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Name:
Ankle Arthritis for Orthopaedic Exams
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Ankle Arthritis for Orthopaedic Exams
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Upload Date:
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Language: EN.
Segment:0 .
OK, OK, guys. Good evening again, welcome to the teaching day when you finish up examination. Um, tonight again, we have Marwan who was recently passed his exam, and he has lots of experience with the exam.
So please try to listen to him carefully. And if you have any questions jot it down on the chat line or raise your hand symbol next to your name. Also, as always, Schwann is here. He will be supervising the session and will answer would help answer all your questions. After this, there will be a hot seat Viva session. The theme tonight is the foot and ankle, so we try to stick to that if we can.
Over to you, man. One go ahead, please. OK, guys. Hi, my name is Marwan Elshafi. So and I would like to thank for us and Sean for asking me to present this. I'm very happy to help. This group has actually provided me with a lot of help before my examination.
And to be honest, without this group, I wouldn't have passed. And so thank you all. So today we presenting on ankle arthritis is a very hot topic, very commonly asked both in vivo and clinical scenarios. I had an ankle arthritis as an intermediate case, so it is very, very quiet. It's quite common and actually it's quite easy to score on such a subject.
So basically ankle arthritis, so it's like any other osteoarthritis. Before we do that, we just go look at the anatomy of the ankle joint quick. You probably you guys probably know all of that anyway, but just a quick review. You've got bony soft tissue and they need to know about the motion. So you've only the tip of the fund.
Taylor's medial matter, malleolus and the soft tissues, the anterior ligament posterior, which is the main kidney fibula and the deltoid syndesmosis. It's quite important to know the anatomy I've got. It's the anterior and the posterior inferior to the ligament and also the transverse tibia ligaments. These are very important to know the anatomy quite well. The ankle joint before starting to talk about the motion, the primary motion is dorsiflexion and flexion.
OK basically, this is what you need to know. Secondary is divergent and Virgin and rotational. And of course, convergent express also got a contribution from the potato joint, which is the primary movement of the separated right now. Any patient comes to you with ankle arthritis symptoms. Are you going to ask you about pain patient? Tell me that a lot of pain. Pain is related to either activity.
You can ask about walking distances. You can ask about what type of three egawa mattress sutures stiffness is a very common problem as well, so decrease in the ankle movement due to the arthritis itself. Instability can be another issue, and instability can be either subjective or objective instability. I feel that my ankle is unstable or in examining the ankle.
Actually, the ankle is absolutely fine, and this stability can be a presentation of a loose body as well. And we talked about the ADLs and the deformities or AIDS or the activity of the living. So you can ask about if it affects the patient's job or work and if the patients are normal or usual supportive per individual. You'll need to ask about that as well.
Deformities you can see from this can be either fixed or flexible, and we'll talk about that later on during the session. Now, most important thing of about the arthritis, the causes of arthritis. So primary, which is very less common, it's about 10% incidence and arthritis is very I'll tell you, it's quite rare to find a normal ankle without any injuries that any problems just having out of the arthritis.
Usually those, of course. Hence it's secondary and the most common cause is post-traumatic that can be post fractures and/or recurrent ankle disabilities over the years. And the case I got in my exam was a post traumatic secondary such as inflammatory, such as rheumatoid, or it can be crystalline orthography, such as gout. That's one of the other things I need to mention infection, such as septic arthritis that can cause arthritis as well.
So that's all that stuff, you know, from history. And then the few other two cause other neuropathic joints, sarcoidosis and the sorry, the osteoarthritis decisions. But you can get as well. Now very put when you get a case of whether the vivo or the clinicals is you take know, you need to know about the presentation and the history. Very importantly, ask the relevant questions in the history in order to get your diagnosis.
And it's for you to show to the examiner that what you're talking about and you're good clinician, you're safe. One so pain you need to ask whether or not the pain is mechanical or just there all the time mechanical as in blocking symptoms. There is a loose body inside that will give you mechanical symptoms, whether it's related to weight bearing or is there all the time?
What are the relieving and aggravating factors? So going to ask about what makes it better, what makes it worse, going up and down stairs, walking for long distances? All that? And do painkillers do anything at all to control the pain they're presenting with swelling and swelling? Is that swelling related to activity?
Yeah or is that there all the time? So if it's there all the time, then you think about sinusitis because it's sinusitis will not get relieved with rest. This is there. There's a swelling that sort of is inflamed and it's big and it's hypo tried and it's there all the time. So one of the other things that you think about it just about walking distances, how long can you walk and what stops you from walking is a pain in the ankle.
Is it pain anywhere else? You know, you talk about the terrain. So if you've got a smooth ground or if you've got a rugged terrain, such as grass or walking up and down uneven ground where the shoes make any difference and has the vision to ensure modification, such as rock-bottom shoes. And of course, the edge is a very important thing for history because that will guide your treatment as well.
History of trauma is very important and previous intervention, whether or not this patient had any injections and orthotics and operations such as arthroscopy, to provide them with open deployment, et cetera plus medical history is quite important, actually. So that the patient developed diabetes, especially tells you, yes, I have got diabetes, and you need to make sure that patients not forgotten your peripheral neuropathy.
And that's one thing they have to demonstrate to the examiners that I need to do this test to make sure that patient has got diabetic neuropathy, peripheral vascular disease. That's another issue that actually limits the surgery that you might do for the patient. And if there is any previous infection, of course, occupation and the BMI body mass index are very important things, and they also die.
You treat them well. Now, clinical examination is very important following your history, the usual medical school stuff. So look for your move and special tests in every clinical examination that you do in your life. For the exam, look for your special test the look. So you stand the patient and then you look, you walk the patient and then you look, you sit the patient and then you look, it's look, look, look.
Yeah so you send the patient, then you look. So you look from behind the patient, from the side, from the front to the hind foot patient's posture, whether the heel is touching the ground or not, whether the patient's got any arches, scores, walking aids. Ok? and also look at the patient's faces, grimacing if he's got any pain. When you're standing up, he's in pain.
But you walk the patient and then you look, look for the gait pattern, any abnormality of the gait pattern at all. Hours the heel strike. What is the initial contact? Is it the heel is at the forefront? Yeah and you look at whether or not it has got any type of antalgic gait or all that. And then you sit the patient and then you look, you look for scars, you look for calluses of the plantar aspect of the foot.
At that point, you look at shoe wear and splints as well. You need to look between the toes as part of your clinical examination as well. And then after that, you're going to feel so tired. Before you ask or before you do anything before you touch the patient, you need to ask the patient a very important question to ask the patient have you got any pain anywhere in your foot, your ankle and where it is?
Or where is it? Yeah, because if you start touching the patient's ankle, you start screaming, oh, that hurts. You screwed up and you need to know people the examination you need to demonstrate to the examiners that you are safe and your a person who actually thinks ahead of yes, I need to make sure the patient is comfortable. Yeah and then you just go on and examine the patient's ankle according to whatever sequence you want to do.
I usually tend to start with the joint line. And then walk my way around. That's a little more complex Achilles tendon syndesmosis. Then the end. You can just mention sensation in my exam. When I was doing that, she asked me sensation. She asked me, what? What are the sensory supply of the foot? The whole thing.
It also means a lateral transfer and you need to know that. And then movement. Movement is you have to do two things active and passive. Yeah, and you just can't do. Massive now you have to do active as well, and then after they do the passive to see if the patient can actually flex or extend more and use ask as well if the patient got any pain or are you doing that? Movements can be the joint, the sub10, a joint showplace joints and whether if there's a deformity, whether it's correctable or not.
OK, now special tests that you need to know about are the various valves if you've got your ligament complex or your deltoid ligaments to make sure that they are intact, because that will guide your treatment, do the anterior test. And also you can do the muscle power and the muscle power. Very easy just to tip and tip post Achilles tendon repair. OK, now investigations that you need to know about starting off with imaging, which would be the plain radiograph.
I need to do that. You need to ask what you tell me standing views which are stressed views and that will show you whether or not the patient's ankle is aligned and that you look for the signs of osteoarthritis. And I tend to divide them into hypertrophic signs and traffic signs that angular deformity, hypertrophic signs, ossified formation and sclerosis, which has reduced joint space and assists.
And that actually guides my treatment. Because if you've got ossify formation or hypertrophic signs, you can still kind of buy time before going into definitive ankle treatment or to treat the arthritis itself. And I'll talk about that later on during my management. So kind of concentrate on that hypertrophic and atrophic and angular deformities. So actually, it makes quite a lot of sense when you think about it that way, other investigations that you might need to use, you don't have to always ask for them.
But if you've got an ankle that doesn't look too bad, you can offer an MRI scan because you might have an desiccants, a defect. And also you want to look at the degree of control loss because that might guide you to whether or not you need to do major surgery or just an arthroscopy. If you're thinking of rheumatoid arthritis, just mentioned blood's inflammatory markers, rheumatoid all that stuff.
OK, now this is a classification called the technical classification. I've read about it before my exam, I did not use in my exam. But if you guys like to mention a classification, this is a good one. To mention it's enforceable. It's in all the books. It's well known. It's everywhere.
You know, you need to know the stages stage one, two, three, 8 and 3 be ready to practice. Now, go into the management. The important stuff would be a non operative and operative. The usual you always have to mention that don't go, don't go rushing into just sorry, 1 minute. Guys, why no one is opening a door. Sorry, guys.
Yeah, so I was just saying, Marwan. Sorry just a show of hands, please on next to your name, guys. Whoever is interested in the Viva section. Viva practice later on. Carry on, Marwan. Yeah so as I said, you have to always mention non operative and operative management. You shouldn't barge in operate.
I'm going to do this. I'm going to do that. That's that's probably going to fail to do that. Non operative management, which works in a lot of the times you start off with activity modification, the weight loss the patient got a high BMI, you know, don't hesitate or awkward to tell the patient you need to is right. This patient needs to lose weight to lose weight because you're the treating clinician.
The next one would be painkillers, so nonsteroidal anti-inflammatory drugs such as naproxen paracetamol, anything to numb, the pain, to settle the inflammation that also helps splints such as ankle photosynthesis that can also limit the ankle movement and help to settle the symptoms in the acute setting. Humidification says rock-bottom feet, so rock bottom shoes, they do help a lot, such as the one in the picture.
There basically limits your ankle with the patient's mobilizing, just like to use them, and they find it quite helpful. And last but not least, injections simple things that we do in clinic, and we tend to do them as a quick procedure, a quick fix. And it does help a lot of times. Now coming to operative interventions can be limited surgical procedures.
I tend to divide them, though, so limited surgical procedures or definitive surgical procedures that's in the book. This is how I studied it, and I find it quite well studied that way. So limited surgical procedures, such as ankle arthroscopy. And as I said when I told you earlier, when you do a plain radiograph and you look at the hypertrophic and atrophic signs of ankle arthritis, this is what you're looking at.
So if you've got an hypertrophic phase, you might be the early stages. This procedure is quite good for it. Yeah so you go inside, basically what you do is you do it right, which you do kind of a collecting kind of thing to the ankle. You move all the osteoarthritis and and that would help a lot of the times to relieve the symptoms.
This one's rock bottom shoes are effective for both hind foot. Sorry, I hope to apologize for times. Mtpa potentially as well. If you have a to shoot the aim behind to compensate for the rockers of your ankle as you're going through. So if you're not flexing or moving them, you're essentially creating a.
A pseudo fusion of the joint as you're using the rock bottom so that you don't have to actually move the joint to move around to that should give you pain relief. That's the NBA. I think mainly what I know about. I don't know much about rocker bottom shoes, but what I know, it's basically I am sure you know this is to offload the midfield area up to the metatarsal heads.
So if you have any patient with diabetes who are at risk of developing ulcers, you want to offload them or you have be short cut foot because the midfoot collapses in chocolate food, so they could be used also to support them at food. So, yeah, so as I said, so uncle frank, when I previously showed you the slide of the radiographs basically showing hypertrophic and a traffic sign, it's very important that you identify that because, as I said, it doesn't make a massive difference to the indications of ankle arthroscopy that are indicated in such stages of arthritis.
So you've got ossify impingement when you do an ankle arthroscopy by the patient, a good two years, even if actually more than that, even before doing anything major. They get a lot of good pain relief 90% of the time. As I said during their two years, this is all evidence based. It also helps you to identify any loose bodies or anything that can be a mechanical block and that can be removed as well.
And it also helps to identify or to establish the degree of control loss to know exactly what you're dealing with. The very important thing is to actually speak to the patient and send the patient in an organized way and convincing way. A lot of these patients, they come back to you or they come to you to have an operation, and the expectations are quite high.
You need to tell them that this is just a temporizing or vaporizing procedure. It will just allow him or her some degree of pain relief for a few years. And then the symptoms will probably come back again. So they need to know that before you elect for such a procedure. So and, of course, in the exam, when you talk, when you mentioned ankle arthroscopy, examiners might just go down the path of ask you about portals and your general setting, and what are the common problems with the floor.
They need to know that inside and out now, another procedure that can be done, which is usually not done these days, is an open and very invasive. You know, you open up the ankle and move all the fights, but you risk a lot of problems nerve problems, tendon damage, infection and hypertrophic scar. I haven't. I've never seen it done. What I've seen was just ankle arthroscopy.
And you can just mention the exam as, as you know, as part of your limited surgical approach. But you say, don't emphasize or don't go in deep into that. Another thing that you just mentioned as well, and just to show that you've got an idea about is the joint destruction using a literal. I haven't seen it as well. But, you know, the literature has shown that it does give some improved pain tolerance and also some range of movement.
If you look at the slide here, it takes two takes about three months and then at six weeks, you start putting a hinge on you start moving to the ankle. But you've got indications that usually it's usually done in patients who are young, such as 45-year-old patients moderate to severe arthritis. And as I said, you need to tell the patient that it's not a long lasting fix. It will.
It will come back again and you tell them about the complications such as like infection. No, on procedures such as the Super manly ulnar nerve tenotomy that's also mentioned, there are a few papers that have shown some good results. I haven't seen that done either, but it's mentioned in the book, and I think it's one thing they also need to mention. Same thing as a typical tenotomy, so you need to have fairly minimal arthritis in the ankle joint and also some minimal tailored health.
There are some degrees that such as doing a high tuberosity the same thing with an ankle. There are Do's and don'ts. When to do it? What degrees of affairs about this you can apply to? And of course, you'd have a very, very good in your normal ankle region movement. Go into the definitive surgical procedures and these are basically that's where all the money is.
So in the exam, you're going to start talking about when you reach that level, you need to know this very well. I've started off with arthritis because it's the gold standard. Some books start off with ankle replacements, but I think arthritis is a preferred option for a lot of people. Um, so it is the gold standard of anchor arthritis or end stage ankle arthritis fusion rates between 80 and 90 percent, and that's about meta analysis have shown that in different papers that the fusion can even get more than 90% as well.
It's got a very good pain of relieving pain quite well. Actually, that's a lot of people come in after it's fused and they have no pain whatsoever, and they're very happy to have that procedure done. There are some problems. So for example, if you're walking uneven ground, that sometimes makes it difficult and that can even lead to further future subtalar arthritis as well.
And one of the side effects is gait. Analysis in the lab have actually shown that open muscular actually decreases after arthritis, but a lot of patients do not actually kind of figure out or can't even see concentre. They've actually got this. Their most important thing is the pain.
And once the pain is sorted, they're very happy. They don't care about whether the water is what you have. So every operation, every major operation has indications contraindications. So indications of Ankara arthritis is usually reserved for younger, active patients. Peel-back your replacement significant ankle bone loss. So in the exam you get your patient was 45 or 50 years old.
He's a truck driver or whatever, and he's fit in well with the virus. Even if you start talking about total ankle replacement, you're probably not going to write bridge because it won't work. Usually, these patients tend to do very well with arthritis of the ankle. They are high demand patients and will probably wear out there and call their patients quite significantly sicker than others.
Contraindications to ankle after arthritis is, first of all, be active infections. So we've got infection inside the joint. You can't do. It won't work. Same thing for a lot of other procedures as well. If you've got profound vascular disease, so if you open up the ankle at the vascular disease to stop using the ankle, it will not unite.
It might even end up with gangrene and amputation. So you need to make sure that the patient has got profound vascular disease. That profound you can do it, especially vascular disease, but you need to refer to vascular surgeons and ask for their advice as well. And of course, if there are severe tibial alignment and at that stage, it's not the ankle that will fix it for you need to pick about things that are higher above, such as tuberosity continues to align you with your lower leg first before you think of the ulnar claw.
So types of ankle fusion, you can talk about those things and you could pick and choose what you see in the exam. I talked about open ankle fusion. I have seen ankle assisted fusion before, but I've seen open ones more often, so I spoke to us both about that. I can use a rigid internal fixation, for example, for ankle, you know, such as cross screws or screw compression or anterior tension plate for arthroscopic assisted ones.
It's very easy. It's good to do, but it's highly technically demanding. And if you haven't got a good joint space to enter, then you probably won't be able to do it. You'll end up doing an open ankle fusion. So basically, look, if you get in the exam, an X-ray with a completely obliterated ankle joint with, you know, five ac, the joint. And then you say, I'm going to do an arthroscopic ankle fusion need to be prepared to, you know, to kind of I wouldn't say fight, but I need to be prepared to look at another option, such as the opener, because it probably won't work because you haven't got any joint space to use your scope.
Other other reasons, other types of activities. You can be laser off techniques that can be used as well. It comes with a price, so perfection. And of course, you can do the hind foot nail, which is something that's usually used in child care joints more often than other programs. Now, it's very important that you get to know of that position infusion. It's very simple.
Just learn it that way. So 5 to 5 degrees of Father's father external rotation neutral also section slight cancellation in the books that says you might even. And you won't lose them, but they say you only do that in the cases of see if they've got problems with the knee system they're walking. But this is what you need to know is so five degrees above the subject of external rotation, mutual suspension and slight bas status translation of the tails.
OK, now complications of ankle arthritis is very important to know. Of course, that's in your history as well. You know, the patient's social history of patients smoking. So if the patient is a smoker, you tell them that you are very high chance of that ending up with a nonunion because it won't be nice, especially with the ankles. So a lot of axilo surgeons I've worked with, they do not do an ankle fusion in patients who are smokers.
They say not going to the operation. You stop smoking first and then come back and then we can do an operation union could be another issue. Have you got adequate that can end up with a mild union or basically if it's adequately positioned in a way that it can't optimally? And the usual stuff, which is infection for wound healing, tract infection as well based on your mind, injury and vascular injury as well.
Although all the normal, all the well known complications, most post-surgical post post-surgical last but not least, would be the total ankle replacement. And that's another type of treatment or definitive surgery that you will be asked about in the exam. I've got asked. I went down to talk about this. So you need to know the indication that the contraindications some books, right?
The contraindications is relative and absolute. You can kind of just put the absolute ones. You can use a relative as much as you like. I tend not to mention relative in the exam because it's relative. So if I mentioned to this relative, he might find it that it's not a relative. I still do it with these patients, so I tend to do. I tend to learn the absolute contraindications and talk about them.
So your indications no physical demand patient. So if patient above 65 70 doesn't do much, know he's not a laborer or whatever you can, you can do an eight more to 55 more to 60 on my alignment, less than 10 degrees of varus and others. And you need to make sure that the ligaments, the lateral and the medial are competent because if they're not, your ankle will fail. That replacement will definitely fail.
And I've written here reconstructed because you can actually some surgeons I tend to recommend if you've got a deltoid ligament rupture, for example, insufficiency some action, some surgeons reconstruct the deltoid ligament and do the ankle replacements. So you can count out that as well. It can be a relative one as well. And of course, d-generation secondary to inflammatory osteoarthritis or post-traumatic arthritis.
These are very difficult for these patients to do an ankle replacement for them because their anatomy is destroyed. They're destroy the soft tissues are not balanced and they're incompetent. So doing that on arthritis is a better option. The contraindications so high physical demand patients. So watch what I was saying earlier. We tend to use for these patients peripheral vascular disease.
So the same thing. So vascular disease, peripheral neuropathy, including chop, don't you should not be doing that. Any new disease that can cause paralysis in my leg, more than 20 degrees and soft tissue compromise. So the things that when I got in my exam, I got an X-ray with this, this X-ray on. So you can see there the star total anchor base, which is very commonly used in the UK.
And the examiner asked me, you know, this implant? And I said, yes, this is a star anchor replacement knew, because it's just common. If I've seen it before, I've worked with those stars. So you need to an implant to talk about. So, you know, design features. So you need to know that successfully executed total anchor patient provides the patient with a new normal pattern of movement and kinematics of the ankle and the joints in three dimensions design.
Both Taylor and typekit elements are metal, so metal with a plastic in between it can be a mobile or a fixed bearing. The star is actually a mobile bearing, so the mobile bearing implants with a highly congruent, very surfaces overcome the problem of high contact stresses. And that's why the star has better results than others. At the same time, they're not constrained as the first generation, which used to share at the bone implant interface and, of course, reduce the Mason.
I know this is probably quite dry, but just read it because, you know, if you understand the philosophy about the star or the evolution of ankle replacements, you probably talk about it in the exam. But the complications can put a long list of complications by. Tend to do it that way, look been which book and I find it very nicely written there. A recent meta analysis identified a few complications following ankle replacement and their likelihood of causing failure.
So they basically they put the complications down as either low or high grade. And what actually, they can actually, at that point, look at whether this implant is going to fail in the future or not. So if you've got a low grade, they've got the low grade complications, which are very likely, very unlikely to cause failure. This is intraoperative fracture and wound healing problems.
Medium grade, such as the failure, occurs less than 5% of the time, such as the technical error. The way you put your implants in external internal rotation pairs allow this substance and post-operative fracture and of course, a high grade, very well known three, which would be the deep affection. Aseptic implant failure. The most common cause or the most common reason the implants or the total ankle fails is aseptic loosening or subsidence.
This is how they fail. This is the most common reason why they fail. OK, so you just need to mention that in that way, I think that's how I've mentioned in the exam and I think I find it quite useful. And of course, evidence at the end, if you reach that level of evidence, not much trial is going on. But at the moment there is one being run at the moment of the UK or the typekit trial, which is the total ankle replacement versus authorities.
I have mentioned in the exam. And I've told the examiner that there is a trial at the moment for the Taylor trial, and it just basically it compares these two procedures together. I think I'm not sure if that would be. I mean, Sean, and I'm not sure if that would be counted as evidence, but I have mentioned it in the exam.
And I've also mentioned what's underneath. The end latest report is 8 failure rate after eight years. I think these were the only two months, basically, well, the ones that I've studied before the exam. And I've went in and started talking about them, so I'm not sure if that would be counted as evidence. It might be. I'm not sure it will count as evidence it does it. Anger definitely comes as evidence, but a prospective, randomized controlled trial that is ongoing and you're waiting for the results means you understand the literature and you it's reasonable to say something like that.
But you mentioned that they're very easy, you're saying, but you're waiting for the results, is what you're saying exactly. At least you're showing the examiners that you know, you're aware of a trial at the moment. And I think I think it depends on where you mention it in your answer. I think you said that I think everyone because it's towards the end of your answer after you covered all the basics and when covered all the options and everything.
And then you put the cherry on the top of the cake by saying, I am aware of this trial that's comparing. We don't know the results yet, but You know something that's coming. And you know, that may be something the examiner himself didn't know about, and that will impress, I think, provided obviously all the basics be covered. Yeah so Yeah. So I think these two, if you mentioned these two in the exam, when you reach that level, then I think you're fine.
Yeah and I think that's it. So my advice for the exam is to keep things simple, really, really, really simple. Be organized and your answers appear confident. You probably won't be confident. Like myself, I was dying from inside, you know? But you have to show yourself, you have to try as much as possible to suppress that feeling and show they actually, you know what you're talking about, what you have to know you told about of I was thinking and actually believe in yourself.
You have to read, you know, that you've done a very good job and that you probably also probably ask all the questions, just listening to the examiner and thinking, thank you very much. I'm sorry. Sorry, sorry, sorry for Marwan one he is in Egypt and very kindly donating his time to us from holiday in Egypt. Thank you, my man.
Thank you very much. It's very good. This is a five star presentation, actually, despite all the distractions you had, but it's honestly top presentation. It has all you need to know about ankle arthritis. Marwan kindly covered the history and he it is. One slide is possibly you could. You could get all the history points from the examination, Rich has been asking about stability, asking about deformity, about activities of daily living, if they just want to listen to the headlines.
It's a simple but very important topic, and I particularly actually like the way you approach the radiographs hypertrophic and atrophic and angular deformity. I use a system to use, yeah, system type everything, and I think that's a good, very good system. And again, I think, you know, a couple of things are common. You covered all the treatment options. You got to go to the examiner through all these treatment options, but don't stick too long on the.
Less important ones, the examiner wants to get into the ankle afterwards as they want to know how you're going to do that. So but mention to them and I just would add Mason, I would probably I would list your options in. None of this is operative and you go through them quickly without actually going into detail with them to make sure your examiner realizes you understand what you have in your arsenal of, as Moran said.
Keep it simple. That was really a very good presentation. I have no further question to start with.
Segment:0 .
OK, OK, guys. Good evening again, welcome to the teaching day when you finish up examination. Um, tonight again, we have Marwan who was recently passed his exam, and he has lots of experience with the exam.
So please try to listen to him carefully. And if you have any questions jot it down on the chat line or raise your hand symbol next to your name. Also, as always, Schwann is here. He will be supervising the session and will answer would help answer all your questions. After this, there will be a hot seat Viva session. The theme tonight is the foot and ankle, so we try to stick to that if we can.
Over to you, man. One go ahead, please. OK, guys. Hi, my name is Marwan Elshafi. So and I would like to thank for us and Sean for asking me to present this. I'm very happy to help. This group has actually provided me with a lot of help before my examination.
And to be honest, without this group, I wouldn't have passed. And so thank you all. So today we presenting on ankle arthritis is a very hot topic, very commonly asked both in vivo and clinical scenarios. I had an ankle arthritis as an intermediate case, so it is very, very quiet. It's quite common and actually it's quite easy to score on such a subject.
So basically ankle arthritis, so it's like any other osteoarthritis. Before we do that, we just go look at the anatomy of the ankle joint quick. You probably you guys probably know all of that anyway, but just a quick review. You've got bony soft tissue and they need to know about the motion. So you've only the tip of the fund.
Taylor's medial matter, malleolus and the soft tissues, the anterior ligament posterior, which is the main kidney fibula and the deltoid syndesmosis. It's quite important to know the anatomy I've got. It's the anterior and the posterior inferior to the ligament and also the transverse tibia ligaments. These are very important to know the anatomy quite well. The ankle joint before starting to talk about the motion, the primary motion is dorsiflexion and flexion.
OK basically, this is what you need to know. Secondary is divergent and Virgin and rotational. And of course, convergent express also got a contribution from the potato joint, which is the primary movement of the separated right now. Any patient comes to you with ankle arthritis symptoms. Are you going to ask you about pain patient? Tell me that a lot of pain. Pain is related to either activity.
You can ask about walking distances. You can ask about what type of three egawa mattress sutures stiffness is a very common problem as well, so decrease in the ankle movement due to the arthritis itself. Instability can be another issue, and instability can be either subjective or objective instability. I feel that my ankle is unstable or in examining the ankle.
Actually, the ankle is absolutely fine, and this stability can be a presentation of a loose body as well. And we talked about the ADLs and the deformities or AIDS or the activity of the living. So you can ask about if it affects the patient's job or work and if the patients are normal or usual supportive per individual. You'll need to ask about that as well.
Deformities you can see from this can be either fixed or flexible, and we'll talk about that later on during the session. Now, most important thing of about the arthritis, the causes of arthritis. So primary, which is very less common, it's about 10% incidence and arthritis is very I'll tell you, it's quite rare to find a normal ankle without any injuries that any problems just having out of the arthritis.
Usually those, of course. Hence it's secondary and the most common cause is post-traumatic that can be post fractures and/or recurrent ankle disabilities over the years. And the case I got in my exam was a post traumatic secondary such as inflammatory, such as rheumatoid, or it can be crystalline orthography, such as gout. That's one of the other things I need to mention infection, such as septic arthritis that can cause arthritis as well.
So that's all that stuff, you know, from history. And then the few other two cause other neuropathic joints, sarcoidosis and the sorry, the osteoarthritis decisions. But you can get as well. Now very put when you get a case of whether the vivo or the clinicals is you take know, you need to know about the presentation and the history. Very importantly, ask the relevant questions in the history in order to get your diagnosis.
And it's for you to show to the examiner that what you're talking about and you're good clinician, you're safe. One so pain you need to ask whether or not the pain is mechanical or just there all the time mechanical as in blocking symptoms. There is a loose body inside that will give you mechanical symptoms, whether it's related to weight bearing or is there all the time?
What are the relieving and aggravating factors? So going to ask about what makes it better, what makes it worse, going up and down stairs, walking for long distances? All that? And do painkillers do anything at all to control the pain they're presenting with swelling and swelling? Is that swelling related to activity?
Yeah or is that there all the time? So if it's there all the time, then you think about sinusitis because it's sinusitis will not get relieved with rest. This is there. There's a swelling that sort of is inflamed and it's big and it's hypo tried and it's there all the time. So one of the other things that you think about it just about walking distances, how long can you walk and what stops you from walking is a pain in the ankle.
Is it pain anywhere else? You know, you talk about the terrain. So if you've got a smooth ground or if you've got a rugged terrain, such as grass or walking up and down uneven ground where the shoes make any difference and has the vision to ensure modification, such as rock-bottom shoes. And of course, the edge is a very important thing for history because that will guide your treatment as well.
History of trauma is very important and previous intervention, whether or not this patient had any injections and orthotics and operations such as arthroscopy, to provide them with open deployment, et cetera plus medical history is quite important, actually. So that the patient developed diabetes, especially tells you, yes, I have got diabetes, and you need to make sure that patients not forgotten your peripheral neuropathy.
And that's one thing they have to demonstrate to the examiners that I need to do this test to make sure that patient has got diabetic neuropathy, peripheral vascular disease. That's another issue that actually limits the surgery that you might do for the patient. And if there is any previous infection, of course, occupation and the BMI body mass index are very important things, and they also die.
You treat them well. Now, clinical examination is very important following your history, the usual medical school stuff. So look for your move and special tests in every clinical examination that you do in your life. For the exam, look for your special test the look. So you stand the patient and then you look, you walk the patient and then you look, you sit the patient and then you look, it's look, look, look.
Yeah so you send the patient, then you look. So you look from behind the patient, from the side, from the front to the hind foot patient's posture, whether the heel is touching the ground or not, whether the patient's got any arches, scores, walking aids. Ok? and also look at the patient's faces, grimacing if he's got any pain. When you're standing up, he's in pain.
But you walk the patient and then you look, look for the gait pattern, any abnormality of the gait pattern at all. Hours the heel strike. What is the initial contact? Is it the heel is at the forefront? Yeah and you look at whether or not it has got any type of antalgic gait or all that. And then you sit the patient and then you look, you look for scars, you look for calluses of the plantar aspect of the foot.
At that point, you look at shoe wear and splints as well. You need to look between the toes as part of your clinical examination as well. And then after that, you're going to feel so tired. Before you ask or before you do anything before you touch the patient, you need to ask the patient a very important question to ask the patient have you got any pain anywhere in your foot, your ankle and where it is?
Or where is it? Yeah, because if you start touching the patient's ankle, you start screaming, oh, that hurts. You screwed up and you need to know people the examination you need to demonstrate to the examiners that you are safe and your a person who actually thinks ahead of yes, I need to make sure the patient is comfortable. Yeah and then you just go on and examine the patient's ankle according to whatever sequence you want to do.
I usually tend to start with the joint line. And then walk my way around. That's a little more complex Achilles tendon syndesmosis. Then the end. You can just mention sensation in my exam. When I was doing that, she asked me sensation. She asked me, what? What are the sensory supply of the foot? The whole thing.
It also means a lateral transfer and you need to know that. And then movement. Movement is you have to do two things active and passive. Yeah, and you just can't do. Massive now you have to do active as well, and then after they do the passive to see if the patient can actually flex or extend more and use ask as well if the patient got any pain or are you doing that? Movements can be the joint, the sub10, a joint showplace joints and whether if there's a deformity, whether it's correctable or not.
OK, now special tests that you need to know about are the various valves if you've got your ligament complex or your deltoid ligaments to make sure that they are intact, because that will guide your treatment, do the anterior test. And also you can do the muscle power and the muscle power. Very easy just to tip and tip post Achilles tendon repair. OK, now investigations that you need to know about starting off with imaging, which would be the plain radiograph.
I need to do that. You need to ask what you tell me standing views which are stressed views and that will show you whether or not the patient's ankle is aligned and that you look for the signs of osteoarthritis. And I tend to divide them into hypertrophic signs and traffic signs that angular deformity, hypertrophic signs, ossified formation and sclerosis, which has reduced joint space and assists.
And that actually guides my treatment. Because if you've got ossify formation or hypertrophic signs, you can still kind of buy time before going into definitive ankle treatment or to treat the arthritis itself. And I'll talk about that later on during my management. So kind of concentrate on that hypertrophic and atrophic and angular deformities. So actually, it makes quite a lot of sense when you think about it that way, other investigations that you might need to use, you don't have to always ask for them.
But if you've got an ankle that doesn't look too bad, you can offer an MRI scan because you might have an desiccants, a defect. And also you want to look at the degree of control loss because that might guide you to whether or not you need to do major surgery or just an arthroscopy. If you're thinking of rheumatoid arthritis, just mentioned blood's inflammatory markers, rheumatoid all that stuff.
OK, now this is a classification called the technical classification. I've read about it before my exam, I did not use in my exam. But if you guys like to mention a classification, this is a good one. To mention it's enforceable. It's in all the books. It's well known. It's everywhere.
You know, you need to know the stages stage one, two, three, 8 and 3 be ready to practice. Now, go into the management. The important stuff would be a non operative and operative. The usual you always have to mention that don't go, don't go rushing into just sorry, 1 minute. Guys, why no one is opening a door. Sorry, guys.
Yeah, so I was just saying, Marwan. Sorry just a show of hands, please on next to your name, guys. Whoever is interested in the Viva section. Viva practice later on. Carry on, Marwan. Yeah so as I said, you have to always mention non operative and operative management. You shouldn't barge in operate.
I'm going to do this. I'm going to do that. That's that's probably going to fail to do that. Non operative management, which works in a lot of the times you start off with activity modification, the weight loss the patient got a high BMI, you know, don't hesitate or awkward to tell the patient you need to is right. This patient needs to lose weight to lose weight because you're the treating clinician.
The next one would be painkillers, so nonsteroidal anti-inflammatory drugs such as naproxen paracetamol, anything to numb, the pain, to settle the inflammation that also helps splints such as ankle photosynthesis that can also limit the ankle movement and help to settle the symptoms in the acute setting. Humidification says rock-bottom feet, so rock bottom shoes, they do help a lot, such as the one in the picture.
There basically limits your ankle with the patient's mobilizing, just like to use them, and they find it quite helpful. And last but not least, injections simple things that we do in clinic, and we tend to do them as a quick procedure, a quick fix. And it does help a lot of times. Now coming to operative interventions can be limited surgical procedures.
I tend to divide them, though, so limited surgical procedures or definitive surgical procedures that's in the book. This is how I studied it, and I find it quite well studied that way. So limited surgical procedures, such as ankle arthroscopy. And as I said when I told you earlier, when you do a plain radiograph and you look at the hypertrophic and atrophic signs of ankle arthritis, this is what you're looking at.
So if you've got an hypertrophic phase, you might be the early stages. This procedure is quite good for it. Yeah so you go inside, basically what you do is you do it right, which you do kind of a collecting kind of thing to the ankle. You move all the osteoarthritis and and that would help a lot of the times to relieve the symptoms.
This one's rock bottom shoes are effective for both hind foot. Sorry, I hope to apologize for times. Mtpa potentially as well. If you have a to shoot the aim behind to compensate for the rockers of your ankle as you're going through. So if you're not flexing or moving them, you're essentially creating a.
A pseudo fusion of the joint as you're using the rock bottom so that you don't have to actually move the joint to move around to that should give you pain relief. That's the NBA. I think mainly what I know about. I don't know much about rocker bottom shoes, but what I know, it's basically I am sure you know this is to offload the midfield area up to the metatarsal heads.
So if you have any patient with diabetes who are at risk of developing ulcers, you want to offload them or you have be short cut foot because the midfoot collapses in chocolate food, so they could be used also to support them at food. So, yeah, so as I said, so uncle frank, when I previously showed you the slide of the radiographs basically showing hypertrophic and a traffic sign, it's very important that you identify that because, as I said, it doesn't make a massive difference to the indications of ankle arthroscopy that are indicated in such stages of arthritis.
So you've got ossify impingement when you do an ankle arthroscopy by the patient, a good two years, even if actually more than that, even before doing anything major. They get a lot of good pain relief 90% of the time. As I said during their two years, this is all evidence based. It also helps you to identify any loose bodies or anything that can be a mechanical block and that can be removed as well.
And it also helps to identify or to establish the degree of control loss to know exactly what you're dealing with. The very important thing is to actually speak to the patient and send the patient in an organized way and convincing way. A lot of these patients, they come back to you or they come to you to have an operation, and the expectations are quite high.
You need to tell them that this is just a temporizing or vaporizing procedure. It will just allow him or her some degree of pain relief for a few years. And then the symptoms will probably come back again. So they need to know that before you elect for such a procedure. So and, of course, in the exam, when you talk, when you mentioned ankle arthroscopy, examiners might just go down the path of ask you about portals and your general setting, and what are the common problems with the floor.
They need to know that inside and out now, another procedure that can be done, which is usually not done these days, is an open and very invasive. You know, you open up the ankle and move all the fights, but you risk a lot of problems nerve problems, tendon damage, infection and hypertrophic scar. I haven't. I've never seen it done. What I've seen was just ankle arthroscopy.
And you can just mention the exam as, as you know, as part of your limited surgical approach. But you say, don't emphasize or don't go in deep into that. Another thing that you just mentioned as well, and just to show that you've got an idea about is the joint destruction using a literal. I haven't seen it as well. But, you know, the literature has shown that it does give some improved pain tolerance and also some range of movement.
If you look at the slide here, it takes two takes about three months and then at six weeks, you start putting a hinge on you start moving to the ankle. But you've got indications that usually it's usually done in patients who are young, such as 45-year-old patients moderate to severe arthritis. And as I said, you need to tell the patient that it's not a long lasting fix. It will.
It will come back again and you tell them about the complications such as like infection. No, on procedures such as the Super manly ulnar nerve tenotomy that's also mentioned, there are a few papers that have shown some good results. I haven't seen that done either, but it's mentioned in the book, and I think it's one thing they also need to mention. Same thing as a typical tenotomy, so you need to have fairly minimal arthritis in the ankle joint and also some minimal tailored health.
There are some degrees that such as doing a high tuberosity the same thing with an ankle. There are Do's and don'ts. When to do it? What degrees of affairs about this you can apply to? And of course, you'd have a very, very good in your normal ankle region movement. Go into the definitive surgical procedures and these are basically that's where all the money is.
So in the exam, you're going to start talking about when you reach that level, you need to know this very well. I've started off with arthritis because it's the gold standard. Some books start off with ankle replacements, but I think arthritis is a preferred option for a lot of people. Um, so it is the gold standard of anchor arthritis or end stage ankle arthritis fusion rates between 80 and 90 percent, and that's about meta analysis have shown that in different papers that the fusion can even get more than 90% as well.
It's got a very good pain of relieving pain quite well. Actually, that's a lot of people come in after it's fused and they have no pain whatsoever, and they're very happy to have that procedure done. There are some problems. So for example, if you're walking uneven ground, that sometimes makes it difficult and that can even lead to further future subtalar arthritis as well.
And one of the side effects is gait. Analysis in the lab have actually shown that open muscular actually decreases after arthritis, but a lot of patients do not actually kind of figure out or can't even see concentre. They've actually got this. Their most important thing is the pain.
And once the pain is sorted, they're very happy. They don't care about whether the water is what you have. So every operation, every major operation has indications contraindications. So indications of Ankara arthritis is usually reserved for younger, active patients. Peel-back your replacement significant ankle bone loss. So in the exam you get your patient was 45 or 50 years old.
He's a truck driver or whatever, and he's fit in well with the virus. Even if you start talking about total ankle replacement, you're probably not going to write bridge because it won't work. Usually, these patients tend to do very well with arthritis of the ankle. They are high demand patients and will probably wear out there and call their patients quite significantly sicker than others.
Contraindications to ankle after arthritis is, first of all, be active infections. So we've got infection inside the joint. You can't do. It won't work. Same thing for a lot of other procedures as well. If you've got profound vascular disease, so if you open up the ankle at the vascular disease to stop using the ankle, it will not unite.
It might even end up with gangrene and amputation. So you need to make sure that the patient has got profound vascular disease. That profound you can do it, especially vascular disease, but you need to refer to vascular surgeons and ask for their advice as well. And of course, if there are severe tibial alignment and at that stage, it's not the ankle that will fix it for you need to pick about things that are higher above, such as tuberosity continues to align you with your lower leg first before you think of the ulnar claw.
So types of ankle fusion, you can talk about those things and you could pick and choose what you see in the exam. I talked about open ankle fusion. I have seen ankle assisted fusion before, but I've seen open ones more often, so I spoke to us both about that. I can use a rigid internal fixation, for example, for ankle, you know, such as cross screws or screw compression or anterior tension plate for arthroscopic assisted ones.
It's very easy. It's good to do, but it's highly technically demanding. And if you haven't got a good joint space to enter, then you probably won't be able to do it. You'll end up doing an open ankle fusion. So basically, look, if you get in the exam, an X-ray with a completely obliterated ankle joint with, you know, five ac, the joint. And then you say, I'm going to do an arthroscopic ankle fusion need to be prepared to, you know, to kind of I wouldn't say fight, but I need to be prepared to look at another option, such as the opener, because it probably won't work because you haven't got any joint space to use your scope.
Other other reasons, other types of activities. You can be laser off techniques that can be used as well. It comes with a price, so perfection. And of course, you can do the hind foot nail, which is something that's usually used in child care joints more often than other programs. Now, it's very important that you get to know of that position infusion. It's very simple.
Just learn it that way. So 5 to 5 degrees of Father's father external rotation neutral also section slight cancellation in the books that says you might even. And you won't lose them, but they say you only do that in the cases of see if they've got problems with the knee system they're walking. But this is what you need to know is so five degrees above the subject of external rotation, mutual suspension and slight bas status translation of the tails.
OK, now complications of ankle arthritis is very important to know. Of course, that's in your history as well. You know, the patient's social history of patients smoking. So if the patient is a smoker, you tell them that you are very high chance of that ending up with a nonunion because it won't be nice, especially with the ankles. So a lot of axilo surgeons I've worked with, they do not do an ankle fusion in patients who are smokers.
They say not going to the operation. You stop smoking first and then come back and then we can do an operation union could be another issue. Have you got adequate that can end up with a mild union or basically if it's adequately positioned in a way that it can't optimally? And the usual stuff, which is infection for wound healing, tract infection as well based on your mind, injury and vascular injury as well.
Although all the normal, all the well known complications, most post-surgical post post-surgical last but not least, would be the total ankle replacement. And that's another type of treatment or definitive surgery that you will be asked about in the exam. I've got asked. I went down to talk about this. So you need to know the indication that the contraindications some books, right?
The contraindications is relative and absolute. You can kind of just put the absolute ones. You can use a relative as much as you like. I tend not to mention relative in the exam because it's relative. So if I mentioned to this relative, he might find it that it's not a relative. I still do it with these patients, so I tend to do. I tend to learn the absolute contraindications and talk about them.
So your indications no physical demand patient. So if patient above 65 70 doesn't do much, know he's not a laborer or whatever you can, you can do an eight more to 55 more to 60 on my alignment, less than 10 degrees of varus and others. And you need to make sure that the ligaments, the lateral and the medial are competent because if they're not, your ankle will fail. That replacement will definitely fail.
And I've written here reconstructed because you can actually some surgeons I tend to recommend if you've got a deltoid ligament rupture, for example, insufficiency some action, some surgeons reconstruct the deltoid ligament and do the ankle replacements. So you can count out that as well. It can be a relative one as well. And of course, d-generation secondary to inflammatory osteoarthritis or post-traumatic arthritis.
These are very difficult for these patients to do an ankle replacement for them because their anatomy is destroyed. They're destroy the soft tissues are not balanced and they're incompetent. So doing that on arthritis is a better option. The contraindications so high physical demand patients. So watch what I was saying earlier. We tend to use for these patients peripheral vascular disease.
So the same thing. So vascular disease, peripheral neuropathy, including chop, don't you should not be doing that. Any new disease that can cause paralysis in my leg, more than 20 degrees and soft tissue compromise. So the things that when I got in my exam, I got an X-ray with this, this X-ray on. So you can see there the star total anchor base, which is very commonly used in the UK.
And the examiner asked me, you know, this implant? And I said, yes, this is a star anchor replacement knew, because it's just common. If I've seen it before, I've worked with those stars. So you need to an implant to talk about. So, you know, design features. So you need to know that successfully executed total anchor patient provides the patient with a new normal pattern of movement and kinematics of the ankle and the joints in three dimensions design.
Both Taylor and typekit elements are metal, so metal with a plastic in between it can be a mobile or a fixed bearing. The star is actually a mobile bearing, so the mobile bearing implants with a highly congruent, very surfaces overcome the problem of high contact stresses. And that's why the star has better results than others. At the same time, they're not constrained as the first generation, which used to share at the bone implant interface and, of course, reduce the Mason.
I know this is probably quite dry, but just read it because, you know, if you understand the philosophy about the star or the evolution of ankle replacements, you probably talk about it in the exam. But the complications can put a long list of complications by. Tend to do it that way, look been which book and I find it very nicely written there. A recent meta analysis identified a few complications following ankle replacement and their likelihood of causing failure.
So they basically they put the complications down as either low or high grade. And what actually, they can actually, at that point, look at whether this implant is going to fail in the future or not. So if you've got a low grade, they've got the low grade complications, which are very likely, very unlikely to cause failure. This is intraoperative fracture and wound healing problems.
Medium grade, such as the failure, occurs less than 5% of the time, such as the technical error. The way you put your implants in external internal rotation pairs allow this substance and post-operative fracture and of course, a high grade, very well known three, which would be the deep affection. Aseptic implant failure. The most common cause or the most common reason the implants or the total ankle fails is aseptic loosening or subsidence.
This is how they fail. This is the most common reason why they fail. OK, so you just need to mention that in that way, I think that's how I've mentioned in the exam and I think I find it quite useful. And of course, evidence at the end, if you reach that level of evidence, not much trial is going on. But at the moment there is one being run at the moment of the UK or the typekit trial, which is the total ankle replacement versus authorities.
I have mentioned in the exam. And I've told the examiner that there is a trial at the moment for the Taylor trial, and it just basically it compares these two procedures together. I think I'm not sure if that would be. I mean, Sean, and I'm not sure if that would be counted as evidence, but I have mentioned it in the exam.
And I've also mentioned what's underneath. The end latest report is 8 failure rate after eight years. I think these were the only two months, basically, well, the ones that I've studied before the exam. And I've went in and started talking about them, so I'm not sure if that would be counted as evidence. It might be. I'm not sure it will count as evidence it does it. Anger definitely comes as evidence, but a prospective, randomized controlled trial that is ongoing and you're waiting for the results means you understand the literature and you it's reasonable to say something like that.
But you mentioned that they're very easy, you're saying, but you're waiting for the results, is what you're saying exactly. At least you're showing the examiners that you know, you're aware of a trial at the moment. And I think I think it depends on where you mention it in your answer. I think you said that I think everyone because it's towards the end of your answer after you covered all the basics and when covered all the options and everything.
And then you put the cherry on the top of the cake by saying, I am aware of this trial that's comparing. We don't know the results yet, but You know something that's coming. And you know, that may be something the examiner himself didn't know about, and that will impress, I think, provided obviously all the basics be covered. Yeah so Yeah. So I think these two, if you mentioned these two in the exam, when you reach that level, then I think you're fine.
Yeah and I think that's it. So my advice for the exam is to keep things simple, really, really, really simple. Be organized and your answers appear confident. You probably won't be confident. Like myself, I was dying from inside, you know? But you have to show yourself, you have to try as much as possible to suppress that feeling and show they actually, you know what you're talking about, what you have to know you told about of I was thinking and actually believe in yourself.
You have to read, you know, that you've done a very good job and that you probably also probably ask all the questions, just listening to the examiner and thinking, thank you very much. I'm sorry. Sorry, sorry, sorry for Marwan one he is in Egypt and very kindly donating his time to us from holiday in Egypt. Thank you, my man.
Thank you very much. It's very good. This is a five star presentation, actually, despite all the distractions you had, but it's honestly top presentation. It has all you need to know about ankle arthritis. Marwan kindly covered the history and he it is. One slide is possibly you could. You could get all the history points from the examination, Rich has been asking about stability, asking about deformity, about activities of daily living, if they just want to listen to the headlines.
It's a simple but very important topic, and I particularly actually like the way you approach the radiographs hypertrophic and atrophic and angular deformity. I use a system to use, yeah, system type everything, and I think that's a good, very good system. And again, I think, you know, a couple of things are common. You covered all the treatment options. You got to go to the examiner through all these treatment options, but don't stick too long on the.
Less important ones, the examiner wants to get into the ankle afterwards as they want to know how you're going to do that. So but mention to them and I just would add Mason, I would probably I would list your options in. None of this is operative and you go through them quickly without actually going into detail with them to make sure your examiner realizes you understand what you have in your arsenal of, as Moran said.
Keep it simple. That was really a very good presentation. I have no further question to start with.
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