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Slipped Upper Capital Femoral Epiphysis for Orthopaedic Exams
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Slipped Upper Capital Femoral Epiphysis for Orthopaedic Exams
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Language: EN.
Segment:0 .
OK, so we're recording now. Hello, everybody. My apologies for the slightly delayed start. We were running into some problems. My name is Shawn Hinari. I'm one of the mentors in the Perseus preparation group. Today we are having a lecture from Mustafa el-gamaty.
He works. He's recently past, the International exam. He works in sulaymaniyah hospital in jeddah, Saudi Arabia. Welcome Mustafa to us. Mentors that are here with us today is Abdullah hanun, hania padayachee and Chetan Georgie. We're very pleased to have you all here as mentors and also very pleased to welcome all our participants.
We look forward to working with you in the future. At the end of this lecture session, you will have Viva sessions. Please stay on. The Viva sessions are not recorded for obvious reasons to give you, first of all, some privacy, but also to allow you to be free to express yourselves. Mustafa is going to give us a talk on sufis, please.
Thank you, Mr hot topic for the forces exam for both first and second, but I'll start from definition until we reach the complication and the management. I try to cover the whole speech for the post part one and the second, but it's a very important and hot topic. I try to cover every point in this one because I think in this case, if the examiners give you this scenario, you have to at least pass by 7 or eight objectives today is to know what is a slap, why and how it happened or how it can be diagnosed.
What are the classifications? What are the treatment options. And what is a complication starting by definition? It's disorder of the proximal femoral choices that lead to slippage of the problem widening displaces anterior and external beauty. So the rest is history in the state was truly similar. And this is very important information because it will affect everything in the clinical picture of the patient and in the management of the patient.
So the exercise is remaining in the problem, but the femoral neck is displaced and displaces anterior and external. So what is the epidemiology? The incidence it is the most common disorder affecting is isn't happening in per 100,000 population. It's more common in obese children and then is the single greatest risk factor. Mason made of immigration is issues to African-Americans because they have huge body mass index and during the period of growth, it's called growth is birth, so the average is 13 for boys, 12 surgeries and it's associated with puberty, as we said, because of the growth spurt.
Education is the most common one. You don't know why, but they think that because of the sitting posture of the right hand, the children who are writing same handwriting people, when you are sitting on the right, quiet sitting position, the left hip is afflicted more and it's bilateral. It's 17 to 50% What is the etiology? It's either mechanical factors, the chronological factors. What about the mechanical factors?
Number one is because of the signing of the bill called the Ring of bricks. All of us know this is the morphology of the basis. As we can see here, this article a cartridge. The article contains classified into the resting zone or the zone and the zone and the hypertrophic zone. As we can see here, the high school is classified into the maturation zone. Degeneration zone and zone was a provisional Constitution.
Here we have what we call the broken the ring of Lacroix. It's a dense, fibrous tissue encircles the emphasis and its supporting suffices. This is Allen, and this is the most important structures of both these allegations from which so ambition to be found, there is something of this wandering. Number two, there is change in the inclination of the proximal humeral faces relative to the femur and what they found, they found inhibition to slip the suffices has become vertical lead to increase the shearing forces at the voices due to its slippage.
Number three, we found many patients with slap has a reversal of the femoral. What are the endocrinology contractors carrying on an obese high? And it's called the syndrome getting more common in hypothyroidism patients and the patient with chronic renal failure or in the classifications? We have many classification for step. We can classify them into the patient is clinically stable or stable, and we speak about it and regional functional classification into mild and moderate and severe would speak about it and temporal classification according to the onset of symptoms into acute, chronic or acute on top of chronic fatigue to provide prognostic information.
And this is a very important classification to classify the slip into stable and unstable. Stable means that the patient has able to be with, even with or without crutches. Why is this important? Because there is minimal, minimal risk of osteonecrosis less than 10% and the only stable patient this patient has unable to emulate, even with crutches. Why is this important?
Because it's associated with high risk of osteonecrosis 47% Why is honesty what cannot be with? Because they say that they said that there is confusion between the basis and the patient. So there has been this information about the patient cannot bear with. So this is unstable and high incidence of chronic illnesses. The classification is classified according to the onset of symptoms into acute Mason symptoms is less than three weeks.
This patient has prodromal symptoms and due to minor trauma. Why these three are important because we have to subdivide or doing like, we have to classify this from the traumatic Salter type 1 fracture because traumatic sort of bone structure. This patient has greater and greater energy trauma and has no trauma symptoms. So we have to classify traumatic slap from acute slippage occurring with trauma symptoms that are developed for acute sleep that has no femoral remodeling changes typical of chronic sleep.
As you can see here, this patient has celebrity here, and there is no in remodeling changes. So this acute sleep in chronic slippage, the patient is symptoms more than three weeks and we have here, as we can see, there is remodeling changes. Acute on top of the patient has prodromal symptoms more than three weeks, but the patient has sudden exacerbation of the symptoms. So how we can differentiate acute on top of chronic from chronic if the slippage occurring more than the degree of the remodeling beyond the remodeling component.
So this is acute on top of chronic. As we can see here, there is remodeling changes here, but the slippage occurring more than remodeling procedures. So as reclassification classified slip, according to the official shaft, angle is measuring the angle in the view and the normal angle is 145 degrees and then the lateral viewing angle is 10 degrees is taking line parallel to the axis from the upper end to the lower end and take the color line and line with the shaft of the femur and the normal angle, and maybe 100 to five.
The lateral degree, it's 10 degrees and is doing comparison between the affected side and the normal side, and you are measuring the difference between both of them. And if the patient has bilateral slippage, he's thinking is a normal degree. 145 degrees as difference. But if the patient has any unilateral use comparing this side to the normal side.
So the classification classified this Libyan for mild if the angle is doesn't serve the degree, the difference between both sides moderate if 30 to 60 degrees and severe if it's more than 60 grading system for slap the grading system into mild, moderate and severe, if less than 33% from 0 to 60% It's a grade 134 to 50 to grade 2 and grade 3 more than 50% of the slippage as we can see here, less than one third to more than 2, 1% more than 2/3.
How the patient is presenting it a clinic. Many patients come in complaining of growing bean or soybean. This is the most common presentation soybean or nepean, and it's getting from 15% to 50% Why it's transmitted through the. This is why it's misdiagnosis. Because patients come complaining of knee nibbling or soybean not having physical examination.
We see the patient has maybe an LG G8 or their gait, and there is decreased range of motion of the head, especially the internal rotation production and the friction driven side. It's obligatory external rotation during the flexion of the hip. Why is this happening? Because when we are doing passive flexion of the hip, we see that the soil and hip become external because there is impingement of the displaced neck on the.
And exhibition is only we can see some of atrophy. Residential in residential finding, as we all know, there is a clear line, it's line Mason line drawn through its superior neck and neck and has to have this line has to cut a piece of the head from the beaches here. As we can see here, this line is not cutting anything here in the. So this is one side, as we can see here. Also on this diagram.
And this is a second radiological finding we can see this is called the metaphysical lawn sign of steel. It's christened the blind with Udinese due to overlapping between the slap devices because suffices slap subsidiary, so there is superimposition between the neck and the slap devices, which will appear in this line. Another ideological fight, and we can see here, this is going to be visualizes or widening, as we can see here in competition to this fight.
And this fighting we can see, even before this slippage. Also, we can see a decrease in the epicondyle height if we measure the physical height in this area and compared to the physical height in this area without this decrease in the zeolite. Because, as we said in the beginning of the definition, suffices is displaced the posterior cryptogenic. How we can manage the patient, there is very good algorithm, it's published in 2017.
They said slap classified into, as we said, stable and unstable if the patient does unstable high incidence of events, about 50% of the patient. So try to save them by doing a modified approach through safe surgical dislocation. I will speak about it later on. If the patient is stable, how much is the degree of the slippage? It's mild less than 30 degree moderate or severe, more than 70 degrees.
If it's mild less than 30 degrees, you are saying if it's impinging or not impinging, what's the difference between Beijing and beijing? They said in Beijing. If the patient clinically has hip flexion, 90 degree or less internal rotation, 50 degrees, 15 degrees or less. So if the patient has internal rotation 15 degrees or less or flexion 90 degree or less, this is good imaging. So if it's not impinging, they are doing in trying to fixation.
If it's impinging, they do inside to fixation blocks to control blast. And I will speak also about those two controls. But if the patient has moderate or severe slap, the more than 30 degree they are depending on the open faces or close devices, if the patient has open faces, the surgical dislocation. Plus, subscapularis alignment, I will speak about it, but if the patient has closed devices they are doing combined tenotomy with us to control lost.
How we can do that continuous insight of extensions is the main management for the patient. I will speak about how we can do the technique, but what about contralateral to it? Can we do prophylactic bidding for the other side or more? It's sort of been controversial. The current indications are if the patient has high risk patients because there is contralateral slippage 40 to 80 percent, like we said in the genital syndrome being a patient hypothyroidism.
And if the patient initially initial slippage occurring at younger age less than 10 degree, this patient may also have open prior cartilage or the nature of the current slippage is very severe. It means that the patient is coming to the clinic, has various virus slippage and the adding one more point if you cannot do close for the patient, if you cannot trust the parents and you can find that the parents will not do for you, so you can assist in the prophylactic fixation, but try to find another algorithm to become more secure on how to do prophylactic excision on the other patients.
So what we did is we did the modified form to score. The score is combined of five categories the ilium, the trial, the cartridge, the head of the femur, the GT and the list of everyone from this is sticking point. Like, as we said here, if we take the biological switch as an example, if the face is clearly hoping to take one point, if the face is partially closed, it took two points.
It suffices as close to 3 points and every one of the sticking points, like four four five. So the score of we calculate this one that is the score is 16 and the highest score is 2026. Hawaii is important because if I this if you do, the patient score is 16, there is probability of the contract has to be 100% So you have to do perfect for this one. And if the score of the mission is 20 six, the probability of the building, which is 0% So you can do.
You cannot do the calculation position. How we can do the cutting inside to fixation, the aim of this is to stabilize the business from further slippage. We are trying to promote promoting the closure of the offices. It's a minimum three threats of closing the suffices I read in many literature, they are saying five threats. Really, what I'm saying is a screw on the basis.
It's very, very small. I don't know how five threats closing without penetrating suffices, but I found the minimum, which is safe. Crews should be at least 5 from the beginning, all views. This is the most important sentence, the ideal placement of the single community, the screw should be in the center of the capital basis and it should be driven to suffices. So the screws should be in the center of the vexes and the.
After fixation, if the situation is stable, he can do bedwetting, offer insight of oxygen. But if the patient is unstable, we make him known with very. This is how we come to insight to prophylactic and scientific excision, as we can see, we put motivations for buying who owns attraction. People without doing inspection. Then we take every shot, we take the 1 Wire and this wire is buried the suffice, as we said, and in the center of the boxes and we take and we draw this line in the skin and then we take a lateral shoot and we take another line between the two slices.
And in the center of the boxes and the intersection between the two points is the entry point that we can see here. This is in the Abbey and this is a lateral and intersection point between the Abbey and the lateral. It's the entry point, and then we are fixing the screw. Why is it so important? Because we found in this diagram diagram, as you can see, there is three bends here been and C then and B. Both of them are contract in 3 bends and da Vinci is in the neck both and B c, as you can see here in the image.
If you can, you can see in the image. It would become like false deceiving perpendicular to the voices and then central services. But if we can see here they are not crossing in the center and they are not fixing good. So this is why we have to make the bend see the interior of the intersection of the two points. How about proximal femoral osteotomy? You are doing to restore the proximal anatomy?
Why? because if we didn't do not restoring this ambition to untreated or comic strip, the patient will complain of femoral impingement later on, and that will has liberal or articular cartilage damage and later on degenerative changes on both sides. We have all of. We know that we have three types of osteotomy. We have the Don of osteotomy and we have besar.
It's called the promoter and we have the entire country. So as to why is this important? Because all of us know the more proximal tenotomy as we can see here, the greater the connection, the degree of the deformity. But the problem is why is this greater degree of corruption? Because it's near to the center of the rotation and conditions of the poor. But the problem?
It's near to the blood supply, so high incidence of chronic disease. What about us to come tuberosity the indication if the patient has symptomatic and Benjamin from metaphysical bump and mild or moderate degree of slippage, and we can do it either arthroscopic as we can see here, it's only about three shaving, shaving or shaving, isn't it? All can do by through limited, limited and/or certain surgical precision.
What about the reduction was committee realignment. It's called safe surgical dislocation or surgical hip dislocation. It's a reduction with spinning. It remains controversial. It's indicated in an unstable or high degree slippage because this patient has high incidence of muscular bruises. We are doing surgical dislocation with orientation through modified procedure.
The interval is official interval between the egawa test maximus and the egawa test medius and the interval down between the minimus and by reforms. The success of this approach, depending on protecting the blood supply. In this diagram, we see why we are doing osteotomy, we have to do short term moves and why is efficient if you have a patient with chronic slippage, why you are not doing for him close the reduction and fixation only because the remodeling changes and after slippage, as we can see here, there is a regular visits become kinkade.
And if we are doing close the reduction traction, there is a thin bit of close the reduction in the blood supply only to come from the AC so it will affect lots of life and the patients will have adverse consequences later on. So if we are right after doing those totally safe surgical dislocation, we are going to shorten, we are trying to do shortening goals. And so with the reductions of lots of light still and not affected.
How we can do safety, surgical dislocation, so by imposition, the interest rate by which we are enticing about 15 centimeter, we we're opening the skin after this offense of fashion that as we can see here. Then we'll find our interval between the egawa test and do internal rotation will find the minimus and so by performance. And then we are finding that we are doing the flip through country because it means the transverse osteotomy and the GTA.
Now we can see here the capsule. We are doing this absolutely in the capsule. Then you dislocate the head after dislocating. Is it useable? Axilo suffices and depending on the intact posterior vessels? We are not disturbing the posterior vessels. Then we are moving the whole colors formation. We do shortening in the neck reshaping. Then we reposition the device again and to fix it again.
As we can see here, we are not disturbing any bas status blood supply. Xinhua affixing bike wires on the score for the. What about the complication of slippage contralateral slap slap progression in 1% to 2% infections 2% and the chronic being 5% to 10% if the patient is not treated good has degenerative arthritis or residual deformity, it's called the pistol grip deformity or just not important.
The most important complication is even on the control license even occurring as a result of the initial trauma itself. Or due to operative intervention, if we put the screw in the posterior superior femoral neck. This patient has high street store, the risk of disrupting the blood supply and high incidence of what's called on cruiser, as we can see here.
The most important second important complication the controls. As we can see here, competition for this year and joint space there is no longer enjoys this year. The count came complaining of stiffness and the persistent beam in the groin or Abishai examination. We have the patient, the loss of outcome of the motion in all the planes, how we can diagnose the results of joint space as we can see here.
And the criteria for this, if the joint is less than 50% in comparison to the other side or absolute measurement of millimeter or less. This is the whole presentation. Thank you. Thank you very much. Most of the presentation was very good. I have a few questions for you, but first put it out to the audience.
And if anyone has any questions, please feel free to unmute mike, ask the question and then renewed. Kashif, please go ahead. Yes thank you, doctor. Dr. Mustafa, I'm not a mentor. I am a I'm a candidate for the May exam, actually, but I failed the November attempt. I think this was a brilliant presentation, but I think there are two or three very important things which the candidates like us.
We have to understand that the most important thing is the controversies which they do, which they usually ask in the exam two or three controversies and one of them you have already mentioned that will you pin the contralateral hip or not? And the second controversy is that the presentation, the time of the presentation, when you are going to operate on an acute or acute on chronic and chronic, if you can explain this because it is written in the postgraduate book and I think it is quite an important thing that the time of the presentation and Opry operation, I think it is quite important.
The Southampton paper of the clerk is the basis of this controversy. If I'm not wrong, Sean, I in just correct me if I'm wrong. And well, first of all, you're right, there is some controversy about time to operation and who is going to operate. And second, the discussion about what you should open, reduce or in situ. Absolutely so will first let Mustafa give his opinion on this.
I'm sorry, I didn't hear the question again. The controversy regarding the timing of the surgery on acute care patients or chronic patients, they say that if the presentation is delayed more than 24 hours, then don't operate on those patients, let that patient to be converted on a chronic slip and then operate on that patient. And the most important thing?
Think that this surgery has to be done by a specialist center in a high tertiary care hospital, not in a district hospital, what they call in the England district General Hospital. OK according to what I read and what I searched for. Yes, I read what you read that if the patient has come and is more than 48 hours, you don't treat him as acute and you do wait for the patient to become chronic and you do correction later on.
But it's a patient coming to you with severe slippage like more than six degrees. This patient has high incidence of outcome already. So, yes, you can transfer him for tertiary center. They are. They are all now speaking about safe surgical dislocation and trying to reposition it, even if the patient loses control because of the procedure itself or because of the trauma itself.
So the patient is 50 percent, has a high incidence of with tuberosity, which so you can wait until the patient become chronic and then you can do suitable for him or you can transfer to him for one and. If I get your point. Yeah, yeah, you're right, you're right, Dr. Mustafa.
And some information here. Hello can I add some information here? But when you are muted yourself. My apologies, yes, sorry, I didn't realize I was sorry, who's speaking? Can I add some information here? Yes sorry. This chicken?
OK, go ahead. Yeah so I prepared the answer in a way that you classify mild, moderate and severe severity. Then if it is grade 1 and 2 and it's presenting any time, you can treat it the next day. But if the management would be initially any management and definitely management of any management would be pain to leave the child. Exclude other differential diagnosis.
Take a history. Any risk factors. Then then you can treat it next day. So if it is grade 3 as a severe slap, if it is presenting less than 24 hours, then you say principles of management here. You say that you discussed this with the tertiary pediatric reference center. Say that this is a treatment is controversial.
You say that there is a bus study is going on about the exact epidemiology and the ideal way of treatment. There are various school of thought. I'm aware that Southampton paper or ground Clark. But that's their view. But there are a lot of other school of thoughts. They examine the different examiners. They think differently.
So don't stick to just say that it's a controversial. Sec Yeah. You know, if it is less than 24 hours, you talk to the referee center, associated press, and it needs building. So also, whether to manipulate or knot is a controversial most of examiners say don't manipulate because the risk of avian is too much so. So most of summer I attended Mr. Bajaj.
Of course, his way of teaching is that you, he says. You can gently manipulate by putting a patient on an action table, but don't put attraction on, but let the hip reduce back on its own. And then you can pin it within 24 hours. But if the child comes to hospital after 24 hours, then you have to treat it converted into chronic slap and then treat it after 10 to 14 days, you can.
You can do open spinning open slap subscapularis to me and we can do open procedure. That's that's what he says. But just how many things in any management definitive management say about controversy, say about past study? He says gentle, gentle, controlled action to bring to a fixable state and fix it.
That's what he says. Thank you, John. I can. I can. I add one thing all these controversies? You have to be aware of. However, the typical exam answer should say that I would follow the local guidelines. The setting in the UK is for each DHG hatch, which you are expected to be a consultant in.
You would have a center for pediatric operations and there would be like a local guidelines telling you what to do in these cases. So the first word that should come from you in the exam would be I would follow the agreed local guidelines with the local pediatric unit. Some units would insist on sending every single patient to them so that they could deal with it because they are part of a research or they have a particular interest in this.
Others would say no, you would deal with stable grade. It ionic or higher grade, you'd immediately refer to the other unit, however, then you can talk, they will tell you, OK, you are at the receiving end. And exactly as Mustafa was explaining, you go on to the following things. But the first thing is safety. And safety is your adyghe hedge consultant.
You speak, you follow the guidelines set by the experts. Absolutely this is wonderful, wonderful. So thank you very much. Mustafa, chewton and Abdul are both a very valid and correct points if anyone else has any questions. Please do raise your hand or on mutual mark and ask. But if not, I do want to ask a couple of questions of our mentors and see what they think.
So one. Sorry sorry. Mustafa, do you mind sharing your screen now? Thank you. Thank you, Mr Parker. So one of the questions is your 13-year-old boy presents Cheney with essentially you get to the Sufi part to the slipped capital femoral part and you've made your diagnosis.
Now they're going to ask you if it's acute or not acute or you've already established that, what do you do with the patient? It's 11 o'clock at NIPE. You send the patient home. Do you admit the patient? So and so forth. The controversy is the testing is sometimes in that. They said if the patient come to.
Number one, don't let the patient walking, you have to make the patient if he's stable, you can do it with bearing you, put him in a wheelchair. Don't let him go home without wheelchair. Don't let him go walking. If the patient is stable or terminal stretcher, not even wheelchair, and not allowing him to go outside the hospital because 50% one in two cases will have necrosis, then 11 o'clock in the right.
No, you will not do surgery for him. You will wait in the morning and you consult is a pediatric section. If they have the ability to do surgical dislocation for the unstable one, it's better for him because they are trying to save his neck more and saving the babies without consequences. But if it is stable, you can do prophylactic excision. And there is one thing I didn't I forget to mention if when you are sending the patient to x-ray, you are doing EB and the cross lateral table, not both the patient and for collateral.
There is controversy on this. They are saying if stable, you can do for collateral position for him. But if unstable, don't put him in for collateral. The most safe ones are supposed to do a review on the collateral table view. You don't do any manipulation for that. I agree. So the other controversy in the sorry mentors, any different viewpoints and anything.
Well, I agree entirely, I agree entirely with you. Mustafa the other controversy is about who does the open reduction and the techniques, so as a reminder to everybody, there is nice guidance on open reduction of slipped capital femoral abscess. I'll put it on the parks telegram group. It is worth quoting this because as you all know, if you quote nice, it's equivalent of quoting literature and if you understand exactly what they're saying.
Remember, if you quote anything like that, you must know exactly what they're saying. OK the just as a summary, a couple of things they are saying that should be performed. First of all, you should speak to your if you as a surgeon plan to do this, you should speak to your clinical lead and your greater referral team to make sure that you've got support, but also the equipment and the referral pathway ready for that.
But also, if you are doing these procedures, they need to be registered with bischoff's so they can measure and check the outcome as part of ongoing assessment. OK, so that's just a quick summary, you guys would need to read this all up. I put it up on the FRC telegram group for later on and be available for everyone. And if there's no more questions from the audience and there's no more comments from the mentors, I'll give you a minute for anyone to think of a question.
We'll move on to the vital part of this, thank you very much, most of all, and again, thank you to all our mentors. Please stay on the line. Until we disconnect the recording part, we will start the vital part in a minute. OK, thank you very much.
Segment:0 .
OK, so we're recording now. Hello, everybody. My apologies for the slightly delayed start. We were running into some problems. My name is Shawn Hinari. I'm one of the mentors in the Perseus preparation group. Today we are having a lecture from Mustafa el-gamaty.
He works. He's recently past, the International exam. He works in sulaymaniyah hospital in jeddah, Saudi Arabia. Welcome Mustafa to us. Mentors that are here with us today is Abdullah hanun, hania padayachee and Chetan Georgie. We're very pleased to have you all here as mentors and also very pleased to welcome all our participants.
We look forward to working with you in the future. At the end of this lecture session, you will have Viva sessions. Please stay on. The Viva sessions are not recorded for obvious reasons to give you, first of all, some privacy, but also to allow you to be free to express yourselves. Mustafa is going to give us a talk on sufis, please.
Thank you, Mr hot topic for the forces exam for both first and second, but I'll start from definition until we reach the complication and the management. I try to cover the whole speech for the post part one and the second, but it's a very important and hot topic. I try to cover every point in this one because I think in this case, if the examiners give you this scenario, you have to at least pass by 7 or eight objectives today is to know what is a slap, why and how it happened or how it can be diagnosed.
What are the classifications? What are the treatment options. And what is a complication starting by definition? It's disorder of the proximal femoral choices that lead to slippage of the problem widening displaces anterior and external beauty. So the rest is history in the state was truly similar. And this is very important information because it will affect everything in the clinical picture of the patient and in the management of the patient.
So the exercise is remaining in the problem, but the femoral neck is displaced and displaces anterior and external. So what is the epidemiology? The incidence it is the most common disorder affecting is isn't happening in per 100,000 population. It's more common in obese children and then is the single greatest risk factor. Mason made of immigration is issues to African-Americans because they have huge body mass index and during the period of growth, it's called growth is birth, so the average is 13 for boys, 12 surgeries and it's associated with puberty, as we said, because of the growth spurt.
Education is the most common one. You don't know why, but they think that because of the sitting posture of the right hand, the children who are writing same handwriting people, when you are sitting on the right, quiet sitting position, the left hip is afflicted more and it's bilateral. It's 17 to 50% What is the etiology? It's either mechanical factors, the chronological factors. What about the mechanical factors?
Number one is because of the signing of the bill called the Ring of bricks. All of us know this is the morphology of the basis. As we can see here, this article a cartridge. The article contains classified into the resting zone or the zone and the zone and the hypertrophic zone. As we can see here, the high school is classified into the maturation zone. Degeneration zone and zone was a provisional Constitution.
Here we have what we call the broken the ring of Lacroix. It's a dense, fibrous tissue encircles the emphasis and its supporting suffices. This is Allen, and this is the most important structures of both these allegations from which so ambition to be found, there is something of this wandering. Number two, there is change in the inclination of the proximal humeral faces relative to the femur and what they found, they found inhibition to slip the suffices has become vertical lead to increase the shearing forces at the voices due to its slippage.
Number three, we found many patients with slap has a reversal of the femoral. What are the endocrinology contractors carrying on an obese high? And it's called the syndrome getting more common in hypothyroidism patients and the patient with chronic renal failure or in the classifications? We have many classification for step. We can classify them into the patient is clinically stable or stable, and we speak about it and regional functional classification into mild and moderate and severe would speak about it and temporal classification according to the onset of symptoms into acute, chronic or acute on top of chronic fatigue to provide prognostic information.
And this is a very important classification to classify the slip into stable and unstable. Stable means that the patient has able to be with, even with or without crutches. Why is this important? Because there is minimal, minimal risk of osteonecrosis less than 10% and the only stable patient this patient has unable to emulate, even with crutches. Why is this important?
Because it's associated with high risk of osteonecrosis 47% Why is honesty what cannot be with? Because they say that they said that there is confusion between the basis and the patient. So there has been this information about the patient cannot bear with. So this is unstable and high incidence of chronic illnesses. The classification is classified according to the onset of symptoms into acute Mason symptoms is less than three weeks.
This patient has prodromal symptoms and due to minor trauma. Why these three are important because we have to subdivide or doing like, we have to classify this from the traumatic Salter type 1 fracture because traumatic sort of bone structure. This patient has greater and greater energy trauma and has no trauma symptoms. So we have to classify traumatic slap from acute slippage occurring with trauma symptoms that are developed for acute sleep that has no femoral remodeling changes typical of chronic sleep.
As you can see here, this patient has celebrity here, and there is no in remodeling changes. So this acute sleep in chronic slippage, the patient is symptoms more than three weeks and we have here, as we can see, there is remodeling changes. Acute on top of the patient has prodromal symptoms more than three weeks, but the patient has sudden exacerbation of the symptoms. So how we can differentiate acute on top of chronic from chronic if the slippage occurring more than the degree of the remodeling beyond the remodeling component.
So this is acute on top of chronic. As we can see here, there is remodeling changes here, but the slippage occurring more than remodeling procedures. So as reclassification classified slip, according to the official shaft, angle is measuring the angle in the view and the normal angle is 145 degrees and then the lateral viewing angle is 10 degrees is taking line parallel to the axis from the upper end to the lower end and take the color line and line with the shaft of the femur and the normal angle, and maybe 100 to five.
The lateral degree, it's 10 degrees and is doing comparison between the affected side and the normal side, and you are measuring the difference between both of them. And if the patient has bilateral slippage, he's thinking is a normal degree. 145 degrees as difference. But if the patient has any unilateral use comparing this side to the normal side.
So the classification classified this Libyan for mild if the angle is doesn't serve the degree, the difference between both sides moderate if 30 to 60 degrees and severe if it's more than 60 grading system for slap the grading system into mild, moderate and severe, if less than 33% from 0 to 60% It's a grade 134 to 50 to grade 2 and grade 3 more than 50% of the slippage as we can see here, less than one third to more than 2, 1% more than 2/3.
How the patient is presenting it a clinic. Many patients come in complaining of growing bean or soybean. This is the most common presentation soybean or nepean, and it's getting from 15% to 50% Why it's transmitted through the. This is why it's misdiagnosis. Because patients come complaining of knee nibbling or soybean not having physical examination.
We see the patient has maybe an LG G8 or their gait, and there is decreased range of motion of the head, especially the internal rotation production and the friction driven side. It's obligatory external rotation during the flexion of the hip. Why is this happening? Because when we are doing passive flexion of the hip, we see that the soil and hip become external because there is impingement of the displaced neck on the.
And exhibition is only we can see some of atrophy. Residential in residential finding, as we all know, there is a clear line, it's line Mason line drawn through its superior neck and neck and has to have this line has to cut a piece of the head from the beaches here. As we can see here, this line is not cutting anything here in the. So this is one side, as we can see here. Also on this diagram.
And this is a second radiological finding we can see this is called the metaphysical lawn sign of steel. It's christened the blind with Udinese due to overlapping between the slap devices because suffices slap subsidiary, so there is superimposition between the neck and the slap devices, which will appear in this line. Another ideological fight, and we can see here, this is going to be visualizes or widening, as we can see here in competition to this fight.
And this fighting we can see, even before this slippage. Also, we can see a decrease in the epicondyle height if we measure the physical height in this area and compared to the physical height in this area without this decrease in the zeolite. Because, as we said in the beginning of the definition, suffices is displaced the posterior cryptogenic. How we can manage the patient, there is very good algorithm, it's published in 2017.
They said slap classified into, as we said, stable and unstable if the patient does unstable high incidence of events, about 50% of the patient. So try to save them by doing a modified approach through safe surgical dislocation. I will speak about it later on. If the patient is stable, how much is the degree of the slippage? It's mild less than 30 degree moderate or severe, more than 70 degrees.
If it's mild less than 30 degrees, you are saying if it's impinging or not impinging, what's the difference between Beijing and beijing? They said in Beijing. If the patient clinically has hip flexion, 90 degree or less internal rotation, 50 degrees, 15 degrees or less. So if the patient has internal rotation 15 degrees or less or flexion 90 degree or less, this is good imaging. So if it's not impinging, they are doing in trying to fixation.
If it's impinging, they do inside to fixation blocks to control blast. And I will speak also about those two controls. But if the patient has moderate or severe slap, the more than 30 degree they are depending on the open faces or close devices, if the patient has open faces, the surgical dislocation. Plus, subscapularis alignment, I will speak about it, but if the patient has closed devices they are doing combined tenotomy with us to control lost.
How we can do that continuous insight of extensions is the main management for the patient. I will speak about how we can do the technique, but what about contralateral to it? Can we do prophylactic bidding for the other side or more? It's sort of been controversial. The current indications are if the patient has high risk patients because there is contralateral slippage 40 to 80 percent, like we said in the genital syndrome being a patient hypothyroidism.
And if the patient initially initial slippage occurring at younger age less than 10 degree, this patient may also have open prior cartilage or the nature of the current slippage is very severe. It means that the patient is coming to the clinic, has various virus slippage and the adding one more point if you cannot do close for the patient, if you cannot trust the parents and you can find that the parents will not do for you, so you can assist in the prophylactic fixation, but try to find another algorithm to become more secure on how to do prophylactic excision on the other patients.
So what we did is we did the modified form to score. The score is combined of five categories the ilium, the trial, the cartridge, the head of the femur, the GT and the list of everyone from this is sticking point. Like, as we said here, if we take the biological switch as an example, if the face is clearly hoping to take one point, if the face is partially closed, it took two points.
It suffices as close to 3 points and every one of the sticking points, like four four five. So the score of we calculate this one that is the score is 16 and the highest score is 2026. Hawaii is important because if I this if you do, the patient score is 16, there is probability of the contract has to be 100% So you have to do perfect for this one. And if the score of the mission is 20 six, the probability of the building, which is 0% So you can do.
You cannot do the calculation position. How we can do the cutting inside to fixation, the aim of this is to stabilize the business from further slippage. We are trying to promote promoting the closure of the offices. It's a minimum three threats of closing the suffices I read in many literature, they are saying five threats. Really, what I'm saying is a screw on the basis.
It's very, very small. I don't know how five threats closing without penetrating suffices, but I found the minimum, which is safe. Crews should be at least 5 from the beginning, all views. This is the most important sentence, the ideal placement of the single community, the screw should be in the center of the capital basis and it should be driven to suffices. So the screws should be in the center of the vexes and the.
After fixation, if the situation is stable, he can do bedwetting, offer insight of oxygen. But if the patient is unstable, we make him known with very. This is how we come to insight to prophylactic and scientific excision, as we can see, we put motivations for buying who owns attraction. People without doing inspection. Then we take every shot, we take the 1 Wire and this wire is buried the suffice, as we said, and in the center of the boxes and we take and we draw this line in the skin and then we take a lateral shoot and we take another line between the two slices.
And in the center of the boxes and the intersection between the two points is the entry point that we can see here. This is in the Abbey and this is a lateral and intersection point between the Abbey and the lateral. It's the entry point, and then we are fixing the screw. Why is it so important? Because we found in this diagram diagram, as you can see, there is three bends here been and C then and B. Both of them are contract in 3 bends and da Vinci is in the neck both and B c, as you can see here in the image.
If you can, you can see in the image. It would become like false deceiving perpendicular to the voices and then central services. But if we can see here they are not crossing in the center and they are not fixing good. So this is why we have to make the bend see the interior of the intersection of the two points. How about proximal femoral osteotomy? You are doing to restore the proximal anatomy?
Why? because if we didn't do not restoring this ambition to untreated or comic strip, the patient will complain of femoral impingement later on, and that will has liberal or articular cartilage damage and later on degenerative changes on both sides. We have all of. We know that we have three types of osteotomy. We have the Don of osteotomy and we have besar.
It's called the promoter and we have the entire country. So as to why is this important? Because all of us know the more proximal tenotomy as we can see here, the greater the connection, the degree of the deformity. But the problem is why is this greater degree of corruption? Because it's near to the center of the rotation and conditions of the poor. But the problem?
It's near to the blood supply, so high incidence of chronic disease. What about us to come tuberosity the indication if the patient has symptomatic and Benjamin from metaphysical bump and mild or moderate degree of slippage, and we can do it either arthroscopic as we can see here, it's only about three shaving, shaving or shaving, isn't it? All can do by through limited, limited and/or certain surgical precision.
What about the reduction was committee realignment. It's called safe surgical dislocation or surgical hip dislocation. It's a reduction with spinning. It remains controversial. It's indicated in an unstable or high degree slippage because this patient has high incidence of muscular bruises. We are doing surgical dislocation with orientation through modified procedure.
The interval is official interval between the egawa test maximus and the egawa test medius and the interval down between the minimus and by reforms. The success of this approach, depending on protecting the blood supply. In this diagram, we see why we are doing osteotomy, we have to do short term moves and why is efficient if you have a patient with chronic slippage, why you are not doing for him close the reduction and fixation only because the remodeling changes and after slippage, as we can see here, there is a regular visits become kinkade.
And if we are doing close the reduction traction, there is a thin bit of close the reduction in the blood supply only to come from the AC so it will affect lots of life and the patients will have adverse consequences later on. So if we are right after doing those totally safe surgical dislocation, we are going to shorten, we are trying to do shortening goals. And so with the reductions of lots of light still and not affected.
How we can do safety, surgical dislocation, so by imposition, the interest rate by which we are enticing about 15 centimeter, we we're opening the skin after this offense of fashion that as we can see here. Then we'll find our interval between the egawa test and do internal rotation will find the minimus and so by performance. And then we are finding that we are doing the flip through country because it means the transverse osteotomy and the GTA.
Now we can see here the capsule. We are doing this absolutely in the capsule. Then you dislocate the head after dislocating. Is it useable? Axilo suffices and depending on the intact posterior vessels? We are not disturbing the posterior vessels. Then we are moving the whole colors formation. We do shortening in the neck reshaping. Then we reposition the device again and to fix it again.
As we can see here, we are not disturbing any bas status blood supply. Xinhua affixing bike wires on the score for the. What about the complication of slippage contralateral slap slap progression in 1% to 2% infections 2% and the chronic being 5% to 10% if the patient is not treated good has degenerative arthritis or residual deformity, it's called the pistol grip deformity or just not important.
The most important complication is even on the control license even occurring as a result of the initial trauma itself. Or due to operative intervention, if we put the screw in the posterior superior femoral neck. This patient has high street store, the risk of disrupting the blood supply and high incidence of what's called on cruiser, as we can see here.
The most important second important complication the controls. As we can see here, competition for this year and joint space there is no longer enjoys this year. The count came complaining of stiffness and the persistent beam in the groin or Abishai examination. We have the patient, the loss of outcome of the motion in all the planes, how we can diagnose the results of joint space as we can see here.
And the criteria for this, if the joint is less than 50% in comparison to the other side or absolute measurement of millimeter or less. This is the whole presentation. Thank you. Thank you very much. Most of the presentation was very good. I have a few questions for you, but first put it out to the audience.
And if anyone has any questions, please feel free to unmute mike, ask the question and then renewed. Kashif, please go ahead. Yes thank you, doctor. Dr. Mustafa, I'm not a mentor. I am a I'm a candidate for the May exam, actually, but I failed the November attempt. I think this was a brilliant presentation, but I think there are two or three very important things which the candidates like us.
We have to understand that the most important thing is the controversies which they do, which they usually ask in the exam two or three controversies and one of them you have already mentioned that will you pin the contralateral hip or not? And the second controversy is that the presentation, the time of the presentation, when you are going to operate on an acute or acute on chronic and chronic, if you can explain this because it is written in the postgraduate book and I think it is quite an important thing that the time of the presentation and Opry operation, I think it is quite important.
The Southampton paper of the clerk is the basis of this controversy. If I'm not wrong, Sean, I in just correct me if I'm wrong. And well, first of all, you're right, there is some controversy about time to operation and who is going to operate. And second, the discussion about what you should open, reduce or in situ. Absolutely so will first let Mustafa give his opinion on this.
I'm sorry, I didn't hear the question again. The controversy regarding the timing of the surgery on acute care patients or chronic patients, they say that if the presentation is delayed more than 24 hours, then don't operate on those patients, let that patient to be converted on a chronic slip and then operate on that patient. And the most important thing?
Think that this surgery has to be done by a specialist center in a high tertiary care hospital, not in a district hospital, what they call in the England district General Hospital. OK according to what I read and what I searched for. Yes, I read what you read that if the patient has come and is more than 48 hours, you don't treat him as acute and you do wait for the patient to become chronic and you do correction later on.
But it's a patient coming to you with severe slippage like more than six degrees. This patient has high incidence of outcome already. So, yes, you can transfer him for tertiary center. They are. They are all now speaking about safe surgical dislocation and trying to reposition it, even if the patient loses control because of the procedure itself or because of the trauma itself.
So the patient is 50 percent, has a high incidence of with tuberosity, which so you can wait until the patient become chronic and then you can do suitable for him or you can transfer to him for one and. If I get your point. Yeah, yeah, you're right, you're right, Dr. Mustafa.
And some information here. Hello can I add some information here? But when you are muted yourself. My apologies, yes, sorry, I didn't realize I was sorry, who's speaking? Can I add some information here? Yes sorry. This chicken?
OK, go ahead. Yeah so I prepared the answer in a way that you classify mild, moderate and severe severity. Then if it is grade 1 and 2 and it's presenting any time, you can treat it the next day. But if the management would be initially any management and definitely management of any management would be pain to leave the child. Exclude other differential diagnosis.
Take a history. Any risk factors. Then then you can treat it next day. So if it is grade 3 as a severe slap, if it is presenting less than 24 hours, then you say principles of management here. You say that you discussed this with the tertiary pediatric reference center. Say that this is a treatment is controversial.
You say that there is a bus study is going on about the exact epidemiology and the ideal way of treatment. There are various school of thought. I'm aware that Southampton paper or ground Clark. But that's their view. But there are a lot of other school of thoughts. They examine the different examiners. They think differently.
So don't stick to just say that it's a controversial. Sec Yeah. You know, if it is less than 24 hours, you talk to the referee center, associated press, and it needs building. So also, whether to manipulate or knot is a controversial most of examiners say don't manipulate because the risk of avian is too much so. So most of summer I attended Mr. Bajaj.
Of course, his way of teaching is that you, he says. You can gently manipulate by putting a patient on an action table, but don't put attraction on, but let the hip reduce back on its own. And then you can pin it within 24 hours. But if the child comes to hospital after 24 hours, then you have to treat it converted into chronic slap and then treat it after 10 to 14 days, you can.
You can do open spinning open slap subscapularis to me and we can do open procedure. That's that's what he says. But just how many things in any management definitive management say about controversy, say about past study? He says gentle, gentle, controlled action to bring to a fixable state and fix it.
That's what he says. Thank you, John. I can. I can. I add one thing all these controversies? You have to be aware of. However, the typical exam answer should say that I would follow the local guidelines. The setting in the UK is for each DHG hatch, which you are expected to be a consultant in.
You would have a center for pediatric operations and there would be like a local guidelines telling you what to do in these cases. So the first word that should come from you in the exam would be I would follow the agreed local guidelines with the local pediatric unit. Some units would insist on sending every single patient to them so that they could deal with it because they are part of a research or they have a particular interest in this.
Others would say no, you would deal with stable grade. It ionic or higher grade, you'd immediately refer to the other unit, however, then you can talk, they will tell you, OK, you are at the receiving end. And exactly as Mustafa was explaining, you go on to the following things. But the first thing is safety. And safety is your adyghe hedge consultant.
You speak, you follow the guidelines set by the experts. Absolutely this is wonderful, wonderful. So thank you very much. Mustafa, chewton and Abdul are both a very valid and correct points if anyone else has any questions. Please do raise your hand or on mutual mark and ask. But if not, I do want to ask a couple of questions of our mentors and see what they think.
So one. Sorry sorry. Mustafa, do you mind sharing your screen now? Thank you. Thank you, Mr Parker. So one of the questions is your 13-year-old boy presents Cheney with essentially you get to the Sufi part to the slipped capital femoral part and you've made your diagnosis.
Now they're going to ask you if it's acute or not acute or you've already established that, what do you do with the patient? It's 11 o'clock at NIPE. You send the patient home. Do you admit the patient? So and so forth. The controversy is the testing is sometimes in that. They said if the patient come to.
Number one, don't let the patient walking, you have to make the patient if he's stable, you can do it with bearing you, put him in a wheelchair. Don't let him go home without wheelchair. Don't let him go walking. If the patient is stable or terminal stretcher, not even wheelchair, and not allowing him to go outside the hospital because 50% one in two cases will have necrosis, then 11 o'clock in the right.
No, you will not do surgery for him. You will wait in the morning and you consult is a pediatric section. If they have the ability to do surgical dislocation for the unstable one, it's better for him because they are trying to save his neck more and saving the babies without consequences. But if it is stable, you can do prophylactic excision. And there is one thing I didn't I forget to mention if when you are sending the patient to x-ray, you are doing EB and the cross lateral table, not both the patient and for collateral.
There is controversy on this. They are saying if stable, you can do for collateral position for him. But if unstable, don't put him in for collateral. The most safe ones are supposed to do a review on the collateral table view. You don't do any manipulation for that. I agree. So the other controversy in the sorry mentors, any different viewpoints and anything.
Well, I agree entirely, I agree entirely with you. Mustafa the other controversy is about who does the open reduction and the techniques, so as a reminder to everybody, there is nice guidance on open reduction of slipped capital femoral abscess. I'll put it on the parks telegram group. It is worth quoting this because as you all know, if you quote nice, it's equivalent of quoting literature and if you understand exactly what they're saying.
Remember, if you quote anything like that, you must know exactly what they're saying. OK the just as a summary, a couple of things they are saying that should be performed. First of all, you should speak to your if you as a surgeon plan to do this, you should speak to your clinical lead and your greater referral team to make sure that you've got support, but also the equipment and the referral pathway ready for that.
But also, if you are doing these procedures, they need to be registered with bischoff's so they can measure and check the outcome as part of ongoing assessment. OK, so that's just a quick summary, you guys would need to read this all up. I put it up on the FRC telegram group for later on and be available for everyone. And if there's no more questions from the audience and there's no more comments from the mentors, I'll give you a minute for anyone to think of a question.
We'll move on to the vital part of this, thank you very much, most of all, and again, thank you to all our mentors. Please stay on the line. Until we disconnect the recording part, we will start the vital part in a minute. OK, thank you very much.
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