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Osteotomies around the Knee for Orthopaedic Exams
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Osteotomies around the Knee for Orthopaedic Exams
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Language: EN.
Segment:0 .
It will to be able to see this presentation in the YouTube channel. As for us, we'll be posting this later on. As I said, my name is Amjad madani. I am based in Ireland in Dublin and your presenter will be Omar Zubair.
Omar is one of the most recent also be the emphasis. Intercollegiate exam. And he achieved this in April, and he is one of the candidates, one of the mentors in the group. He's working in University Hospital in Birmingham. His talk is mainly around about the osteotomy around the knee, and I cannot emphasize how important is this topic?
And Omar, you are online. Sorry for the delay regarding this presentation. Start up. OK, so I'm going to focus on the topic of the osteotomy is around the knee. It's very kind. My name is a Muslim country University Hospital of Birmingham. And yet next, please.
So I gather that most of us do have some basic knowledge about the osteotomy. It's a very important topic in the sense that we sometimes ignore this topic when we are preparing, but it's an easy topic if it comes across to you guys in the exam. So let's start osteotomy is ramdani. It's an old concept. It was introduced in the 60s and a lot of people were doing it.
There was a lot of data published in those days, but then, with the advent of the knee replacements total as well as the units, this topic got out. Fashion people shied away from this topic and they were not doing that much. Hence, it was not popularized until 1990s, when this concept gained another appreciation by the especially by the work done in the European centers. And that's how the topic got introduced.
And a recent Royal College suggestion regarding this concept has included us to be a part of this discussion. Now, going back to the discussions, as we all know, it's most common indication is the isolated immediately, OK. And I have intentionally put the tibial union. I will come back to this particular reason, especially at the end of this discussion.
You will see why it has been put it ligaments and stability. More specifically, the vastness, instability or the lesions or the osteogenic resolved. All various indications to perform the osteotomy around the knee joint could be intra or extra articular or could be combined, in particular, always challenging. As we all orthopedic surgeons know, anything involving the joint is difficult, and extra articular is taken as a relatively easy option, though, is not always.
And there are various techniques I'm getting next, please. Going back a little bit to the table union, as I mentioned in my previous light, Bill Allen is very specifically related to our discussion today. A brief background knowledge of which I'm sure all of us know is healing an abnormal position. It could again be in traject article, or it could be a combination of both.
The most important bit of here, which you guys have to keep in mind and obviously express this, particularly in the exam, is that it can cause angulation rotational component, translational element, as well as issues with the length. And it can cause pain, deformity, functional deficiency and arthritis in the long run. I won't emphasize any further on the Civil union, but as I said earlier, we will come to this point in the end.
Now you got a patient which has got medial sided knee osteoarthritis. How are you going to assess it? The first thing in the exam I will obviously mention about taking a history and in the history I will be talking about the pain. Now, I can't emphasize any further about the element of pain in this regard, because if someone comes to you with a mild bit of pain which is well-controlled with analgesics or the pain is not stopping the person doing his activities of daily living or his profession or his any other activities that many symptoms are not worth any surgical intervention.
So you have to make sure that either the examiner is in giving you the indication that the pain is bad enough or you are showing it to the examiner that you want to know that the pain is bad enough. Obviously, you need to know about the past medical history. Social history, smoking, very important, as you will be aware of, the fact that most of the osteotomy are breaking a bone and then letting it heal. So smokers bones not heal very easily.
And patient expectation that is another important element of our assessment. Someone who is expecting to go back to his very high level of activities or someone who is not able to tolerate a bit of pain is not a very ideal candidate for these kind of procedures. After taking history, I will focus on my clinical assessment, which would involve assessment is a generic term, which will obviously involve almost everything that you can think of about assessing a limb, the length, the rotation, the angulation, any problems with the joints above or below.
Any arthritis, anywhere else. We strength the neuromuscular condition or any vascular issues. Next is the radiological assessment, which is appropriate radiology. That's the buzzword that one needs to say over there, which is the x-rays and x-rays could be a stress few x-rays. Obviously, the baseline x-rays are the AP, the lateral, the skyline views CT scan of ground and MRI scan to assess the extent of the joint involvement.
So once we have made a brief assessment of how your patient is looking like, then obviously we'll proceed to our next step. Next, let's focus on the bit of the basic concept, which I would take it as a bit of the in-depth knowledge of what we are talking about. So for someone to be aware of the potential of the femoral head is taken as the center of the health center of the knees, the midpoint of the line connecting the two spines, the medial and the lateral spines central of angle is obviously a joint center as well, which is the midpoint of the Kessler height, as well as the width and the mechanical axis versus anatomical axis of the femur and tibia.
A very basic concept, which I am aware of us would be aware of this and mechanical axis of the lower limb, which is the weight bearing. Another name given to that is the weight bearing line, and we will come to it in the next few slides. We have got some pictures where we can very quickly go through these basic things. Next, please. So here we can see for just four.
Recapitulation the line. The lines which are drawn from the center of the head to the center of the femoral, head to the center of the knee and going all the way up to them, to the boutella joint and the anatomical axis, which are the anatomical axis. Are the lines going through the shaft of the femur and the tbm? Next slide, please. There is a bit more information in the coming slides, which you can see mechanical.
This is a very commonly asked concept, which I myself was asked and very simple, straightforward definition a straight line from the center of the hip to the center of the ankle, and that is the weight bearing line. It is equal to the weight bearing line. All our discussion is it just passes through the center of the knee. That's the normal bit, but we will find a lot of variations.
Different studies have given us different values and obviously pathologies the abnormal version of the normal thing. Just think of how you calculate how you assess the anatomical axis. Tip of the greater traject to the center of the femoral condyle distally mechanical axis is central of the head to again the center of the knee joint. And as far as the TBS concerned, both the mechanical and the anatomical axis are they are so close to each other that they can be reciprocally taken as one line.
Next, please. Now, that's the long view, which is, as we mentioned earlier, appropriate investigations, so this is part of the appropriate investigations. Just looking at the knee joint, you can never assess the true picture of the limb, assess the limb alignment.
You need to have either the long leg x-rays or you can do a CT scan of gram to see what is the situation in terms of the alignment. Please do remember this is the alignment of any limb is a 3D deformity and we do an X-ray. We are just looking at a 2D picture of a 3D object, and it just gives you an idea about what the frontal deformity, which is again, a coronal deformity.
Looking at the lateral views gives you only the surgical deformity, which is important, but but not that important in this particular discussion. And there are elements of rotational deformity which are very difficult to be assessed or even measured or even corrected. In particular, surgery people have tried talking about it and people have tried addressing it, but it is a technically challenging issue.
Next is no going back. Every one of us will. Whenever we see a medial sided knee osteoarthritis problem, we will straightaway jump to the right side of the top of this slide, which is the knee replacement. And some of us will say, OK, maybe unique, and very few of us will mention about the history of that's why I have put it the other way around and histo versus unique versus knee replacement and replacement.
It also gives you an idea about the age and the activities of the patient. Now, the reason that I have to be honest chosen this topic was a commissioning guideline by the Royal College of Surgeons in London. They have suggested that one can consider hasto in a selected patient groups. We will come to this in a bit of detail in the coming few slides.
What that selected patient group is. How do I identify that the patient, which I am dealing with, falls in one of that selected group and what the patient's expectation and what my expectations should be? Now what it is just I have just put the I've just literally copied the guidelines from the Royal College site. Over here, there's the moderate to severe knee pain, which is not controlled by the non-surgical management, which we all know, like analgesics, physiotherapy or the bracing.
And they have put it as three months time and there should be a very similar alignment. They have quantified it how much someone was asking about this question, I think earlier. And again, the threat level of arthritis, I mean, grading of arthritis should be grade 1 to 3 and it should be unique compartmented, though there is a talk about having arthritis in the PFG area as well.
We will come to it because there are some studies which address this issue saying people have done in people with of mild PFO and they have got good results as well. And the most important young patient. Uh, we will come to this bit as well that what is the definition of young patient? And again, just to summarize that the basic technique over here is we are actually trying to unload the medial compartment, which is the disease compartment to reduce the pain and delay the TKR.
So this was the one line, which I think can make a huge difference when you are sitting in an exam in front of the examiners. If you say this single line sentence, I believe that conveys a lot about your thought process going on regarding the management of a medial sided knee arthritis in a young patient. You are unloading the medial compartment, you are reducing the pain, you are not eliminating the pain and you are delaying the TKR.
You are not avoiding it altogether. So that means when you talk to your patients, you tell them, I am reducing your pain, but I cannot cure it. You will have some element of pain. And I'm delaying this is a time buying measure, only I will I cannot promise that doing this procedure will give you a lifelong relief from arthritis or from your symptoms. You will need at some point.
Knee replacement and there is no good competition. To be honest, there is no good competitive evidence available to suggest. Hysteria is better versus units better versus taste better in young patients, especially, so that's why I have mentioned this. OK next, please. So when you are planning an hischier, obviously you have done your basic workup, which are put in the next slide as well.
So you first of all, you determine the food is our point, which we all know is like 62% or some people say, 63% of the tibial plateau. When you start measuring from the medial aspect and keep going up to the lateral side and wherever you reach up to the 62% mark, that's the food. You have a point. There are different methods. Some people have tried two different methods of assessing the food slap point, which is the point to which your mechanical axes should fall after doing this.
That's the target that we are trying to achieve. Some people have said that we can use mechanical axes and it should be within three to five degrees of the mechanical axilo. Some people have talked about doing an osteotomy and then target is taken against the anatomical axis you are making at anatomical values angle about 8 to 10 degrees and you are trying to put a weight bearing line through the 62 to 66 the various studies.
If you just put a number, there. No there are various numbers. So one of these numbers or even just saying that you are aware of what is Fujii slap point should be more than enough. And another important aspect. We need to be aware of is the joint obliquity, if someone has got a joint line obliquity the process, the procedure becomes quite complex because Hischier does involve a bit of joint level change.
We will come to it in the coming slides. So short the short messages, if there is joint line obliquity present, preferably don't do tibial osteotomy of any kind. Next, please know someone asked about some question about when you do the CT or the arthroscopy area. Generally speaking, when I'm doing a workup, I will prefer to have to start with weight bearing epi lateral in the skyline skyline views.
I don't need to go into the details of this thing that why and what? What, what is the relative importance of all these three views, all standing views, as we know, we have already talked about stresses. Someone has got arthritis. You cannot forget the fact that you may not know a patient will never tell you that the patient might have any ligament injury in the past, which has given him all this problem height because doing all this procedure does alter patella heights to some extent.
Various studies have shown that patella height, whatever kind of procedure you do, patella does alter. So if someone has already had a pathological patella height, patella specifically, that patient is not a good candidate. OK and tibial bone valleys angle, this is a concept which I myself was not aware of until I went to the exam.
So that's an that's an angle which we'll come to it. And it's more specifically important Asian population for some reasons. And obviously, MRI scan and arthroscopy are possible options to work up. If you are suspecting signs of the disease affecting the other compartments within the media compartment, doing arthroscopy is always an option. You can do it on table before planning or as part of your workup.
Preoperatively you can. Some people like the arthroscopy, just map out the lesions and to see if there is anything else that needs to be done. No, I want to de-stress within the year. OK, now that was the tibial valve angle. So what is the temporal bone marrow single is the extra angle between is the difference between the epimysium angle, which is represented over here in the yellow line.
And the red line is showing the mechanical axis of the tibia, which again, as we said earlier, that in tibia, anatomical and mechanical axis, the overlap so closely to each other that they can be taken as one line. So normally this is about 5 to six degrees of the value, and the importance of this value is that measuring this angle gives us a lot of information about my cure of the symptoms. Next slide, please.
So there was a very good study, which was from states where they have shown that if the tibial bone virus angle is up to five degrees or so more than five degrees, then you can literally say that doing an Hischier will correct the. This problem is usually a congenital problem, and it is one of the reasons where one of the indications where we can use the hashtag to address the joint line obliquity.
But again, if someone has got a very severe deformity where they develop one by a single, it's gone up to 15 degrees that must be formed. Proximal tibia is there, then it is kind of a palliative treatment. It is not curative. So that means there will be some symptoms left because you can never achieve a better reduction of the angles.
Now this slide I will put as the gist of all of our discussion today. This is the International Society of arthroscopy and sports medicine people where they have this. They published this in 2004. I knew this thing. I never knew before my exams that this is AI guess, guideline, but someone has told me in a different way.
And I literally spoke for a few minutes on this particular table in my exam, and I think that helped me a lot. So as you can see, they have divided the patients into three groups ideal, possibly ideal or possible groups, and people who are not serious. So you can say this is the indication versus contraindications versus the gray zone in the middle where you may or may not do.
So isolated media lawyer will very quickly go through it. Moderate osteoarthritis age 40 to 60 years. The Scandinavian people, they have stretched across 70 years. And I've seen some papers where people have done and are still doing high tibial osteotomy up until 70 years of age. BMI very important. Less than 30 having a high BMI. Big no.
For any kind of osteotomy. Again, this is a procedure for high demand people. People who have high demand because of any reason, because of their profession, because of their leisure activities and alignment is not severe. Less than 15 decrees against Libyan born were single to five degrees is a good. But as we saw previously, you can go ahead and do it if there is a bit of deformity up to 15 degrees, but you have to tell the patient that we will not be able to achieve much.
There should be nearly any stiffness full run of the knee joint. No, I understand. Everyone should be aware of this. That's the lesion. When rich people get with the ACL injuries or deficient ACL. Obviously, ligament ligaments balance should be good, which means all the ligaments should be working fine nonsmoker.
I think I should have highlighted it much more because this was a question which was very specifically asked to me in the exam as well, that the patient is a smoker. What are you going to do? And last but not the least, your patient is happy to take a bit of pain. So the patient has got pain tolerance. You tell the patient this procedure will never cure your symptoms.
100% can't quantify it. 60 70 80% can give you a number. But the long story short is you will have an element of pain if you are happy to accept. Yes, this is a procedure for you. I don't. I don't think I need to go into further, further these guidelines. You guys can have a go to it later on and it's, yeah, self-explanatory.
So you know how we do, how do we do the job? There are various methods described in literature. Various procedures are performed. I think most of us are aware of the medial opening versus lateral closing osteotomy. I have seen most of the European papers they are saying, suggesting about lateral closing osteotomy. So recently, people are more aligned towards the medial opening osteotomy because of the better work which is available to type osteotomy is another kind of astrologists complex, not very commonly done.
And again, not very commonly asked or expected to be known by the candidates. Now, if you do a bit of permitting, you will see every technique has got good short to midterm results. So there is no technique which is superior than the other. So as a surgeon, whatever I'm comfortable doing, I will do that, that in my opinion, the answer should be. So what is the most important predictor?
You are not doing the osteotomy for a very little deformity or a very severe deformity. So if everything is little bit bad, there is no point doing it, or if something is very severely their level of arthritis, pain levels or obesity, then obviously you're not going to do this procedure. If you talk about the numbers, it's a when you are creating the value, you are trying to create about 8 to 10 degrees well, gets to the anatomical axis.
And if you want to measure it from the mechanical axis, it's about 5 to eight degrees. Again, it's a number. You don't need to remember the exact numbers, even if you just say I will try to create a well-guarded knee that is acceptable few degrees of vulgarity, in my opinion, that is absolutely acceptable. Next place.
So now this is something if you want to know about, if you can remember fine, otherwise just read it and forget it. There was a paper, there's a big, actually quite long follow up. It's a randomized controlled trial by then, by this Agnes kershner, where they have the dynamic loading before and after the history, and just to see when people are doing history or using various techniques, how much the weight is transmitted from medial to the lateral aspect.
We all know that most of the weight passes through the medial side, and less amount of it goes through the lateral aspect of the knee joint. So doing osteotomy and then measuring it, they found that the most important bit over here is the most important combination. The most successful combination was opening a osteotomy. And making sure that post-op the mechanical axilo is passing through the food have a point and you have done the NCL release.
It's a supervision and seal that we release. The people say 50 percent, 60% I don't know the exact amount, but just cutting the MCL. So those were the people when they were tested in the labs. So it was a cadaver. It was not a. These were found to have the maximum amount of load transmission from the medial the lateral who have had these three targets achieved or performed.
And again, another important part over here is slope correction ACL deficiencies. We all know we tend to decrease the tibial slope because of the tendency of the tibia to translate into. Usually, ACL is the main restraint in terms of interior translation, and the right opposite is the PCL deficient use, where you try to increase the tibial slope and doing the osteotomy as you can control the tibial slope.
But again, it is a controversial issue. If asked an exam, I will just say I'm aware increased the tibial slope efficiently. OK next page. What exact technique are you going to use? All you need to know is that there are some techniques available medial opening, wedge, lateral closing wedge or a distal femoral.
There is nothing more than that you guys need to know. The work up, there are three different schools of thought. Coventry noise energy. Everyone has got their own ways of doing it. Now people have developed softwares aware of the software, which is developed in Cumbria region. Anything you say in the exam is fine, as long as you can see that this is a kind of look up, which is actually the calculation of the angles, how much ammunition you need to correct to get a better result.
Benefits of there are different benefits of media opening wedge or the lateral closing wedge of the distal families, which you will see in the next slide, please. Next slide presented just summarized the benefits of lateral closing or the middle opening, as you can see, obviously lateral side, we are always scared of commenting on ulnar nerve sitting very close.
You have to do the fibular osteotomy. You have to literally dislocate the tibia, family, proximal joint and people can have issues in the coming days. TBI becomes shortened with this technique, but the good point the one point is that it's just a unique manner. You cannot correct the deformity in the multiple. So OK, well, we'll come to this point, and then you do these measurements preoperative egawa intraoperatively media opening wedge again, whether do we need a bone graft?
Again, a lot of debates about it, do we need to use? Can do we need to use a bone graft or just leave it alone or just put some bone substitutes? Every technique has got their own pros and cons. There is not no level one study showing that one is better than the other. Again, you can use either one. So if you want to correct the deformity in a unique plane, or you can use to source if you want to correct the pipeliner deformity slightly better in terms of it gives you the unique across the frontal deformity correction, as well as control the tibial slope.
But the bad side is you need a really strong fixation construct, which was the reason that people initially shied away from medial epicondylitis because the constructs were not strong enough. They were not able to take the weight. People have to stay for a long time, non weight bearing. And that created the problems of their own. But these days, there are new constructs available, which are giving good results and allowing early weight bearing as well.
Next place. Now, when the discussion reaches to this level, I'm sure you will yourself realize that you have already passed the exam if you are asked, OK, what kind of fixation are you going to use or how it works? We all know it's a micro version that we want across the splinted zone.
Various techniques historically, people have used cars for this purpose, as well as fixes, staples, fixation plates, angles, table implants, which are very popular these days. What have you? And some people have used a bone graft or bone substitute as a kind of fixation method aid, rather than a true fixation method. Everything has got its own pros and cons.
Pretty simple things. You know, the cylinder cost issues. I don't need to go into that detail at this level with you guys ex fix or staples. Everything is up in the exam. I was asked, OK, what implant are you going to use? I knew just one name that was fixed and I just said, tommo fix. I did laugh.
And he asked, why automatics? And the answer to that is it's rigid. It's long, and it has got the benefit of locking bolt. And it gives you too much fixation. Hence, it is more stable. That's the only thing you need to know. Now there osteotomy that have been described, just need to know the names they still usually Dan Rather. The only indication is in a balcony where you want to convert the Volga into the various names and hear the purpose is to unload the lateral side.
Again, the concept is the same just reversed that it restores the weight bearing line to neutral or bit of within five degrees of tenotomy. Well, guess, and it is converting the tension site to the lateral aspect, which has been reversed in the first instance when it becomes available. Now again, same principle of high TBL lateral closing or media closing is applied to the distal femoral as well would be lateral opening wedge distal femoral osteotomy is better than the mesial closing osteotomy.
These days, this is the latest. Studies have shown that most of the studies have shown that the lateral opening is better. If you have to do, that is the option. But again, there is very limited literature. Very few people have done the medial closing in the distal femur. Most of the people they only do the lateral opening is. And if you are doing very well, you can say the world, I will follow the palace principle.
Which is in the frontal plane. You try to address the anatomical and the mechanical axis, and in the sagittal plane, you only addressed the anatomical axis. There's a big book written by this gentleman, pele, and I don't think it's at our level to discuss or we need to discuss this. No complications, general risks, which you just mentioned, but any other surgery that you do and you say the general risk of all this infection and injury, the nerves of blood vessels, specifically speaking nonunion or union fixation can get long can be lost.
Loss of fixation patella height can be altered. Even patella can be so bloody. People do come back, sometimes having issues with their patella. They were having a nice patella tracking, but the surgeon has a osteotomy which has healed as well. But not the patient has developed anterior knee pain as well as his not happy. Bones can be reduced.
Obviously, when you're doing them, especially if you're doing the opening by the osteotomy bone stock is not very good if you want to do the knee replacement in future, and it becomes a difficult knee replacement if you need to do one. Next, please. OK last slide, don't open the next slide, please. This is the last slide take home message.
This is a simple exam, so guys, please keep it simple. When, when I was asked about this, obviously you will not be asked like, OK, what do you know about osteotomy? Is it underneath the exam will never, ever be a straightforward memory exam. You will be given a picture. So whatever knowledge you have, you have to apply to that.
And even if you have got a very superficial level of knowledge, but if you are applying it, sure you will pass. I still remember it said in the beginning in the letter that FRC is about the breadth of the knowledge rather than the depth. So and I believe in it now after going through this, it's an exam of your thought process. How you are thinking it's not an exam of the nitty gritty is not the exam of the technical aspects.
It's not an exam of how confidently you can do a procedure which no one else can do in the region. It's just an exam of a very simple technique, which is safe, safe and safe. And to do that, you have to practice, practice and practice. I will stop here. Let's go to the questions around the chat. Kindly, you answer one of them.
Atif was saying that what is the rationale of city's can do you? Not again? Yep, go ahead. Open up the marketplace. So if the rationale doing the CT scan is one is a CT scanner gram that gives you more detailed information about not only the alignment, but also the rotation. Because a lot of times and I'm sure you might have come across this scenario that we do the long leg fence and people there standing in various directions in various positions.
They want to stand. And it gives you a very bluffing picture because I myself came across this kind of scenario where we sent a patient for a long leg when he was standing in a position, whatever he wanted or he felt comfortable and the picture was so much, so much falsely benign looking. And then we send the patient back for a CT scan and we got the real measurements, which were like quite different.
So for but sometimes if you are happy that the patient can stand in the proper way and you are happy to have your measurements on the x-rays alone don't need to go for unnecessary radiation. But city's cancer preferred. And again in the exam. I think you need to say this word that I will prefer from this particular reason. And another question from Mohammed.
He says that how much the degree of correction and how we calculate it, I think you went through this. Yeah but then we went through this again. As I said, you don't need to remember the numbers. If you just say 5 to 10 degrees, though, they were not. The question is whether you are calculating those five degrees from. So the report is your reference point. So it will just open a big discussion topic that they can measure it from on the anatomical axis.
No imaging from the mechanical axis. OK, then again, the question if someone tries to ask you a question, there are a lot of questions you can. Well, how do you measure? What is the best way of assessing the mechanical axis? How do you do it? And then you take. There are a lot of other things I don't think at our level in Air Force or any of these things.
I'm going to within like 5 to 10 degrees of the neutral axis, the weight bearing line to assess how to assess the arthritis in the latter compartment and joint. Would you score? Yeah, I mean, as I said, if there is a suspicion, again, scoping means an intervention, which obviously you have to put the patient to sleep and then I have just put it as an option.
The better thing is MRI scan. I'm sure all of us are aware that whenever we are having a suspicion or when we are trying to map out the lesions, it depends. If we are trying, trying to do something like someone has got an obstruction necrosis or someone has got an ulcer on the lesion and we want to do something about it. And obviously scoping is better because you may go the or stabilize or do some procedure on the same time.
But if you are thinking about hischier, then MRI scan is better. The options are there, so you just have to use them according to the need of your patient. OK and would you do stress views under? No, I'm not aware of any don't. I mean, if someone has got instability, you can do a simple ball test and be very lucky. You need a very good geologist to kind of, but usually you do it.
Well, to be honest with you, you don't need like a jar for stress. You just do it. No, no, no, no. Not the Department. Now how could I increase the slope? The technique? I mean the. OK, so intra operatively, what people do is they do the osteotomy are done in the troop plane.
The first osteotomy is done as a horizontal in the second osteotomy is done at a slight angulation and that second osteotomy for the medial epicondylitis journey is the one which controls your tibial slope. But as I said earlier, I have some serious doubts that anyone would be asked about this. This I mean, yeah, you can be asked if you're doing very, very well. You could be taken to any levels, but I'm very happy that someone has asked this question because I was thinking about giving a message earlier.
I calculated I faced 32 scenarios during my that two days of examination, which are all of us face. So knowing about 32 topics, if you calculate, it's literally impossible for everyone to know all these minor details of an individual procedure. Again, a procedure which is not done very commonly in our day to day life. Even one of the knee Fellows here or a sports fellow, I'm sure they even don't do more than 20 or 30 in a very big, busy sports injury center live alone that people who are working in the eggheads.
So please do not go into the minor details of things I was looking into. The previous threads and myself have been part of this telegram group when I was studying and other guys were helping us out by guiding us. A lot of people ask a lot of questions and I don't think they would have helped them in the exam. Trust me, exam is all about knowing the basics, playing safe, showing them.
I know my basics, I know my limitations. This is where I stop. This is where I refer. This is where I seek help from my other colleagues and I know the theoretical things I couldn't. I couldn't agree more. I think I think it's very important to on like one in one of your slides saying that the principle of the treatment you and I. But before passing my exam, I was making sure that to say this phrase, the principle of the treatment is to do this, to do this, to do this.
And here, like you said, the principle of the treatment is regarding the promotion of the two that will kind of get the examiner on track there. I don't think this is about details. So the devil is in the details in this example.
Segment:0 .
It will to be able to see this presentation in the YouTube channel. As for us, we'll be posting this later on. As I said, my name is Amjad madani. I am based in Ireland in Dublin and your presenter will be Omar Zubair.
Omar is one of the most recent also be the emphasis. Intercollegiate exam. And he achieved this in April, and he is one of the candidates, one of the mentors in the group. He's working in University Hospital in Birmingham. His talk is mainly around about the osteotomy around the knee, and I cannot emphasize how important is this topic?
And Omar, you are online. Sorry for the delay regarding this presentation. Start up. OK, so I'm going to focus on the topic of the osteotomy is around the knee. It's very kind. My name is a Muslim country University Hospital of Birmingham. And yet next, please.
So I gather that most of us do have some basic knowledge about the osteotomy. It's a very important topic in the sense that we sometimes ignore this topic when we are preparing, but it's an easy topic if it comes across to you guys in the exam. So let's start osteotomy is ramdani. It's an old concept. It was introduced in the 60s and a lot of people were doing it.
There was a lot of data published in those days, but then, with the advent of the knee replacements total as well as the units, this topic got out. Fashion people shied away from this topic and they were not doing that much. Hence, it was not popularized until 1990s, when this concept gained another appreciation by the especially by the work done in the European centers. And that's how the topic got introduced.
And a recent Royal College suggestion regarding this concept has included us to be a part of this discussion. Now, going back to the discussions, as we all know, it's most common indication is the isolated immediately, OK. And I have intentionally put the tibial union. I will come back to this particular reason, especially at the end of this discussion.
You will see why it has been put it ligaments and stability. More specifically, the vastness, instability or the lesions or the osteogenic resolved. All various indications to perform the osteotomy around the knee joint could be intra or extra articular or could be combined, in particular, always challenging. As we all orthopedic surgeons know, anything involving the joint is difficult, and extra articular is taken as a relatively easy option, though, is not always.
And there are various techniques I'm getting next, please. Going back a little bit to the table union, as I mentioned in my previous light, Bill Allen is very specifically related to our discussion today. A brief background knowledge of which I'm sure all of us know is healing an abnormal position. It could again be in traject article, or it could be a combination of both.
The most important bit of here, which you guys have to keep in mind and obviously express this, particularly in the exam, is that it can cause angulation rotational component, translational element, as well as issues with the length. And it can cause pain, deformity, functional deficiency and arthritis in the long run. I won't emphasize any further on the Civil union, but as I said earlier, we will come to this point in the end.
Now you got a patient which has got medial sided knee osteoarthritis. How are you going to assess it? The first thing in the exam I will obviously mention about taking a history and in the history I will be talking about the pain. Now, I can't emphasize any further about the element of pain in this regard, because if someone comes to you with a mild bit of pain which is well-controlled with analgesics or the pain is not stopping the person doing his activities of daily living or his profession or his any other activities that many symptoms are not worth any surgical intervention.
So you have to make sure that either the examiner is in giving you the indication that the pain is bad enough or you are showing it to the examiner that you want to know that the pain is bad enough. Obviously, you need to know about the past medical history. Social history, smoking, very important, as you will be aware of, the fact that most of the osteotomy are breaking a bone and then letting it heal. So smokers bones not heal very easily.
And patient expectation that is another important element of our assessment. Someone who is expecting to go back to his very high level of activities or someone who is not able to tolerate a bit of pain is not a very ideal candidate for these kind of procedures. After taking history, I will focus on my clinical assessment, which would involve assessment is a generic term, which will obviously involve almost everything that you can think of about assessing a limb, the length, the rotation, the angulation, any problems with the joints above or below.
Any arthritis, anywhere else. We strength the neuromuscular condition or any vascular issues. Next is the radiological assessment, which is appropriate radiology. That's the buzzword that one needs to say over there, which is the x-rays and x-rays could be a stress few x-rays. Obviously, the baseline x-rays are the AP, the lateral, the skyline views CT scan of ground and MRI scan to assess the extent of the joint involvement.
So once we have made a brief assessment of how your patient is looking like, then obviously we'll proceed to our next step. Next, let's focus on the bit of the basic concept, which I would take it as a bit of the in-depth knowledge of what we are talking about. So for someone to be aware of the potential of the femoral head is taken as the center of the health center of the knees, the midpoint of the line connecting the two spines, the medial and the lateral spines central of angle is obviously a joint center as well, which is the midpoint of the Kessler height, as well as the width and the mechanical axis versus anatomical axis of the femur and tibia.
A very basic concept, which I am aware of us would be aware of this and mechanical axis of the lower limb, which is the weight bearing. Another name given to that is the weight bearing line, and we will come to it in the next few slides. We have got some pictures where we can very quickly go through these basic things. Next, please. So here we can see for just four.
Recapitulation the line. The lines which are drawn from the center of the head to the center of the femoral, head to the center of the knee and going all the way up to them, to the boutella joint and the anatomical axis, which are the anatomical axis. Are the lines going through the shaft of the femur and the tbm? Next slide, please. There is a bit more information in the coming slides, which you can see mechanical.
This is a very commonly asked concept, which I myself was asked and very simple, straightforward definition a straight line from the center of the hip to the center of the ankle, and that is the weight bearing line. It is equal to the weight bearing line. All our discussion is it just passes through the center of the knee. That's the normal bit, but we will find a lot of variations.
Different studies have given us different values and obviously pathologies the abnormal version of the normal thing. Just think of how you calculate how you assess the anatomical axis. Tip of the greater traject to the center of the femoral condyle distally mechanical axis is central of the head to again the center of the knee joint. And as far as the TBS concerned, both the mechanical and the anatomical axis are they are so close to each other that they can be reciprocally taken as one line.
Next, please. Now, that's the long view, which is, as we mentioned earlier, appropriate investigations, so this is part of the appropriate investigations. Just looking at the knee joint, you can never assess the true picture of the limb, assess the limb alignment.
You need to have either the long leg x-rays or you can do a CT scan of gram to see what is the situation in terms of the alignment. Please do remember this is the alignment of any limb is a 3D deformity and we do an X-ray. We are just looking at a 2D picture of a 3D object, and it just gives you an idea about what the frontal deformity, which is again, a coronal deformity.
Looking at the lateral views gives you only the surgical deformity, which is important, but but not that important in this particular discussion. And there are elements of rotational deformity which are very difficult to be assessed or even measured or even corrected. In particular, surgery people have tried talking about it and people have tried addressing it, but it is a technically challenging issue.
Next is no going back. Every one of us will. Whenever we see a medial sided knee osteoarthritis problem, we will straightaway jump to the right side of the top of this slide, which is the knee replacement. And some of us will say, OK, maybe unique, and very few of us will mention about the history of that's why I have put it the other way around and histo versus unique versus knee replacement and replacement.
It also gives you an idea about the age and the activities of the patient. Now, the reason that I have to be honest chosen this topic was a commissioning guideline by the Royal College of Surgeons in London. They have suggested that one can consider hasto in a selected patient groups. We will come to this in a bit of detail in the coming few slides.
What that selected patient group is. How do I identify that the patient, which I am dealing with, falls in one of that selected group and what the patient's expectation and what my expectations should be? Now what it is just I have just put the I've just literally copied the guidelines from the Royal College site. Over here, there's the moderate to severe knee pain, which is not controlled by the non-surgical management, which we all know, like analgesics, physiotherapy or the bracing.
And they have put it as three months time and there should be a very similar alignment. They have quantified it how much someone was asking about this question, I think earlier. And again, the threat level of arthritis, I mean, grading of arthritis should be grade 1 to 3 and it should be unique compartmented, though there is a talk about having arthritis in the PFG area as well.
We will come to it because there are some studies which address this issue saying people have done in people with of mild PFO and they have got good results as well. And the most important young patient. Uh, we will come to this bit as well that what is the definition of young patient? And again, just to summarize that the basic technique over here is we are actually trying to unload the medial compartment, which is the disease compartment to reduce the pain and delay the TKR.
So this was the one line, which I think can make a huge difference when you are sitting in an exam in front of the examiners. If you say this single line sentence, I believe that conveys a lot about your thought process going on regarding the management of a medial sided knee arthritis in a young patient. You are unloading the medial compartment, you are reducing the pain, you are not eliminating the pain and you are delaying the TKR.
You are not avoiding it altogether. So that means when you talk to your patients, you tell them, I am reducing your pain, but I cannot cure it. You will have some element of pain. And I'm delaying this is a time buying measure, only I will I cannot promise that doing this procedure will give you a lifelong relief from arthritis or from your symptoms. You will need at some point.
Knee replacement and there is no good competition. To be honest, there is no good competitive evidence available to suggest. Hysteria is better versus units better versus taste better in young patients, especially, so that's why I have mentioned this. OK next, please. So when you are planning an hischier, obviously you have done your basic workup, which are put in the next slide as well.
So you first of all, you determine the food is our point, which we all know is like 62% or some people say, 63% of the tibial plateau. When you start measuring from the medial aspect and keep going up to the lateral side and wherever you reach up to the 62% mark, that's the food. You have a point. There are different methods. Some people have tried two different methods of assessing the food slap point, which is the point to which your mechanical axes should fall after doing this.
That's the target that we are trying to achieve. Some people have said that we can use mechanical axes and it should be within three to five degrees of the mechanical axilo. Some people have talked about doing an osteotomy and then target is taken against the anatomical axis you are making at anatomical values angle about 8 to 10 degrees and you are trying to put a weight bearing line through the 62 to 66 the various studies.
If you just put a number, there. No there are various numbers. So one of these numbers or even just saying that you are aware of what is Fujii slap point should be more than enough. And another important aspect. We need to be aware of is the joint obliquity, if someone has got a joint line obliquity the process, the procedure becomes quite complex because Hischier does involve a bit of joint level change.
We will come to it in the coming slides. So short the short messages, if there is joint line obliquity present, preferably don't do tibial osteotomy of any kind. Next, please know someone asked about some question about when you do the CT or the arthroscopy area. Generally speaking, when I'm doing a workup, I will prefer to have to start with weight bearing epi lateral in the skyline skyline views.
I don't need to go into the details of this thing that why and what? What, what is the relative importance of all these three views, all standing views, as we know, we have already talked about stresses. Someone has got arthritis. You cannot forget the fact that you may not know a patient will never tell you that the patient might have any ligament injury in the past, which has given him all this problem height because doing all this procedure does alter patella heights to some extent.
Various studies have shown that patella height, whatever kind of procedure you do, patella does alter. So if someone has already had a pathological patella height, patella specifically, that patient is not a good candidate. OK and tibial bone valleys angle, this is a concept which I myself was not aware of until I went to the exam.
So that's an that's an angle which we'll come to it. And it's more specifically important Asian population for some reasons. And obviously, MRI scan and arthroscopy are possible options to work up. If you are suspecting signs of the disease affecting the other compartments within the media compartment, doing arthroscopy is always an option. You can do it on table before planning or as part of your workup.
Preoperatively you can. Some people like the arthroscopy, just map out the lesions and to see if there is anything else that needs to be done. No, I want to de-stress within the year. OK, now that was the tibial valve angle. So what is the temporal bone marrow single is the extra angle between is the difference between the epimysium angle, which is represented over here in the yellow line.
And the red line is showing the mechanical axis of the tibia, which again, as we said earlier, that in tibia, anatomical and mechanical axis, the overlap so closely to each other that they can be taken as one line. So normally this is about 5 to six degrees of the value, and the importance of this value is that measuring this angle gives us a lot of information about my cure of the symptoms. Next slide, please.
So there was a very good study, which was from states where they have shown that if the tibial bone virus angle is up to five degrees or so more than five degrees, then you can literally say that doing an Hischier will correct the. This problem is usually a congenital problem, and it is one of the reasons where one of the indications where we can use the hashtag to address the joint line obliquity.
But again, if someone has got a very severe deformity where they develop one by a single, it's gone up to 15 degrees that must be formed. Proximal tibia is there, then it is kind of a palliative treatment. It is not curative. So that means there will be some symptoms left because you can never achieve a better reduction of the angles.
Now this slide I will put as the gist of all of our discussion today. This is the International Society of arthroscopy and sports medicine people where they have this. They published this in 2004. I knew this thing. I never knew before my exams that this is AI guess, guideline, but someone has told me in a different way.
And I literally spoke for a few minutes on this particular table in my exam, and I think that helped me a lot. So as you can see, they have divided the patients into three groups ideal, possibly ideal or possible groups, and people who are not serious. So you can say this is the indication versus contraindications versus the gray zone in the middle where you may or may not do.
So isolated media lawyer will very quickly go through it. Moderate osteoarthritis age 40 to 60 years. The Scandinavian people, they have stretched across 70 years. And I've seen some papers where people have done and are still doing high tibial osteotomy up until 70 years of age. BMI very important. Less than 30 having a high BMI. Big no.
For any kind of osteotomy. Again, this is a procedure for high demand people. People who have high demand because of any reason, because of their profession, because of their leisure activities and alignment is not severe. Less than 15 decrees against Libyan born were single to five degrees is a good. But as we saw previously, you can go ahead and do it if there is a bit of deformity up to 15 degrees, but you have to tell the patient that we will not be able to achieve much.
There should be nearly any stiffness full run of the knee joint. No, I understand. Everyone should be aware of this. That's the lesion. When rich people get with the ACL injuries or deficient ACL. Obviously, ligament ligaments balance should be good, which means all the ligaments should be working fine nonsmoker.
I think I should have highlighted it much more because this was a question which was very specifically asked to me in the exam as well, that the patient is a smoker. What are you going to do? And last but not the least, your patient is happy to take a bit of pain. So the patient has got pain tolerance. You tell the patient this procedure will never cure your symptoms.
100% can't quantify it. 60 70 80% can give you a number. But the long story short is you will have an element of pain if you are happy to accept. Yes, this is a procedure for you. I don't. I don't think I need to go into further, further these guidelines. You guys can have a go to it later on and it's, yeah, self-explanatory.
So you know how we do, how do we do the job? There are various methods described in literature. Various procedures are performed. I think most of us are aware of the medial opening versus lateral closing osteotomy. I have seen most of the European papers they are saying, suggesting about lateral closing osteotomy. So recently, people are more aligned towards the medial opening osteotomy because of the better work which is available to type osteotomy is another kind of astrologists complex, not very commonly done.
And again, not very commonly asked or expected to be known by the candidates. Now, if you do a bit of permitting, you will see every technique has got good short to midterm results. So there is no technique which is superior than the other. So as a surgeon, whatever I'm comfortable doing, I will do that, that in my opinion, the answer should be. So what is the most important predictor?
You are not doing the osteotomy for a very little deformity or a very severe deformity. So if everything is little bit bad, there is no point doing it, or if something is very severely their level of arthritis, pain levels or obesity, then obviously you're not going to do this procedure. If you talk about the numbers, it's a when you are creating the value, you are trying to create about 8 to 10 degrees well, gets to the anatomical axis.
And if you want to measure it from the mechanical axis, it's about 5 to eight degrees. Again, it's a number. You don't need to remember the exact numbers, even if you just say I will try to create a well-guarded knee that is acceptable few degrees of vulgarity, in my opinion, that is absolutely acceptable. Next place.
So now this is something if you want to know about, if you can remember fine, otherwise just read it and forget it. There was a paper, there's a big, actually quite long follow up. It's a randomized controlled trial by then, by this Agnes kershner, where they have the dynamic loading before and after the history, and just to see when people are doing history or using various techniques, how much the weight is transmitted from medial to the lateral aspect.
We all know that most of the weight passes through the medial side, and less amount of it goes through the lateral aspect of the knee joint. So doing osteotomy and then measuring it, they found that the most important bit over here is the most important combination. The most successful combination was opening a osteotomy. And making sure that post-op the mechanical axilo is passing through the food have a point and you have done the NCL release.
It's a supervision and seal that we release. The people say 50 percent, 60% I don't know the exact amount, but just cutting the MCL. So those were the people when they were tested in the labs. So it was a cadaver. It was not a. These were found to have the maximum amount of load transmission from the medial the lateral who have had these three targets achieved or performed.
And again, another important part over here is slope correction ACL deficiencies. We all know we tend to decrease the tibial slope because of the tendency of the tibia to translate into. Usually, ACL is the main restraint in terms of interior translation, and the right opposite is the PCL deficient use, where you try to increase the tibial slope and doing the osteotomy as you can control the tibial slope.
But again, it is a controversial issue. If asked an exam, I will just say I'm aware increased the tibial slope efficiently. OK next page. What exact technique are you going to use? All you need to know is that there are some techniques available medial opening, wedge, lateral closing wedge or a distal femoral.
There is nothing more than that you guys need to know. The work up, there are three different schools of thought. Coventry noise energy. Everyone has got their own ways of doing it. Now people have developed softwares aware of the software, which is developed in Cumbria region. Anything you say in the exam is fine, as long as you can see that this is a kind of look up, which is actually the calculation of the angles, how much ammunition you need to correct to get a better result.
Benefits of there are different benefits of media opening wedge or the lateral closing wedge of the distal families, which you will see in the next slide, please. Next slide presented just summarized the benefits of lateral closing or the middle opening, as you can see, obviously lateral side, we are always scared of commenting on ulnar nerve sitting very close.
You have to do the fibular osteotomy. You have to literally dislocate the tibia, family, proximal joint and people can have issues in the coming days. TBI becomes shortened with this technique, but the good point the one point is that it's just a unique manner. You cannot correct the deformity in the multiple. So OK, well, we'll come to this point, and then you do these measurements preoperative egawa intraoperatively media opening wedge again, whether do we need a bone graft?
Again, a lot of debates about it, do we need to use? Can do we need to use a bone graft or just leave it alone or just put some bone substitutes? Every technique has got their own pros and cons. There is not no level one study showing that one is better than the other. Again, you can use either one. So if you want to correct the deformity in a unique plane, or you can use to source if you want to correct the pipeliner deformity slightly better in terms of it gives you the unique across the frontal deformity correction, as well as control the tibial slope.
But the bad side is you need a really strong fixation construct, which was the reason that people initially shied away from medial epicondylitis because the constructs were not strong enough. They were not able to take the weight. People have to stay for a long time, non weight bearing. And that created the problems of their own. But these days, there are new constructs available, which are giving good results and allowing early weight bearing as well.
Next place. Now, when the discussion reaches to this level, I'm sure you will yourself realize that you have already passed the exam if you are asked, OK, what kind of fixation are you going to use or how it works? We all know it's a micro version that we want across the splinted zone.
Various techniques historically, people have used cars for this purpose, as well as fixes, staples, fixation plates, angles, table implants, which are very popular these days. What have you? And some people have used a bone graft or bone substitute as a kind of fixation method aid, rather than a true fixation method. Everything has got its own pros and cons.
Pretty simple things. You know, the cylinder cost issues. I don't need to go into that detail at this level with you guys ex fix or staples. Everything is up in the exam. I was asked, OK, what implant are you going to use? I knew just one name that was fixed and I just said, tommo fix. I did laugh.
And he asked, why automatics? And the answer to that is it's rigid. It's long, and it has got the benefit of locking bolt. And it gives you too much fixation. Hence, it is more stable. That's the only thing you need to know. Now there osteotomy that have been described, just need to know the names they still usually Dan Rather. The only indication is in a balcony where you want to convert the Volga into the various names and hear the purpose is to unload the lateral side.
Again, the concept is the same just reversed that it restores the weight bearing line to neutral or bit of within five degrees of tenotomy. Well, guess, and it is converting the tension site to the lateral aspect, which has been reversed in the first instance when it becomes available. Now again, same principle of high TBL lateral closing or media closing is applied to the distal femoral as well would be lateral opening wedge distal femoral osteotomy is better than the mesial closing osteotomy.
These days, this is the latest. Studies have shown that most of the studies have shown that the lateral opening is better. If you have to do, that is the option. But again, there is very limited literature. Very few people have done the medial closing in the distal femur. Most of the people they only do the lateral opening is. And if you are doing very well, you can say the world, I will follow the palace principle.
Which is in the frontal plane. You try to address the anatomical and the mechanical axis, and in the sagittal plane, you only addressed the anatomical axis. There's a big book written by this gentleman, pele, and I don't think it's at our level to discuss or we need to discuss this. No complications, general risks, which you just mentioned, but any other surgery that you do and you say the general risk of all this infection and injury, the nerves of blood vessels, specifically speaking nonunion or union fixation can get long can be lost.
Loss of fixation patella height can be altered. Even patella can be so bloody. People do come back, sometimes having issues with their patella. They were having a nice patella tracking, but the surgeon has a osteotomy which has healed as well. But not the patient has developed anterior knee pain as well as his not happy. Bones can be reduced.
Obviously, when you're doing them, especially if you're doing the opening by the osteotomy bone stock is not very good if you want to do the knee replacement in future, and it becomes a difficult knee replacement if you need to do one. Next, please. OK last slide, don't open the next slide, please. This is the last slide take home message.
This is a simple exam, so guys, please keep it simple. When, when I was asked about this, obviously you will not be asked like, OK, what do you know about osteotomy? Is it underneath the exam will never, ever be a straightforward memory exam. You will be given a picture. So whatever knowledge you have, you have to apply to that.
And even if you have got a very superficial level of knowledge, but if you are applying it, sure you will pass. I still remember it said in the beginning in the letter that FRC is about the breadth of the knowledge rather than the depth. So and I believe in it now after going through this, it's an exam of your thought process. How you are thinking it's not an exam of the nitty gritty is not the exam of the technical aspects.
It's not an exam of how confidently you can do a procedure which no one else can do in the region. It's just an exam of a very simple technique, which is safe, safe and safe. And to do that, you have to practice, practice and practice. I will stop here. Let's go to the questions around the chat. Kindly, you answer one of them.
Atif was saying that what is the rationale of city's can do you? Not again? Yep, go ahead. Open up the marketplace. So if the rationale doing the CT scan is one is a CT scanner gram that gives you more detailed information about not only the alignment, but also the rotation. Because a lot of times and I'm sure you might have come across this scenario that we do the long leg fence and people there standing in various directions in various positions.
They want to stand. And it gives you a very bluffing picture because I myself came across this kind of scenario where we sent a patient for a long leg when he was standing in a position, whatever he wanted or he felt comfortable and the picture was so much, so much falsely benign looking. And then we send the patient back for a CT scan and we got the real measurements, which were like quite different.
So for but sometimes if you are happy that the patient can stand in the proper way and you are happy to have your measurements on the x-rays alone don't need to go for unnecessary radiation. But city's cancer preferred. And again in the exam. I think you need to say this word that I will prefer from this particular reason. And another question from Mohammed.
He says that how much the degree of correction and how we calculate it, I think you went through this. Yeah but then we went through this again. As I said, you don't need to remember the numbers. If you just say 5 to 10 degrees, though, they were not. The question is whether you are calculating those five degrees from. So the report is your reference point. So it will just open a big discussion topic that they can measure it from on the anatomical axis.
No imaging from the mechanical axis. OK, then again, the question if someone tries to ask you a question, there are a lot of questions you can. Well, how do you measure? What is the best way of assessing the mechanical axis? How do you do it? And then you take. There are a lot of other things I don't think at our level in Air Force or any of these things.
I'm going to within like 5 to 10 degrees of the neutral axis, the weight bearing line to assess how to assess the arthritis in the latter compartment and joint. Would you score? Yeah, I mean, as I said, if there is a suspicion, again, scoping means an intervention, which obviously you have to put the patient to sleep and then I have just put it as an option.
The better thing is MRI scan. I'm sure all of us are aware that whenever we are having a suspicion or when we are trying to map out the lesions, it depends. If we are trying, trying to do something like someone has got an obstruction necrosis or someone has got an ulcer on the lesion and we want to do something about it. And obviously scoping is better because you may go the or stabilize or do some procedure on the same time.
But if you are thinking about hischier, then MRI scan is better. The options are there, so you just have to use them according to the need of your patient. OK and would you do stress views under? No, I'm not aware of any don't. I mean, if someone has got instability, you can do a simple ball test and be very lucky. You need a very good geologist to kind of, but usually you do it.
Well, to be honest with you, you don't need like a jar for stress. You just do it. No, no, no, no. Not the Department. Now how could I increase the slope? The technique? I mean the. OK, so intra operatively, what people do is they do the osteotomy are done in the troop plane.
The first osteotomy is done as a horizontal in the second osteotomy is done at a slight angulation and that second osteotomy for the medial epicondylitis journey is the one which controls your tibial slope. But as I said earlier, I have some serious doubts that anyone would be asked about this. This I mean, yeah, you can be asked if you're doing very, very well. You could be taken to any levels, but I'm very happy that someone has asked this question because I was thinking about giving a message earlier.
I calculated I faced 32 scenarios during my that two days of examination, which are all of us face. So knowing about 32 topics, if you calculate, it's literally impossible for everyone to know all these minor details of an individual procedure. Again, a procedure which is not done very commonly in our day to day life. Even one of the knee Fellows here or a sports fellow, I'm sure they even don't do more than 20 or 30 in a very big, busy sports injury center live alone that people who are working in the eggheads.
So please do not go into the minor details of things I was looking into. The previous threads and myself have been part of this telegram group when I was studying and other guys were helping us out by guiding us. A lot of people ask a lot of questions and I don't think they would have helped them in the exam. Trust me, exam is all about knowing the basics, playing safe, showing them.
I know my basics, I know my limitations. This is where I stop. This is where I refer. This is where I seek help from my other colleagues and I know the theoretical things I couldn't. I couldn't agree more. I think I think it's very important to on like one in one of your slides saying that the principle of the treatment you and I. But before passing my exam, I was making sure that to say this phrase, the principle of the treatment is to do this, to do this, to do this.
And here, like you said, the principle of the treatment is regarding the promotion of the two that will kind of get the examiner on track there. I don't think this is about details. So the devil is in the details in this example.
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Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
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You Size - Responsive
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We Size - Responsive
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Picture Overlay Popup
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400 x 225
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512 x 288
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400 x 700
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768 x 1024
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1024 x 512
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1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode