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Prosthetics for Postgraduate Orthopaedic Exams
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Prosthetics for Postgraduate Orthopaedic Exams
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Upload Date:
2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
Welcome to. This teaching session of the farc, a group. Preparing for the fastest examination tonight, you have really thank you for everyone who attended. Tonight we have a guest really star guest who is teaching us. He is the mentor of all of us. Mr Maher looks to my father. He is runs.
A lot of activities, really is very busy, but he is very, very well known. Trainer and educator in the UK, he is a consultant from Harlow princess Alexandra Hospital. He's very busy, has very busy practice, but she's also very interested in teaching and training. He he runs the Royal College of England. Fast course.
Very well known and recommended course. And we all attended a lot of most of the mentors here have attended this course, I attended myself very good commended. You can always guys find it here on this website, doctors Academy. And he's also takes part in a lot of education activities related to the farc, including the well-known Cambridge FARC schools run by orthopedic Research UK.
He's been here with us supporting our group since we started and. We are very pleased to have him with us tonight, so I will. Over to you, Mr Maddox, from to start. Thank you very much. So for this introduction for us. And so this topic is prosthetics.
But actually, it is. Amputation and. And prosthetics. Uh, sorry, I just. Can I sorry my screen, I can't I can't get it forward just a minute.
Yeah, that's fine. That's fine. So while Mr. Meyer looks on mobile, is working on this. We will. This is very useful presentation and it's presented in courses in the UK and it's very, very useful. And the best way to run it is sort of simulated or type of Viber question and answer. And then we will give you the answer afterwards, so we will encourage you to take active part.
So please, anyone interested in being taking part of the hot seat, please raise your hand or send the message the chat box so I can allocate you an next opportunity. Oh, great. So I've got it now. So basic topics like this are important is because these topics like amputation, prosthetics, genetics, orthotics.
As you agree, we don't discuss in the copy room. We don't discuss day to day. Unfortunately, as you know, and all the senior mentors would have told you that these topics unfortunately are part of our syllabus, so I'll try to keep it simple. Those of you are giving the exam in 10 days, you can get the knowledge from this to keep it simple. That's great. Those who are giving it later on, once again, it's a difficult topic to get from books, so I'll try to simplify it.
So basically, the plan of the talk will be let's talk about indications and nomenclature, correct words for things which we don't normally use. Then we go to surgeon factors. So it will be the ideas, stump, idea, length, et cetera then we'll be prosthetic factors and then problems and complication and less common amputation. So let's start.
We're asking each other. Ask someone. So, Ibrahim, are you still with us? Brahim, yeah, yeah, Yeah. So, Ibrahim, you are through with Mr. Mahalakshmi mvala for a question, please. Yeah OK.
So this is your basic science favour, and I'll start with a few questions. Let's start with the first one. What do you understand, bioprosthetic? Or a prosthesis? A birth is an external device helping in replacing body parts or replacing body function. OK, that's fine. And if you're shown in the Viva and once again, it's your basic science.
You will be shown a picture of a really open fracture with the vascular injury. And the question then comes to you is what will you do for this patient? Really like to do a limb salvage? Or would you like to do an amputation? And how will you make your decision? What do you say for that? Yeah actually, this is a matter of debate in the literature.
But the most commonly used decision is use of this mangled extremity, which will help the surgeon to take the decisions. But tell me about it is 4 components. The first part is shock and awe. Eight of the patients below then 30 from 30 to 50 more older than 50 and the shock. But they are above 90. Transient responder or permanent and responder.
Then the state of ischemia of the limb. If there is a pulse or the second stage is bas status, but the limit is still warm and there is a prolonged intraoperatively fell. And the last stage that is called this is called the 3 is pulseless since problem within the last components.
OK, thank you. And the next question is the simplest definition would be, of course, this embraces all substitutes for bodily defects, so this could be in any part of the body. Not necessarily. Remember this three words embraces all substitutes for bodily defects. Now, in the nomenclature, generally we talk about below knee above knee, but the correct new nomenclature should be to the bone.
So let's speak now as friends and family, and it'll be to me and to. Rather than knee and hip. Now, us as general orthopedic surgeons, the communists would be trauma and tumor surgery. But otherwise most of the amputations, as you know, are done in the vascular for vascular disease, like Ibrahim rightfully said. You need to do mass.
Just a point, just a little point for the exam. There's a scoring system, which has scores. Don't try to worry about the scores itself. Just try to keep in mind the five headings or headings of a particular score. And then if the examiner asks you, what about the scoring, say I cannot. I cannot recall the score. But what I will do in real life is I will make sure that I look off the score at that time because it's a very vital decision I make so that I didn't know that you made a decision on your mess, as well as with your other colleagues that you want to do an amputation.
All right. In a young person who a trauma surgeon trauma patient, what do you think the patient will come back to work faster with an amputation with multiple of success? You say, like you said, rightfully, I will do a suture removal at about the two week mark. I will use. You agree that you need a good stump.
And when you said good stump, we now need to know what would be the ideal stump to take things forward, right? So you want what is called a shrink sock? Will you remember that? And so you put on a string of sock for a few weeks? Then, of course, it will be taken off that stump so that the prosthesis can be made right. And you will have a temporary prosthesis given to you on which the patient starts putting weight on it, or 25 to 40 out.
Yeah, so not full weight, but that happens. So that's your six week mark, like you rightfully said. Then at the six week mark, the definitive prostheses would have been ready. And then the patient stands for another two weeks and then increases as you and that you happy with that Ibrahim. So what he said was correct. I've just broken it down to be a little more slick. Yeah now let's go back to know what else can I carry on with a wrap?
One more question. Let me go to someone else. OK keep an eye on them again. So now the next question I may ask you is you've decided now, and I want to ask you, what if you have to do a transfer bill or a transfer? Do you always want to preserve length or do you want to go shorter and why?
Yeah, I always wanted to preserve the length because this will decrease the injury expenditure. During the walking. The first reason is the more proximal I go with my amputation. Unfortunately, the patient will have increased oxygen consumption, or you can use the words increased energy expenditure. Stick to 1 whatever you want to use.
Yeah, we agree that one reason and the second reason you say is that I unfortunately, as I go higher in my amputation, the patient's self regulated walking speed. If I remember these four words, self regulated walking speed decreases. So in other words, all of us can walk faster if we want to one day and then we walk slower. You agree. But otherwise, if you go higher.
So if you have a hip, this articulation or a very high transfemoral, that patient cannot go any faster than what he is. So that's call your self regulated walking speed. And there are two reasons you'll give for vision length. One is option consumption, and second is self-regulating walking speed. And then you can show through two graphs to the examiner. So this is it.
And what you said was very correct about energy expenditure. So now if you're asking, we have someone else, thank you, Abraham. Thank you. Thank you. Thank you. Thank you for being the first candidate and for being brave. I'm sure that will pay off.
Thank you for that. Six times. Yes, sir. Oh, it's your trauma, but let's give it to basic science. And because you have a choice and I show you a picture of an open fracture and you've said yes, I would consider amputation or ICU amputation stop. And the question I'm asking you is that you have two choices the mangled foot, and you have a choice of doing a science, which is a true ankle, or you have a choice of doing a trans tibial, which is below knee, right?
You have two choices. Yes the advantages of a science and the disadvantages of a science. So the advantages of science will be a longer stump. And since it is just through the Dome of the telescope, so patients may be able to even walk without prosthesis for a short distance. The disadvantage of science is since the amputation in the heel flap, which we make in the times, depends on the posture military.
So if there is any injury to the posture or if there is any heel pad necrosis, the amputation stump will fail. So that is one disadvantage of. Another disadvantage of science. I'm not recollecting. Now tell me that you, therefore you've said that you would, let's say now give me the advantage of a trance, tibial trance, tibial more options of prosthetic fitting and better fitting of the processes.
What do you mean by better fitting? What is the thing? Patients would like about that compared to the time. So the look of the process is like the normal leg. So the acceptance of the cosmetically. Yes yes, sir. So you wanted it very well. The only thing I'll say for everyone.
The opening? Thing to impress now you had you, could you just discuss two points which were important, like energy expenditure? So I know you felt it was we had discussed it, but try to say it when you're practicing with your colleagues. So the advantage of science is the longer lever arm or to the ends.
I know that with a longer, longer stump, energy expenditure is better and the patient self-regulate is peel-back. So you've already impressed your examiners by something you can repeat all the time. See where we are. So the advantage of science for everyone is that, like krunal said, you can walk on the rest unsupported and in poorer countries, developing countries.
This is done, ok? What is the disadvantage of science? The technical word, what you were trying to say is let's call it fat. Bad migration. Easy to say. Easy to impress. All right. Call the other disadvantages because unfortunately, if we have to put up prostheses on that same socket is bulky.
Hence, it is cost. The word I want you to use ground is cosmetically dispositive. Yes the patient will need a contralateral race. Yes Yes. I would prefer a transtibial advantage would be cosmetically using better prostheses fitting and easier matching side to side. Right?
Yes. But I do know that the range extender may be higher. You know, you keep it like that. So we have to get it. Yes, sir. Right now, this next question to you. I'm going to ask you that once again, you have a proximal tibia fracture, OK, and you made a decision to amputate.
You have two choices. You can do a knee or you can do a transfemoral, which is above you. OK these are advantages and disadvantages. Start with a true knee. What is the advantage of a truly stay there. I'll ask you one more question. Yes, so let's go through it. If you go through knee, that advantage up like we said energy expenditure and said clearly walking speed, then you say, because of the bulbous shape of the stump, yes, get a better stability.
And therefore, for those patients who may be sitting more because they are bilateral, it may be to agree. We go very high slap lesion. You know, it's a difficult point to stabilize. What is the disadvantage of three knee? It's very clear that cosmetics you cannot get because the knee joint will be at a different level. So cosmetically this people use the word asymmetry of knee joint.
And you can also say that in a rest right for giving length, which you and me want to use, that we may have gone through bad tissue use already and that will lead to more healing. So that's another reason to consider happy with that. Yes yes, sir. Epicondyle last thing for you. Yes, sir. Tell me what would be your ideal length for a below?
For example, I'm showing your picture. Now Imagine that your basic science and I show you a picture of a stamp and where do you want to cut this ball? It's a bill. What is your ideal length? So I'm not able to see any picture. No, no.
I'm just asking. OK, so ideally, bill, I would like to take the roughly 12.5 to 17.1 length away from what point I order. The other way to take is like for every 30 centimeters of height, I'll keep a 2.5 centimeters of length. OK, good. And so the stock might say, I would always want to have a longer lever.
Ok? that same reasons which we said anything to and speak and then say, however, any length in the body. I want to make sure that there's space for any available components cosmetically. That would be OK. And then say in my transtibial list, remember for everyone, for you and everyone, if you don't mind, there's something called a 5 inch rule.
The 5 inches is 5 inches below the knee, joint five inches. OK exactly what you said, which was 12% All right. Yes, sir. Yes everyone wants to remember something because you remember so the number is 5 inches below the knee or below five inches above the transformer. And you tell the examiner, I do know, however, the bare minimum would be to gain my attention.
It makes sense. Yes Yes. Yes OK, now then say tell me about the soft tissue coverage. What? how are you going to do with a soft tissue in your body? So what they see in trauma situations is that if you have recognized the pre-op X-ray as a severe serious bodily injury with a fibula and the fibula was going to be separated apart, then your amputation, you can still put us in this body screw.
Yes at the level of amputation so that the weight bearing is better for the patient. But just out of interest, it's a good thing to know for the group. So they stay there for a moment or not. So, yes, everyone with the posterior slap diameter plus centimeter. Most of the time, tell the examiner, I know I will have to do the fibula of 1 centimeter shorter than the tibia.
But however you say for trauma patients, there's something called a platform theory whether people have the same level. Then say if there was preoperative interosseous membrane disruption, then I may consider us in this moving screw. All right. Is this ok? Just keep in mind, the best answer would be just say you need to be five inches above the knee joint, OK, so that's your level, like you said, so five inches above your knee joint now, ok?
Is that suppose you have told me that you want to make it keep linked? Is that right? You always want to preserve? What did you make it so disturbed that you're just about 2 inches above the knee joint? Is that acceptable or is that not good? Let's go to it now. Stay there and I'll just go through it.
So for everyone, the best answer would be, like you said initially when you started, you need 50% to 70% of the female needed. The best answer to give is a 5 inch rule, like I told you, is 5 inches above the knee joint. Then say, however, you cannot be less than three inches above the knee joint and the knee. The reason for this is exactly like we had discussed earlier that you need for your knee component, right?
So if your knee component will be below the other knee and will be cosmetically displeasing and you cannot do that. All right. So the bare minimum is 3 inches above the knee jerk. The next answer you have to give is how short can you be? So I suppose you have a very severe injury to the mid femur. We always want to preserve length, but what length do we need?
And the answer is about 2 inches below the lesser tuberosity or two inches of egawa is needed for it to behave like this again. The reason for the maximum why you were not less than 2 inches again, the reason. So yeah, which one? The three inches is because of the knee prosthesis, right? Correct Yeah. But why we don't want to remove a huge amount of FEMA is that you need some bare minimum of the femur before a stump can be put on.
Right? and that bare minimum is supposed to be 2 inches. Let's keep that in mind. You need two inches of your femur way to behave like a transfemoral. Unfortunately, if you have such a short femur and it behaves like her hip dysplasia, OK, you move on. So what now you need to know until the examiner, I know there are some prerequisites for a trans debate, so the prerequisite of the bill will be we need to have full knee extension.
And you need to have 70 degrees of flexion possible. Otherwise you shouldn't be doing amputation. And can you tell me, abdulkareem, you know, any requisites for a transfemoral? In other words, we want to know that there's no pre-existing problem where the patient cannot have an amputation to the people, like you said, free range of movement of the hip. And if at all, you cannot have a fixed flexion deformity of more than 10 degrees.
Yes, and you cannot have a fixed abduction deformity that can be used when you remember that a two year degree cannot have more than that. Great So. One more question for you, and then we'll move on. What you want the soft tissue coverage to be, what is your ideas? Did you go?
It was skin, you mean any better word you want to use? Can you see the world through thick skin? That's what you're saying. You need a full thickness skin color. Right? and you need a muscle mass cover. Yeah Yes. OK, very good. So I'll just tell you for you and for everyone.
What are you going to tell the examiner? So so far, just to recap, we've talked about the indication. You talked about the best stump. We've talked about length. And now we are coming to soft tissues. So you tell the examiner that my ideal stump would be mobile with a non-southern. Do you remember that aberrant muscle mass covered with full thickness skin?
And the reason is that it should be able to tolerate, share and redistribute load to the bill. So everyone, I'll just repeat, it is a good statement to make. I want a mobile non-actor in muscle mass covered with full speaking skin, which is able to tolerate share and it distributes low to the bone. All right. So what you said was right, just a few better words. Yeah, Yeah.
Yes thank you very much. Thank you, Mr. I think we'll move to the next one. Yeah really? Next question that if you had to this way, everyone, the muscle repair. Remember, there's something called my opacity and my body since. And tell the examiner that, yes, I will do a combination of both.
If you have to do a mile lusty moment. What tension will you put that out? How will you decide the tension for a mile plus? So the best you say, I want it to be done at the resting status, is that what you mean? So you don't want to join to be in flexion or extension or abduction reduction. So it's a mild blast done at the resting status of that joint, and it should be done without excessive flexion or extension or values vary so that you're not putting it a new contractures.
That's that's good. And just for everyone. If you do, there's something called the abductor lurch, and you avoid that by doing a mild disease by your abductors, you attach onto the distal femur and tell the examiner, if you're talking about a transfemoral that I do this because I want to prevent the abductors from giving the patient what is called an abductor urge.
All right. Moment happy with that. Yes thank you. Thank you. Now, tell me. Now we are moving on, and I'm going to ask you a question. Tell me at the basic science level, what is the use of a prosthesis in trying to transfer load? Or do any different types of load transfers in amputations and prosthetics?
It's not going to be asked like I ask you, but it's good to have that information because you it'll score you points because you may be now showing a prostheses and you want to talk about it. All right. So let me tell you something, and then I'll ask you another question. So for everyone. Say that there are two types of law transfers when you put on a prosthesis, say the first one is called a direct load transfer and that's called end bearing.
And the second type is called indirect load transfer. And the other word for that is total contact. So when you repeat that moment for me, the two types of Yes no transfer in varying and total contact, direct and indirect, so direct and bearing interconnect. Now that I've given you a clue, can you tell me in which type of prosthesis you have a direct load transfer or in which type of amputations, or which type of amputations in the body or through get and you need a direct load transfer, direct load transfer also?
Well and bearing happens when I as a surgeon or you as a surgeon, do a through knee or through ankle, through a joint and then say in this condition, the metaphysics is wide. Is that correct? You have a wider metamorphosis. You have a larger surface area. You agree you have a. The Young's modulus of cancellous bone is less stiff than particular bone.
Agreed and hence, you need this bone or this end of the stump can directly take the load. Yeah, so that's called direct load transfer. So just repeat it again for me. How are you going to formulate this answer? So what do you understand about direct load transfer? In which conditions do you get an indirect load transfer? Well, once again, it's a difficult question, but tell me how you formulate it.
That's fantastic. Very good. So hence you will use an indirect load transfer. Yeah, they're very good. So let's just go through it again for you exactly what you said. Plans to build transfemoral the terminal surface is not capable of accessing the load because you said narrow. Correct and bonus.
Yeah and hence you will use an indirect load transfer and you tell the examiner I will need a very snug fit so that the load is dissipated around, not just the end around the entire prosthetic stuff. We get happy with that. So the more you start by saying phantom pain, phantom pain is a pain that you have at the park, which is removed, then you have rescued limping and you have distressing thing.
OK so in other words, pain like this is psychologically. There's neuroma. And then you talk about contractures. Infection then you talk about bony prominences, like you said, ulcers break down and bony from. And then you have your problem, get very good hyperplasia. OK so happy with that moment I asked you, I asked you the most, most difficult questions, so but I hope now you know this when it comes to start talking about the procedure.
Thank you very much. Yeah, Yeah. Different parts of the prosthesis. Our practices would have just for everyone. Let's remember these are all words that you need to know they every post is given to another subject, which is, yeah, yeah, you'll have a suspension mechanism of some sort. Correct what you said.
So suspension, this is all in the 1960s. Should you just to show that you need some method of suspending your sock it onto the body? All right. All right. You said the word which I wanted, which you said the correct part, but let's all of us use the word pylon. Yeah then you have some degree of the city of afoot.
Yeah and you have a mechanical knee jerk. So it's going to be for everyone to do it. Suspension is a socket, a suspension mechanism. This is a pylon and there's a foot and a mechanical egawa. Now, tell me, remember when he started talking? I remember you've amputated the stitches, taking a more prostheses giving you. Right? next thing I want to tell you is the minute, of course, photograph showing you the word should be, is this a preparatory prosthesis or is it a definite prosthetic, right?
So if this were ever shown to you, what are you going to say? It's a definite prosthesis. Well, let's use that word from now on. So most of the time is different. And what do you mean by that? There are two types definitive and preparation, right? So that's where we are. All right. Right now we come to the second book is we just give you a little bit more about the technical words which are given in most textbooks.
The remember the two things what are the modes of transfer? We talk about the two types of things direct and indirect transfer, correct. So that's a transfer. It's not truly the type of procedure, but it's the type of socket. Right, right, right. So keep in mind the below knee types of prostheses or socket socket BTV and a total surface barrier.
OK, so. So you say the PTB is one way it depends on the patellar tendon and it. Yeah, and the port itself is bearing is one with which the weight bearing. Remember, you talk about the word yeah, yeah, that I imagine this. It shouldn't be there. This is what type of, Uh, nerve transfer is this?
This is a direct mode. Direct was mainly for your below knee, right? Yeah right, right. About the indirect one is what is the more important because you want something very snugly effect, right? And we want it to distribute the load over the entire stump? Right, right. And most of the time nowadays, we don't do most of the above or below, right?
So most of the time certainly be doing this. Yeah so this is an indirect one, no transfer. And it's tell them that it's a is opinion silicone line. Yes and now you need two different forms of suspensions. So the only channel suspensions were bells. Remember 1962, and now you can have vacuum assistance. Yeah, vacuum assistance to you and you can start using if it's there. Yeah, yeah, Yeah.
Yeah now tell me about the pylon shanks. Tell me what you imagine. I'm showing you a photograph. You want the patient to Christopher slap lesion wants to kiss, you want to do this or not? You want to work. Yeah OK, so you want good reason. So let's use this and examine my ideal prostheses will be made of aircraft with aluminum or carbon to make it light.
Yeah, I will want it to have some degree of shock absorption. Use these words earlier. It's a very good option. Yeah, it could have the advanced ones have transverse. Ridiculous all right. So you can feel it right? Then tell me a few words about the prostitute. So do any different types of prostheses?
Yes let's start by saying, like you said. The simplest is a single axis. Yeah then there's something called a locking mechanism. Your stance is locking. So tell dance for. Is it locks? Dance it? Yeah then say, I know that some people are for burn me, which is good for longer limbs.
Yeah, Yeah. Then the more advanced ones now is hydraulic knees, pneumatic polycentric, like you said, and microprocessors. Yeah Yeah. Very difficult to know everything about it. None of us orthopedic surgeons want to know what prostheses, but we need to know some people say, are you happy? So we now just use the tightest single axis and then say, it's like that and 3 is locking.
Yes and then you come to the newer three, which are hydraulic, hydraulic, polycentric and pneumatic pneumatic microprocessor, hydraulic pneumatic, polycentric and microprocessor rubber. So I'm coming to the end. So one more person, thank you very much. Thank you, sir. Thank you. So the last lucky person.
But OK, so tell me about the different types of prosthetic foot nomenclature of that. Can you just start talking about? Prosthetic foot nomenclature, Yeah. What are the types of prosthetic feet, which we have, so let's say a picture showing you. Are they made of carbon fiber or are they made of?
Uh, at least, you know, so far, therefore, the entire process is only dividing into the many parts to just destroy the parts to me and me again, it will be a subject. We had a circuit of suspension we have to fill on. We have got a terminal device and these are the parts. Yeah, terminal device, let's stick to terminal devices has to be the foot right standard. So therefore, when it comes to the foot, you have different types of prosthesis.
Mm-hmm So I'll just tell you and then we come there. So just keep in mind that the more modern feet are all made of carbon fiber. Yeah and if you just keep in mind, if you see these, we see this a lot in the paralympics, you agree. Yeah, Yeah. And it may be shown to you in the exam. So you describe this as a terminal device. You agree because it's terminal.
You say it's a foot. You say it's made out of carbon. You'll say it's called a dynamic response. You remember the three words. Yes and why? And then say it is it has a short and a long keel and this absorbs energy under load. Right? let's go on before that.
The question I ask you is, let's go through few amputations. You have three sections you rightfully said that you have your midpoint, which is your also this. Right? then you have in your hind foot. Just remember lces Liz Franks. Yes, he is a short what would you said? Galchenyuk boy B is to give you an assistant in the end.
So when do you want? We need to know about is midfoot and the science. The question I asked is why do we not do amputations commonly is, like you said, you have two deformities which can happen get iguanas and you get ovaries. So if you get ovaries, you have to transfer your peel-back. If you get equinix, you have to do a labor, right? And just to let in a time, like you said, just for everyone.
What are the prerequisites you need a to posterior artery? You need a heat bed to remember one of what are the disadvantage, the disadvantage of asylum? Get it. One more time one. So that's what he said was migration, peel-back migration. Correct and one more disadvantage. Is it is very bulky, so it's cosmetically depleted.
Yeah, but who does that? OK, thank you, onwurah. Thank you very much. Yeah, very good. Thanks so now we go on is finish. Just for upper extremity. I don't think you need much, but just what I'll say is that just keep in mind, if you're showing a prosthesis, let's say that are three parts of a couple in prostheses.
There's a shoulder part, which is a center of your functional sphere. You have your hand, which is the end extreme end of the functional sphere. So I want you to just remember one word or two words. Shoulder is a center and is an extreme, and the elbow is a caliper. So the three parts of that. And if you're talking about where we amputate once again through risk better, so you're keeping length.
If you're going to do a trans radiant, you go to a junction in the middle and this could always do my open muscular and is very important. They say that in your prosthetic fitting as you start very early. That's the difference. So thank you for us. Thanks very much. I've done so.
Thank you. Ask anyone or any of the senior people want to contribute. Contribute all the seniors. Thank you, Mr mattress sutures. Really, really appreciate all the efforts. But you are giving and I hope the older participant tonight make the best of it. Make notes of everything. Say it really is a perfect answer for all the questions that could be asked about this topic.
It's thank you for us. You clearly gave very good, clear sequence of answers and the right terminology to use, so there's nothing like I could add to it. Definitely oh, thank you. In fact, a lot to learn. Thank you, Sean. Would you like? I think there would be some questions.
Just we just want to reiterate what you've said this, guys. This is gold. You won't find it summarized so well. And so beautifully with phrases or buzz words like that. Please do take note of everything that's been said. Another sentence, which I remember I'm a big fan of using multidisciplinary team in your answers. So a sentence which I would throw in there at the very beginning to buy you time to prepare.
Your answer is to say my approach to an amputation will be to develop a patient centered treatment plan using a multidisciplinary team. Very correct. Very correct. Include your surgeon prosthesis, prosthetic prosthetic service, your physiotherapists, occupational therapists, counselors because the psychiatric issues your nursing team, as well as our broader teams, such as your physicians for managing medical comorbidities and optimizing medical problems and application.
Some factors that would need to be considered as the level of viable tissue and the ability of the patient to manage physically and mentally with the different prostheses that are available, and that just buys you time to then get your resting answer in line. It's a sentence that you should fall out. Always develop one sentence topics that we're correct. I think let's just use the word you need a long, longer amputation stop is your goal?
Yeah, I don't. So thank you very much, everyone. I think if everyone happy, we will end it tonight. We all have work tomorrow morning. So thank you, everyone who took part again to the 58 people who attended, Thanks to all the painters, mvala in particular. And we will see you again next Wednesday with another topic. we haven't decided yet on the topic next week, but.
Segment:0 .
Welcome to. This teaching session of the farc, a group. Preparing for the fastest examination tonight, you have really thank you for everyone who attended. Tonight we have a guest really star guest who is teaching us. He is the mentor of all of us. Mr Maher looks to my father. He is runs.
A lot of activities, really is very busy, but he is very, very well known. Trainer and educator in the UK, he is a consultant from Harlow princess Alexandra Hospital. He's very busy, has very busy practice, but she's also very interested in teaching and training. He he runs the Royal College of England. Fast course.
Very well known and recommended course. And we all attended a lot of most of the mentors here have attended this course, I attended myself very good commended. You can always guys find it here on this website, doctors Academy. And he's also takes part in a lot of education activities related to the farc, including the well-known Cambridge FARC schools run by orthopedic Research UK.
He's been here with us supporting our group since we started and. We are very pleased to have him with us tonight, so I will. Over to you, Mr Maddox, from to start. Thank you very much. So for this introduction for us. And so this topic is prosthetics.
But actually, it is. Amputation and. And prosthetics. Uh, sorry, I just. Can I sorry my screen, I can't I can't get it forward just a minute.
Yeah, that's fine. That's fine. So while Mr. Meyer looks on mobile, is working on this. We will. This is very useful presentation and it's presented in courses in the UK and it's very, very useful. And the best way to run it is sort of simulated or type of Viber question and answer. And then we will give you the answer afterwards, so we will encourage you to take active part.
So please, anyone interested in being taking part of the hot seat, please raise your hand or send the message the chat box so I can allocate you an next opportunity. Oh, great. So I've got it now. So basic topics like this are important is because these topics like amputation, prosthetics, genetics, orthotics.
As you agree, we don't discuss in the copy room. We don't discuss day to day. Unfortunately, as you know, and all the senior mentors would have told you that these topics unfortunately are part of our syllabus, so I'll try to keep it simple. Those of you are giving the exam in 10 days, you can get the knowledge from this to keep it simple. That's great. Those who are giving it later on, once again, it's a difficult topic to get from books, so I'll try to simplify it.
So basically, the plan of the talk will be let's talk about indications and nomenclature, correct words for things which we don't normally use. Then we go to surgeon factors. So it will be the ideas, stump, idea, length, et cetera then we'll be prosthetic factors and then problems and complication and less common amputation. So let's start.
We're asking each other. Ask someone. So, Ibrahim, are you still with us? Brahim, yeah, yeah, Yeah. So, Ibrahim, you are through with Mr. Mahalakshmi mvala for a question, please. Yeah OK.
So this is your basic science favour, and I'll start with a few questions. Let's start with the first one. What do you understand, bioprosthetic? Or a prosthesis? A birth is an external device helping in replacing body parts or replacing body function. OK, that's fine. And if you're shown in the Viva and once again, it's your basic science.
You will be shown a picture of a really open fracture with the vascular injury. And the question then comes to you is what will you do for this patient? Really like to do a limb salvage? Or would you like to do an amputation? And how will you make your decision? What do you say for that? Yeah actually, this is a matter of debate in the literature.
But the most commonly used decision is use of this mangled extremity, which will help the surgeon to take the decisions. But tell me about it is 4 components. The first part is shock and awe. Eight of the patients below then 30 from 30 to 50 more older than 50 and the shock. But they are above 90. Transient responder or permanent and responder.
Then the state of ischemia of the limb. If there is a pulse or the second stage is bas status, but the limit is still warm and there is a prolonged intraoperatively fell. And the last stage that is called this is called the 3 is pulseless since problem within the last components.
OK, thank you. And the next question is the simplest definition would be, of course, this embraces all substitutes for bodily defects, so this could be in any part of the body. Not necessarily. Remember this three words embraces all substitutes for bodily defects. Now, in the nomenclature, generally we talk about below knee above knee, but the correct new nomenclature should be to the bone.
So let's speak now as friends and family, and it'll be to me and to. Rather than knee and hip. Now, us as general orthopedic surgeons, the communists would be trauma and tumor surgery. But otherwise most of the amputations, as you know, are done in the vascular for vascular disease, like Ibrahim rightfully said. You need to do mass.
Just a point, just a little point for the exam. There's a scoring system, which has scores. Don't try to worry about the scores itself. Just try to keep in mind the five headings or headings of a particular score. And then if the examiner asks you, what about the scoring, say I cannot. I cannot recall the score. But what I will do in real life is I will make sure that I look off the score at that time because it's a very vital decision I make so that I didn't know that you made a decision on your mess, as well as with your other colleagues that you want to do an amputation.
All right. In a young person who a trauma surgeon trauma patient, what do you think the patient will come back to work faster with an amputation with multiple of success? You say, like you said, rightfully, I will do a suture removal at about the two week mark. I will use. You agree that you need a good stump.
And when you said good stump, we now need to know what would be the ideal stump to take things forward, right? So you want what is called a shrink sock? Will you remember that? And so you put on a string of sock for a few weeks? Then, of course, it will be taken off that stump so that the prosthesis can be made right. And you will have a temporary prosthesis given to you on which the patient starts putting weight on it, or 25 to 40 out.
Yeah, so not full weight, but that happens. So that's your six week mark, like you rightfully said. Then at the six week mark, the definitive prostheses would have been ready. And then the patient stands for another two weeks and then increases as you and that you happy with that Ibrahim. So what he said was correct. I've just broken it down to be a little more slick. Yeah now let's go back to know what else can I carry on with a wrap?
One more question. Let me go to someone else. OK keep an eye on them again. So now the next question I may ask you is you've decided now, and I want to ask you, what if you have to do a transfer bill or a transfer? Do you always want to preserve length or do you want to go shorter and why?
Yeah, I always wanted to preserve the length because this will decrease the injury expenditure. During the walking. The first reason is the more proximal I go with my amputation. Unfortunately, the patient will have increased oxygen consumption, or you can use the words increased energy expenditure. Stick to 1 whatever you want to use.
Yeah, we agree that one reason and the second reason you say is that I unfortunately, as I go higher in my amputation, the patient's self regulated walking speed. If I remember these four words, self regulated walking speed decreases. So in other words, all of us can walk faster if we want to one day and then we walk slower. You agree. But otherwise, if you go higher.
So if you have a hip, this articulation or a very high transfemoral, that patient cannot go any faster than what he is. So that's call your self regulated walking speed. And there are two reasons you'll give for vision length. One is option consumption, and second is self-regulating walking speed. And then you can show through two graphs to the examiner. So this is it.
And what you said was very correct about energy expenditure. So now if you're asking, we have someone else, thank you, Abraham. Thank you. Thank you. Thank you. Thank you for being the first candidate and for being brave. I'm sure that will pay off.
Thank you for that. Six times. Yes, sir. Oh, it's your trauma, but let's give it to basic science. And because you have a choice and I show you a picture of an open fracture and you've said yes, I would consider amputation or ICU amputation stop. And the question I'm asking you is that you have two choices the mangled foot, and you have a choice of doing a science, which is a true ankle, or you have a choice of doing a trans tibial, which is below knee, right?
You have two choices. Yes the advantages of a science and the disadvantages of a science. So the advantages of science will be a longer stump. And since it is just through the Dome of the telescope, so patients may be able to even walk without prosthesis for a short distance. The disadvantage of science is since the amputation in the heel flap, which we make in the times, depends on the posture military.
So if there is any injury to the posture or if there is any heel pad necrosis, the amputation stump will fail. So that is one disadvantage of. Another disadvantage of science. I'm not recollecting. Now tell me that you, therefore you've said that you would, let's say now give me the advantage of a trance, tibial trance, tibial more options of prosthetic fitting and better fitting of the processes.
What do you mean by better fitting? What is the thing? Patients would like about that compared to the time. So the look of the process is like the normal leg. So the acceptance of the cosmetically. Yes yes, sir. So you wanted it very well. The only thing I'll say for everyone.
The opening? Thing to impress now you had you, could you just discuss two points which were important, like energy expenditure? So I know you felt it was we had discussed it, but try to say it when you're practicing with your colleagues. So the advantage of science is the longer lever arm or to the ends.
I know that with a longer, longer stump, energy expenditure is better and the patient self-regulate is peel-back. So you've already impressed your examiners by something you can repeat all the time. See where we are. So the advantage of science for everyone is that, like krunal said, you can walk on the rest unsupported and in poorer countries, developing countries.
This is done, ok? What is the disadvantage of science? The technical word, what you were trying to say is let's call it fat. Bad migration. Easy to say. Easy to impress. All right. Call the other disadvantages because unfortunately, if we have to put up prostheses on that same socket is bulky.
Hence, it is cost. The word I want you to use ground is cosmetically dispositive. Yes the patient will need a contralateral race. Yes Yes. I would prefer a transtibial advantage would be cosmetically using better prostheses fitting and easier matching side to side. Right?
Yes. But I do know that the range extender may be higher. You know, you keep it like that. So we have to get it. Yes, sir. Right now, this next question to you. I'm going to ask you that once again, you have a proximal tibia fracture, OK, and you made a decision to amputate.
You have two choices. You can do a knee or you can do a transfemoral, which is above you. OK these are advantages and disadvantages. Start with a true knee. What is the advantage of a truly stay there. I'll ask you one more question. Yes, so let's go through it. If you go through knee, that advantage up like we said energy expenditure and said clearly walking speed, then you say, because of the bulbous shape of the stump, yes, get a better stability.
And therefore, for those patients who may be sitting more because they are bilateral, it may be to agree. We go very high slap lesion. You know, it's a difficult point to stabilize. What is the disadvantage of three knee? It's very clear that cosmetics you cannot get because the knee joint will be at a different level. So cosmetically this people use the word asymmetry of knee joint.
And you can also say that in a rest right for giving length, which you and me want to use, that we may have gone through bad tissue use already and that will lead to more healing. So that's another reason to consider happy with that. Yes yes, sir. Epicondyle last thing for you. Yes, sir. Tell me what would be your ideal length for a below?
For example, I'm showing your picture. Now Imagine that your basic science and I show you a picture of a stamp and where do you want to cut this ball? It's a bill. What is your ideal length? So I'm not able to see any picture. No, no.
I'm just asking. OK, so ideally, bill, I would like to take the roughly 12.5 to 17.1 length away from what point I order. The other way to take is like for every 30 centimeters of height, I'll keep a 2.5 centimeters of length. OK, good. And so the stock might say, I would always want to have a longer lever.
Ok? that same reasons which we said anything to and speak and then say, however, any length in the body. I want to make sure that there's space for any available components cosmetically. That would be OK. And then say in my transtibial list, remember for everyone, for you and everyone, if you don't mind, there's something called a 5 inch rule.
The 5 inches is 5 inches below the knee, joint five inches. OK exactly what you said, which was 12% All right. Yes, sir. Yes everyone wants to remember something because you remember so the number is 5 inches below the knee or below five inches above the transformer. And you tell the examiner, I do know, however, the bare minimum would be to gain my attention.
It makes sense. Yes Yes. Yes OK, now then say tell me about the soft tissue coverage. What? how are you going to do with a soft tissue in your body? So what they see in trauma situations is that if you have recognized the pre-op X-ray as a severe serious bodily injury with a fibula and the fibula was going to be separated apart, then your amputation, you can still put us in this body screw.
Yes at the level of amputation so that the weight bearing is better for the patient. But just out of interest, it's a good thing to know for the group. So they stay there for a moment or not. So, yes, everyone with the posterior slap diameter plus centimeter. Most of the time, tell the examiner, I know I will have to do the fibula of 1 centimeter shorter than the tibia.
But however you say for trauma patients, there's something called a platform theory whether people have the same level. Then say if there was preoperative interosseous membrane disruption, then I may consider us in this moving screw. All right. Is this ok? Just keep in mind, the best answer would be just say you need to be five inches above the knee joint, OK, so that's your level, like you said, so five inches above your knee joint now, ok?
Is that suppose you have told me that you want to make it keep linked? Is that right? You always want to preserve? What did you make it so disturbed that you're just about 2 inches above the knee joint? Is that acceptable or is that not good? Let's go to it now. Stay there and I'll just go through it.
So for everyone, the best answer would be, like you said initially when you started, you need 50% to 70% of the female needed. The best answer to give is a 5 inch rule, like I told you, is 5 inches above the knee joint. Then say, however, you cannot be less than three inches above the knee joint and the knee. The reason for this is exactly like we had discussed earlier that you need for your knee component, right?
So if your knee component will be below the other knee and will be cosmetically displeasing and you cannot do that. All right. So the bare minimum is 3 inches above the knee jerk. The next answer you have to give is how short can you be? So I suppose you have a very severe injury to the mid femur. We always want to preserve length, but what length do we need?
And the answer is about 2 inches below the lesser tuberosity or two inches of egawa is needed for it to behave like this again. The reason for the maximum why you were not less than 2 inches again, the reason. So yeah, which one? The three inches is because of the knee prosthesis, right? Correct Yeah. But why we don't want to remove a huge amount of FEMA is that you need some bare minimum of the femur before a stump can be put on.
Right? and that bare minimum is supposed to be 2 inches. Let's keep that in mind. You need two inches of your femur way to behave like a transfemoral. Unfortunately, if you have such a short femur and it behaves like her hip dysplasia, OK, you move on. So what now you need to know until the examiner, I know there are some prerequisites for a trans debate, so the prerequisite of the bill will be we need to have full knee extension.
And you need to have 70 degrees of flexion possible. Otherwise you shouldn't be doing amputation. And can you tell me, abdulkareem, you know, any requisites for a transfemoral? In other words, we want to know that there's no pre-existing problem where the patient cannot have an amputation to the people, like you said, free range of movement of the hip. And if at all, you cannot have a fixed flexion deformity of more than 10 degrees.
Yes, and you cannot have a fixed abduction deformity that can be used when you remember that a two year degree cannot have more than that. Great So. One more question for you, and then we'll move on. What you want the soft tissue coverage to be, what is your ideas? Did you go?
It was skin, you mean any better word you want to use? Can you see the world through thick skin? That's what you're saying. You need a full thickness skin color. Right? and you need a muscle mass cover. Yeah Yes. OK, very good. So I'll just tell you for you and for everyone.
What are you going to tell the examiner? So so far, just to recap, we've talked about the indication. You talked about the best stump. We've talked about length. And now we are coming to soft tissues. So you tell the examiner that my ideal stump would be mobile with a non-southern. Do you remember that aberrant muscle mass covered with full thickness skin?
And the reason is that it should be able to tolerate, share and redistribute load to the bill. So everyone, I'll just repeat, it is a good statement to make. I want a mobile non-actor in muscle mass covered with full speaking skin, which is able to tolerate share and it distributes low to the bone. All right. So what you said was right, just a few better words. Yeah, Yeah.
Yes thank you very much. Thank you, Mr. I think we'll move to the next one. Yeah really? Next question that if you had to this way, everyone, the muscle repair. Remember, there's something called my opacity and my body since. And tell the examiner that, yes, I will do a combination of both.
If you have to do a mile lusty moment. What tension will you put that out? How will you decide the tension for a mile plus? So the best you say, I want it to be done at the resting status, is that what you mean? So you don't want to join to be in flexion or extension or abduction reduction. So it's a mild blast done at the resting status of that joint, and it should be done without excessive flexion or extension or values vary so that you're not putting it a new contractures.
That's that's good. And just for everyone. If you do, there's something called the abductor lurch, and you avoid that by doing a mild disease by your abductors, you attach onto the distal femur and tell the examiner, if you're talking about a transfemoral that I do this because I want to prevent the abductors from giving the patient what is called an abductor urge.
All right. Moment happy with that. Yes thank you. Thank you. Now, tell me. Now we are moving on, and I'm going to ask you a question. Tell me at the basic science level, what is the use of a prosthesis in trying to transfer load? Or do any different types of load transfers in amputations and prosthetics?
It's not going to be asked like I ask you, but it's good to have that information because you it'll score you points because you may be now showing a prostheses and you want to talk about it. All right. So let me tell you something, and then I'll ask you another question. So for everyone. Say that there are two types of law transfers when you put on a prosthesis, say the first one is called a direct load transfer and that's called end bearing.
And the second type is called indirect load transfer. And the other word for that is total contact. So when you repeat that moment for me, the two types of Yes no transfer in varying and total contact, direct and indirect, so direct and bearing interconnect. Now that I've given you a clue, can you tell me in which type of prosthesis you have a direct load transfer or in which type of amputations, or which type of amputations in the body or through get and you need a direct load transfer, direct load transfer also?
Well and bearing happens when I as a surgeon or you as a surgeon, do a through knee or through ankle, through a joint and then say in this condition, the metaphysics is wide. Is that correct? You have a wider metamorphosis. You have a larger surface area. You agree you have a. The Young's modulus of cancellous bone is less stiff than particular bone.
Agreed and hence, you need this bone or this end of the stump can directly take the load. Yeah, so that's called direct load transfer. So just repeat it again for me. How are you going to formulate this answer? So what do you understand about direct load transfer? In which conditions do you get an indirect load transfer? Well, once again, it's a difficult question, but tell me how you formulate it.
That's fantastic. Very good. So hence you will use an indirect load transfer. Yeah, they're very good. So let's just go through it again for you exactly what you said. Plans to build transfemoral the terminal surface is not capable of accessing the load because you said narrow. Correct and bonus.
Yeah and hence you will use an indirect load transfer and you tell the examiner I will need a very snug fit so that the load is dissipated around, not just the end around the entire prosthetic stuff. We get happy with that. So the more you start by saying phantom pain, phantom pain is a pain that you have at the park, which is removed, then you have rescued limping and you have distressing thing.
OK so in other words, pain like this is psychologically. There's neuroma. And then you talk about contractures. Infection then you talk about bony prominences, like you said, ulcers break down and bony from. And then you have your problem, get very good hyperplasia. OK so happy with that moment I asked you, I asked you the most, most difficult questions, so but I hope now you know this when it comes to start talking about the procedure.
Thank you very much. Yeah, Yeah. Different parts of the prosthesis. Our practices would have just for everyone. Let's remember these are all words that you need to know they every post is given to another subject, which is, yeah, yeah, you'll have a suspension mechanism of some sort. Correct what you said.
So suspension, this is all in the 1960s. Should you just to show that you need some method of suspending your sock it onto the body? All right. All right. You said the word which I wanted, which you said the correct part, but let's all of us use the word pylon. Yeah then you have some degree of the city of afoot.
Yeah and you have a mechanical knee jerk. So it's going to be for everyone to do it. Suspension is a socket, a suspension mechanism. This is a pylon and there's a foot and a mechanical egawa. Now, tell me, remember when he started talking? I remember you've amputated the stitches, taking a more prostheses giving you. Right? next thing I want to tell you is the minute, of course, photograph showing you the word should be, is this a preparatory prosthesis or is it a definite prosthetic, right?
So if this were ever shown to you, what are you going to say? It's a definite prosthesis. Well, let's use that word from now on. So most of the time is different. And what do you mean by that? There are two types definitive and preparation, right? So that's where we are. All right. Right now we come to the second book is we just give you a little bit more about the technical words which are given in most textbooks.
The remember the two things what are the modes of transfer? We talk about the two types of things direct and indirect transfer, correct. So that's a transfer. It's not truly the type of procedure, but it's the type of socket. Right, right, right. So keep in mind the below knee types of prostheses or socket socket BTV and a total surface barrier.
OK, so. So you say the PTB is one way it depends on the patellar tendon and it. Yeah, and the port itself is bearing is one with which the weight bearing. Remember, you talk about the word yeah, yeah, that I imagine this. It shouldn't be there. This is what type of, Uh, nerve transfer is this?
This is a direct mode. Direct was mainly for your below knee, right? Yeah right, right. About the indirect one is what is the more important because you want something very snugly effect, right? And we want it to distribute the load over the entire stump? Right, right. And most of the time nowadays, we don't do most of the above or below, right?
So most of the time certainly be doing this. Yeah so this is an indirect one, no transfer. And it's tell them that it's a is opinion silicone line. Yes and now you need two different forms of suspensions. So the only channel suspensions were bells. Remember 1962, and now you can have vacuum assistance. Yeah, vacuum assistance to you and you can start using if it's there. Yeah, yeah, Yeah.
Yeah now tell me about the pylon shanks. Tell me what you imagine. I'm showing you a photograph. You want the patient to Christopher slap lesion wants to kiss, you want to do this or not? You want to work. Yeah OK, so you want good reason. So let's use this and examine my ideal prostheses will be made of aircraft with aluminum or carbon to make it light.
Yeah, I will want it to have some degree of shock absorption. Use these words earlier. It's a very good option. Yeah, it could have the advanced ones have transverse. Ridiculous all right. So you can feel it right? Then tell me a few words about the prostitute. So do any different types of prostheses?
Yes let's start by saying, like you said. The simplest is a single axis. Yeah then there's something called a locking mechanism. Your stance is locking. So tell dance for. Is it locks? Dance it? Yeah then say, I know that some people are for burn me, which is good for longer limbs.
Yeah, Yeah. Then the more advanced ones now is hydraulic knees, pneumatic polycentric, like you said, and microprocessors. Yeah Yeah. Very difficult to know everything about it. None of us orthopedic surgeons want to know what prostheses, but we need to know some people say, are you happy? So we now just use the tightest single axis and then say, it's like that and 3 is locking.
Yes and then you come to the newer three, which are hydraulic, hydraulic, polycentric and pneumatic pneumatic microprocessor, hydraulic pneumatic, polycentric and microprocessor rubber. So I'm coming to the end. So one more person, thank you very much. Thank you, sir. Thank you. So the last lucky person.
But OK, so tell me about the different types of prosthetic foot nomenclature of that. Can you just start talking about? Prosthetic foot nomenclature, Yeah. What are the types of prosthetic feet, which we have, so let's say a picture showing you. Are they made of carbon fiber or are they made of?
Uh, at least, you know, so far, therefore, the entire process is only dividing into the many parts to just destroy the parts to me and me again, it will be a subject. We had a circuit of suspension we have to fill on. We have got a terminal device and these are the parts. Yeah, terminal device, let's stick to terminal devices has to be the foot right standard. So therefore, when it comes to the foot, you have different types of prosthesis.
Mm-hmm So I'll just tell you and then we come there. So just keep in mind that the more modern feet are all made of carbon fiber. Yeah and if you just keep in mind, if you see these, we see this a lot in the paralympics, you agree. Yeah, Yeah. And it may be shown to you in the exam. So you describe this as a terminal device. You agree because it's terminal.
You say it's a foot. You say it's made out of carbon. You'll say it's called a dynamic response. You remember the three words. Yes and why? And then say it is it has a short and a long keel and this absorbs energy under load. Right? let's go on before that.
The question I ask you is, let's go through few amputations. You have three sections you rightfully said that you have your midpoint, which is your also this. Right? then you have in your hind foot. Just remember lces Liz Franks. Yes, he is a short what would you said? Galchenyuk boy B is to give you an assistant in the end.
So when do you want? We need to know about is midfoot and the science. The question I asked is why do we not do amputations commonly is, like you said, you have two deformities which can happen get iguanas and you get ovaries. So if you get ovaries, you have to transfer your peel-back. If you get equinix, you have to do a labor, right? And just to let in a time, like you said, just for everyone.
What are the prerequisites you need a to posterior artery? You need a heat bed to remember one of what are the disadvantage, the disadvantage of asylum? Get it. One more time one. So that's what he said was migration, peel-back migration. Correct and one more disadvantage. Is it is very bulky, so it's cosmetically depleted.
Yeah, but who does that? OK, thank you, onwurah. Thank you very much. Yeah, very good. Thanks so now we go on is finish. Just for upper extremity. I don't think you need much, but just what I'll say is that just keep in mind, if you're showing a prosthesis, let's say that are three parts of a couple in prostheses.
There's a shoulder part, which is a center of your functional sphere. You have your hand, which is the end extreme end of the functional sphere. So I want you to just remember one word or two words. Shoulder is a center and is an extreme, and the elbow is a caliper. So the three parts of that. And if you're talking about where we amputate once again through risk better, so you're keeping length.
If you're going to do a trans radiant, you go to a junction in the middle and this could always do my open muscular and is very important. They say that in your prosthetic fitting as you start very early. That's the difference. So thank you for us. Thanks very much. I've done so.
Thank you. Ask anyone or any of the senior people want to contribute. Contribute all the seniors. Thank you, Mr mattress sutures. Really, really appreciate all the efforts. But you are giving and I hope the older participant tonight make the best of it. Make notes of everything. Say it really is a perfect answer for all the questions that could be asked about this topic.
It's thank you for us. You clearly gave very good, clear sequence of answers and the right terminology to use, so there's nothing like I could add to it. Definitely oh, thank you. In fact, a lot to learn. Thank you, Sean. Would you like? I think there would be some questions.
Just we just want to reiterate what you've said this, guys. This is gold. You won't find it summarized so well. And so beautifully with phrases or buzz words like that. Please do take note of everything that's been said. Another sentence, which I remember I'm a big fan of using multidisciplinary team in your answers. So a sentence which I would throw in there at the very beginning to buy you time to prepare.
Your answer is to say my approach to an amputation will be to develop a patient centered treatment plan using a multidisciplinary team. Very correct. Very correct. Include your surgeon prosthesis, prosthetic prosthetic service, your physiotherapists, occupational therapists, counselors because the psychiatric issues your nursing team, as well as our broader teams, such as your physicians for managing medical comorbidities and optimizing medical problems and application.
Some factors that would need to be considered as the level of viable tissue and the ability of the patient to manage physically and mentally with the different prostheses that are available, and that just buys you time to then get your resting answer in line. It's a sentence that you should fall out. Always develop one sentence topics that we're correct. I think let's just use the word you need a long, longer amputation stop is your goal?
Yeah, I don't. So thank you very much, everyone. I think if everyone happy, we will end it tonight. We all have work tomorrow morning. So thank you, everyone who took part again to the 58 people who attended, Thanks to all the painters, mvala in particular. And we will see you again next Wednesday with another topic. we haven't decided yet on the topic next week, but.
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