays because logically, if you look at these two guys, you can have a small guy.
And a massive guy. If you move to be able to 5 medially, you would have different impacts or outcomes and those two guys because 5 millimeters on a little bit different impact compared to the big guy. And also, we have the same problem. TTG is measured in different ways. It's measured in flexion and extension, normally very nice.
There is the interest rate reliability of three to 5 millimeter measurement. The difference between the. So it isn't as reliable as people claim for the exact purpose. You can mention, you know, you can q angle, but I wouldn't, you know, think of them and being Allen and all the swear by them. It is one of many investigations that help you in making up your mind, and they are not the most reliable one.
And of course, we've published on this and shown that the US is not a decisive element in establishing therapeutic choices for instability. Now with instability, do we really have to jump on the bandwagon like everybody else and do they do you have to think for yourself what is useful, what's not, what are the exam papers? You just have to have an understanding of what are the main contributing factors in stability and then how to investigate them, how to identify them and generally how to correct them.
If there are different anatomical factors which are abnormal, by the end of this, you would understand how to deal with instability in the exam. Now, I simplify things a lot because I think there's very little point of knowing that not being able to apply clinical. So to me, stability. Again, it is a spectrum.
It's not a continuum. It's a spectrum, so there are people who have a normal. There are others in a five mile typekit that may or may not meet. And then in that group, there something happens that lead them to decompensation, and then some of them may be compensated to an extent to have a recurrent dislocation. And others may have nothing to do with it.
Just be dislocating it all the time. That's what I'm saying. There are a group that is dislocated, though, another group that is dislocated all the time. They simply have two different pathways in the treatments which are available to us and the stability it is. Dislocated patella, so the people are sitting there.
This is all Oh. Each of them would need different treatment. So essentially, the first one would need a simple intervention, such as soft tissue procedures, such as empathetic inspection if the other parameters are not normal. The second one would need to be three four five operations to correct.
What are those things to do? The procedures are. So we have a tendency, as surgeons to apply attrition. We know everybody. And that's what happens with in this situation where people suddenly start doing medical searching and they started doing them and everybody. Yeah so I acknowledge that MPFL is important and it is I've done a lot of research on it personally and before my dissection, and it is well documented in the literature when there is almost 100% chance of being ruptured.
If not, put it up to be partially injured. Now, I also have also published that empathetic instruction is it's a very good procedure. However, there are other procedures which are necessary in certain individuals, and that is trivial to transfer men immediately. And that is because you have abnormality, so you deal with that.
But I will give you an indication. The indications for that in a second. You would also consider a patient who have circular displays that you consider your plastic. And very important operation, which is not very commonly done. It is crystallization of the tibial tubercle for patella Alta. I think I believe patella ulcer is a serious pathology and one of those problems that cannot be corrected by the soft tissue procedure.
You need to do this. Validation and crystallization is a very successful. So the treatment summary is this so you can do a reconstruction in probably 80 or more of the patients and that is on the patients who have had this dislocation NPF rupture. They have a small degree of small degree of dysplasia, white overall hypermobility and muscle alignment and modification, but not severe enough for you to consider legalization or destabilization.
However, if somebody and I in my practice, mainly you have to think about digitalization, primarily if somebody that is more than 1.4, 1.4 and more as you do, you do your measurement. There are different ways of measuring out. You need to know them, for example. There is a Black here, right? There's any question there is a condition that is being used for stability.
So it is one of those things, but it's mainly about digitalization and the indication for it. And I did you hear me when I was talking about different measurements? Yes Yeah. So so if the measurement of any of these indices more than one point two, then you're thinking there's abnormality. And if it is one point four, there is. Where do you think I should be doing this?
Utilization of the tibial tubercle? And if somebody has so clear dysplasia, which is grade C or d, according to law, then that means when it is completely deformed, not just slightly shallow, then one has to talk to your class. Distal femur or body rotation osteotomy are very rare, but occasionally useful if somebody has massive rotation.
Now, this patient of mine had more than one problem, so he was she was dislocated all the time. So in order to put the patella back and keep it on the top of the knee, one has to do release legalization, crystallization added clear plastic and empathetic answer all of them in one go. So that I can control the patella. Simply, people who have a soft tissue problem made painful rupture with some anatomical abnormalities would benefit from ampofo reconstruction, and that is the group which are dislocated both.
However, there are. There are a group of patients who have the patella dislocated all the time. Then that group needs more than one operation altogether to put the patella back on track and then keep it there. Now, the surgical technique for it, I'm not sure how much if you are, if you know that much. I don't think you would probably be asked about technicality of this in the exam, but you know, if you're doing well, then people would ask, so the surgical technique, and for those of you who practice this or see this in theater, it is important that you pick the correct channel placement and not to position your channels.
And I'll show you how it works, I've done a lot of work in the lab on this time of 2012 and all that published in American Journal of Sports Medicine. So the bottom line is previous research, which was done in the same lab by Andrew Amos showed that the MPFL attaches to the medial epicondyle, but that is subsequently have been shown by myself and few people that it is wrong.
It is attached to the. If you look at here, you can see the MPFL is attached to the upper third of the patella and also to the midpoint between adductor tubercle and the medial epicondyle, so it doesn't attach to the medial epicondyle as it was previously believed. Now you can see also where it is attached and it is relation to the shuttle work or the point, which is a lot of people reconstruct their MPFL using the red dot, which is we think not it is not just me.
In fact, today I had some communication from a Japanese soldier who's done a very nice basic science study showing that the attachment is in the green area. Exactly not the right, but there is where it should be the placement. And that point is we call the confluence point, not the cader point with the confluence point. The reason we call it confidence because it is a confluence of things in mind, which is can see where it's coming from and the extension of the line coming from the posterior cortex of the femur.
So those two lines they meet at the point there is where the anatomical point is in the biomechanical study to show that visually and as it happened, that point is in the center of the rotation. And the techniques are to either you do a medial trough or bony tunnel or multiple other ways. You just have to apply the principles of reconstruction.
Now the principles are not to overturn them and fix them the wrong angle. Generally, attention then to New things to 202 or three drums and at a flexion angle of 60 degrees. 30 is acceptable, too, but the reason I'm saying 60 occurs at 60. The Kessler will be constrained by whatever move you have left in the cochlea.
And then you are not going to be over tension in it because it is being buttressed by the top layer at six degrees or. Now, just want to say that the rehab of reconstruction should be just straightforward, just like a Getting them going quickly. No brace for weight bearing as able flex and extend as far as they can.
And of course, you go through different stages. But the reason I'm saying all this, because the tensile strength of Apfel is 218. So essentially, you're really not going to apply massive amount of force to the PFO reconstruction. The epithelial reconstruction is necessary in the first 30 days. Just touch the patella, enter the groove so you put in a graft that is multiple times stronger than the MPFL itself.
So know, the load two failures of a semi and the nurses is much higher. So if we're talking about the poor bundle, which is 4,000 meeting and so a single bundle would be less than that, but still will be much stronger than the reconstruction. Of course, here we have a client who bundle instead of four. So we're probably still about seven or eight times stronger.
And we are reaching the end here, so I personally think, first of all, it is so unnecessary for the reasons I've mentioned earlier and also because they are having uncomfortable skin problems and they have no benefit and they cause muscle weaknesses. Now, so the take-home message here is that an accurate dislocation, consider surgery in a very small subgroup of the treatment of this patient is so conservative and you have to remember that when you dislocated patella first time, there is a 50% chance of redistricting in certain group, not in every individual.
And there are also possibilities of damaging the or 0 control part of. Now, if you have a recurrent dislocation, it is wise not to delay the surgical intervention and not to persevere too long. The more teeth and sending from the freezer because that will lead to a fight.
And you have to also remember, there are multiple anatomical factors that lead to instability. So one has to be mindful of various potential pathology. And we also discussed that is very difficult to quantify and stability, so you really have to use your word or the example of you, of course, for any exam, you need to make sure that you have an understanding of the different types of investigations and the use of them collectively rather than individually.
I wouldn't rely too much on strong go in my clinical practice or for, you know, for theoretical purposes either. Now so it is important to reconstruct anatomically, as I said to the confluence point, rather than to the saddle point. I have to tell you that people do not dislocate after your reconstruction if you use the abnormal tunnel system.
But what they do, they will be tight inspection. The other thing is they will be now tracking for life and probably end up with arthritis. And the other thing is don't apply and for reconstruction to everyone. And remember, we don't need too much force or tension on the NPF every construction and mobilize the early. Thank you very much.
That's our next course in Hyderabad in October. Thanks to everyone. If you have any questions, I'm happy to answer. Thank you. That's amazing. As expected, obviously, clearly I don't have anything to add to it. I thank you very nicely cover the topic. I think this is a summary of years and years of experience, both academically and clinically.
I learned a lot, and I'm going to listen to this lecture again and again to consolidate my knowledge about it. But I liked how. He explained how the TTG is not just a. No, it's actually relative to the patients. You know, so therefore, you know, there's no right answer. It's a 12 the 20s. If we put onto that to the examiners in the exam that it is, it is a relative number and the patient factor.
Body habitats that have told the patient is important that, you know, examiners will then understand that we know we are treating patients rather than treating scans. Or I think if you just take we're not engineers, you know, we didn't with biology and we were dealing with variation and in height, weight and sex and all.
There are multiple factors and can affect all these members. So therefore, we have to just show the maturity of saying, well, I know this is being said 20 is the magic figure, but it is, you know, it can vary because the measurement is not reliable and you could use them for a CT scan or, you know, and there is interactive. The rater reliability of these measurements is very low.
So therefore it just shows you have an analytic mind not repeating what says what is being said in the books. That's what exam is about, isn't it? And so I yeah, I picked up this nice spectrum you put off of the telephone and stability. I don't think I've heard that before, and it's very nice concept. Yeah so I think it's really very interesting.
How you personalize your treatment to depends. It depends on where your patient is in the spectrum. So there is no one right operation, no do two procedure in one patient. You do as you demonstrated multiple procedures or just one. And in this spectrum, I really need to sit down later on and look at that again and. It's very, very interesting concept.
Have any questions. So we have, we have. How is the ttg? Distance is measured and I'm not sure you would they ask this question in the exams or I don't know. They are all sort of weird and wonderful question. And I wouldn't get I wouldn't get too kind of warmed up about anything because people ask all sorts of questions. The thing is the end the exam you, you are.
What what we want to reach is the point that this person is ready to become a consultant by having a depth of analytic brain, I wouldn't say knowledge just because you could have the knowledge that you don't apply properly. So it is the depth of thinking, the analysis, the it is just it isn't about listing 10 causes of death and 12 20 differential diagnosis definitely is not.
And you trying to avoid asking people these direct questions, it is about what would be the situation, how would you handle it? So if I ask you, how would you manage with somebody with instability? Of course, you have to have in the back of your mind all the causes which are causing instability. But then you would say that I would consider if the patient is young or old, hyper mobile, not they have rotational or alignment or not.
And then if they have a femoral intervention, muscle weakness, gait abnormality. So that just shows that you've not just learned about the causes. You can also apply them clinically. And that is a big problem with a lot of people who just know a lot of things can't apply it. And then, you know, what's the point of knowing too much but can be confused with all that traffic in your brain?
So the question was what sort of the question is, how do you measure that? The effect is that you rely on your audiologist to measure it for you? Or do you have to have a first scan? You don't have to have a scan of the as I've shown there of the head and the ankle can be measured by from an MRI scan scan.
But what they do, they align the posterior and then simply measure the distance from the deepest point. I think I have a slide showing that I think, yeah, one of you. Yeah, Yeah. It was a slide show in how to measure it. Yes, you superimposed the two of them. It's not going to work by. So you need a radiologist to work with you to measure them for you.
But if you look at here, they see it anyway. The third image, you see the slide I have, I have. I stopped sharing it. No, no. You are still sharing. We can see. We can see there. There, there are three images. So if you look at the first one, which shows the femur the deepest part, they pick the deepest part of the cochlea, the highest point of the tibial tuberosity.
And these are all controversial because some people say, is this the highest cartilaginous or the highest bone? So if you are a scientist, then you start becoming a bit panicky. Here is the third image here shows that they have been superimposed and that distance is being measured. Yeah OK.
Thank you very much. And is there a difference between doing CT or MRI scan or the equally accurate? No, they're equally inaccurate. Equally inaccurate. That's a profound way to say. And then there is this problem because the cartilage on the top layer and the bone they don't match. So the college may be exaggerating or otherwise the distance.
So both of them have their own problems. Generally, people use ct, but MRI scan could be used. It gives you an idea. I think what you do with a lot of investigations, these are one of them. There are other investigations you do, for example, for infected and arthroplasty. And those investigation, none of them are on its own are useful. But you have to take them all in context.
And in consideration. So then you have this art of. You know, guesstimating this is an infection or not, there is pretty much the same. You have multiple measurements. You just have to decide at the end, which treatment I could use to make a difference. I put it to you that the most important one is the patella Alta.
If you have a high patella, then you're not going to get away with just episodic construction. No further construction is good and probably 80% or more of those patients. But there are people who have abnormalities and primarily the people who are dislocated all the time or people will have to Kessler out. They need more than just for the construction. Thank you.
I think there was one question about when to do soft tissue procedure. I want to do bony procedure, but I think he already answered this. This depends on the etiology of the condition. What's what's behind it? I think I've put it down as a cookbook a La Carte treatment. But yes, you know, in medicine, that doesn't work. I mean, you can.
I think there was. Yeah so you do a reconstruction if you have just soft tissue problem, tibial tubercle, media lines or digitalized if you have a very high TTG. But generally, I don't do. A lot of people don't do medial idealization on their own, and they do just stylization on their own. But when you just alive, you do the operation primarily for the stabilization.
But if I show you as I, if you look at, I can't see it because there are a lot of sequencing. Here you go. So if you look at these, see the image with two screws in the yeah, right. Yes, right. So all right. But at the same time, it has been realized if you look at the gap in the top and it has medium size and the size at the same time.
So that that's why we do crystallization visualization at the same time. But digitalization is the driver here. So to see how different is those kneecaps, you know? So look at the picture here and again, it's been brought down and the work a lot to be uncovered because it is too long. OK Yeah. You have to anchor that, OK, so one more question was about the sign also is that something you would use clinical assessment or you experience?
I think I've mentioned that. Well, I didn't read it, but I don't think I have put in clinical examination. I haven't. No, I haven't. But essentially for the exam, I think you're not going to take that. I don't think I have it for the exam. Yeah, no.
I don't think there is. So in the end, the exam, it is important if you see something, you say that I've made this observation, that is a sign Mason is, you know, it is theoretically, it is supposed to indicate some overall moral alignment. Yeah alignment means in more technical terms that the T2D or the extensor mechanism is not aligned properly.
And it is more naturalized than normal. So that's why the patellar tend to have the reverse J sign when you are. Yeah, well, you mentioned that. But truthfully, I mean, it's not going to change. You just say, well, because they have de sign. I'm going to have to do legalization that doesn't work like that. Some people probably a simpleton and they say that it's OK, but I don't think you can just immediately correlate those to.
But it's something you observe. You mentioned you say theoretically with the suggestion of moral alignment of the extensor mechanism and may be one of those factors which lead you to choose. That really makes sense. It's 21 hours, but it isn't just that you have to remember. Do all the other tests, the clinical ones?
And then so Beaton's what is important for the I'm sorry, I had those slides, but I didn't put them in because I just picked this presentation from ASCO last week. Yeah, Yeah. Score, I think I think one of the things I could say is if a clinical, maybe in a clinical examination situation, anything about instability, shoulder patella, anything? Yeah, straight away.
Check for the bittern. Yeah, of course. Hyper mobility. Yeah first, what is it in the exam? You don't do the apprehension test with enthusiasm, because that could lead to a problem. So it is very important that you don't cause too much pain or plaques test or there are tests you do that causes pain. So you're trying to leave those to the end or ask if it is necessary for you to do them, but for instability purposes, it is, you know, it is just observing certain things, you observing their gait, you are looking at the mobility from for you said something about the gene.
If there is, if there is one, if the patella is pointing or you see them there, work with massive femoral integration, you have to just make a comment on those things. And believe me, none of the things I asked are typical in our exam or in anywhere else. But I think it's just the stress level is too high and people get a bit flustered and confused. Yeah, Yeah.
And we hear that. I mean, it is with time and time again, we remind ourselves and colleagues that these guys are I can speak for the UK exam. It's one of the fairest in the world and I quite important, which you have to be wary about if you are going to answer in the exam when you operate on a first time dislocate or patella dislocation. Yeah prof.
I think I think I've answered that in a way saying that if somebody generally for the exam purposes, you say, I would treat those who treat them conservatively, but there's a subgroup. So it's the subgroup is people who have a strong family history. Had the other side dislocated people who have multiple abnormal anatomical abnormality there, and then there is those who have, for example, a big ostrich control fragments in there on top of these things.
But at least you need to remove that control fragment if you went there and somebody who that a 50% chance of them dislocating, it makes absolute sense to do something about it rather than waiting for them to dislocate again. But it is all dependent on how comfortable you are with treating this condition. So if you are somebody who does that day in, day out and it's fine, you can.
On top of the removing of Austria and then you can do an MPFL reconstruction or even repair or augmentation. But if you are, you know, if you are not comfortable, you can just do the removal of their body and then, you know, leave it somebody else or wait. Yeah and that actually brings up the next question, which is, I'm sorry, but I think it's quite in the exam.
Being prepared for this type of question in pediatrics situations. Is the management the same in these cases? No, I was asked exactly the same question. You know, I have a first time dislocation now at that age group. You can do a medial application. What media application means is you use not five strong bones sutures and you can do it topically or assisted our facility with a small slap over the medial aspect of the patella.
And then you tie all these sutures so that you implicate the medial side and that we make them last for a few years, as you did that adults. After six months, it will all fall apart. They work very well, but I don't think it can withstand the forces of an adult patient. Now the there are times you need to do an MPFL reconstruction with open prices.
There are two different techniques. One of them, you use an eye and then trying to avoid devices. And the other one. Some people try not to make panels in the field, but then they will try to give you something to sling around the adaptive magnet tendon insertion along the tuberosity, because that's one of the techniques that people use that to avoid.
But I have always done the tunnel and I have kept away from it by using this intense file and then the topography. It's important that they know that they have a sound plan for the management of this condition and then some understanding of the causes and the potential factors, then the technicality of things that will take you to more than. OK, you want just for everyone who's about to sit the exam in the summer.
My advice is exactly as prof. Has just said, focus on the management, the principles behind it. Don't get into the acute how you're going to manage the operation itself until you've discussed the basic management in your clinic, in the A&E and long term physical plan and so on. Essentially, develop a walking plan where surgery is your final option and you're not going to discuss the operative technique until you've discussed everything else around it first.
Yeah that you in your talk, you mentioned a few references, and I do recommend that candidates, maybe they should remember this for the exam and the court them if they can. You do you think that's a good idea? Oh, no, no, not necessary. No, I think there's a lot made of it. You know, you need to put this paper, that paper. Yeah, I think it is.
Before that, you need to know your stuff before you stage of putting icing on the cake. So I think first thing first, you have to have an analytic mind and the knowledge to, you know, to just come across as somebody who understands what's going on. And then if you know, papers and you don't have to be very detailed about them, but if you know them, then say, well, this, you know, paper from London or from wherever it shows this.
But it's very important to be a reasonable and neutral and don't be a radical in things that are rubbish in treatment. They stay on the fence. It's not something I would do in also. Is there any guideline broad? No, that no particular test is useful and just, you know, your measurements of the patella, you know, the dysplasia score, you know, a high probability score.
You know that some people have more than one factor. And then you have them all in consideration when you have managing this condition. You also know that MPFL is a very important strain to the patella and ruptures in almost 95% Reconstruction is common. More than 80% of the time you get away with for reconstruction other times.
Thank you, prof. I think that's really amazing. I think, you know, today 51 people attended. That's the most attended event we had so far. You have raised who is really very happy to step in and take the challenge of teaching all of us. We appreciate the time you put it into this presentation, really appreciate that very much and I think a very kind of to offer Viva practice for us on a later day, not today, coming to talk to us, really appreciate what you see and also the general advice for the exam.
It's very useful. We look forward to having you with our group as much as possible. Hey, guys, well, you guys have a nice evening. Thank you very much. Thank you. And thank you everyone for attending and for all the questions have been asked and we will see you again next Wednesday.
All right, guys. Thank you. Thank you very much. Bye bye.
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