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Update on the Treatment of Peri-Trapezial Osteo-Arthritis - A clinical debate on 6 cases
Panel
Friday, June 15, 2018 · 4:30 p.m. · 01h 00m 14s
Faculty: Claus Hjorth Jensen (Denmark), Filip Stockmans (Belgium), Jean Goubau (Belgium), Kevin Chung (USA), Nadine Hollevoet (Belgium), Torben Bæk Hansen (Denmark)
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00:00:01
like the gentleman uh um what come to decision um it is
00:00:06
a deep eight on it uh in the surgical treatment off
00:00:11
a a so a thump arthritis c. m. c. one arthritis
00:00:17
um we have a selected six cases and we will
00:00:22
all present our view on the these cases um
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then we will have a a fruit for each case we
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what the audience would prefer as treatment after that
00:00:38
we we have presented our opinion on it just batteries in your hands not precise go
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and shall we start talking okay
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uh the
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the first case is thus errors sixty four year old woman returns from work
00:00:58
left handed knows it serves a introverted effect the injection and printing
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he's a he has increased pain doing the last year and he's got a rascal during a deal of
00:01:12
it's of seven out of ten or seventy out of
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one hundred he has a quick dashboard fifty eight
00:01:21
this is e. x. rays
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yeah the first
00:01:30
expert with you
00:01:33
so for me this is a fairly classic case of a
00:01:38
the um lady presenting uh at the beginning of her retirement
00:01:43
with a painful c. m. c. r. tried this yes no s. t. t.
00:01:47
involvement which is for me a contra indication to do an order plastic
00:01:51
um the age is appropriate uh it's not a a young patient with um
00:01:57
high demands so i expected join survival to be more than ten years
00:02:02
uh so for me this would be a bowling ball and socket are too classy anders enough bone stock to do this
00:02:13
well because you have to join such a common problem uh yeah i'm really not in favour pretty
00:02:18
income implants because one a longevity i don't wanna see my patients ten years revise the joint
00:02:24
so my preferences trapeze and excision a little reconstruction or change the ligament reconstruction from
00:02:30
a very complicated of c. r. two a. p. l. reconstruction which um
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you can see that diagram but i need doesn't require draw holes in this operation for the
00:02:39
twenty could tie about twenty minutes which i'm which actually is quite suitable uh in mice
00:02:45
series i have not seen the patient come back for any revision for this operation
00:02:53
yeah
00:02:54
uh my appreciation about the joint was a more uh uh that one of up entropy sherlock right this
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what a trapeze or you don't skip skip first proposal we'll try to this
00:03:05
um um my preferred option would be a better remembered some uh are
00:03:09
too closely with a creamy from astronomy as proposed by sherman
00:03:13
of the trip is are we to avoid the a persistent pain at the wrist after the l. r. t. i.
00:03:25
does the patient presents with a very common problem seen in clinic
00:03:30
uh we would the the invited to participate in our quality assurance program we got enough
00:03:36
problems you use use one joint else showed a little bit of this later on
00:03:42
uh so we would do a that modify plea cream or a
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suspension of props to use to fix a copy radius tent
00:03:54
i would do i total uh john and percy yes i'm constrained
00:03:59
and cement it then i would worry patients that it's
00:04:03
it's also mention any they're not very efficient operation because uh survivor right
00:04:07
after kenny air is about eighty percent of patients who who went
00:04:12
add every yeah it does too don't you need revision is usually they have
00:04:17
very good outcomes so i can i would make the patient shapes
00:04:23
okay so we have a very different uh opinions we have also different happenings
00:04:29
um why do you get a green e. and get a green out and what is all that about uh is that to say
00:04:39
well i think i started out you need to divide the plastic
00:04:44
which does not a lot that i it will hold in the base of the first meet a couple only later
00:04:48
on like chains that sorta like to uh to hold the base of the first and it's a couple bone
00:04:54
and i read the uh the issue i wrapped around the remnant of the physical radials
00:05:00
tended and the up that says this is my colleague that let people it's an
00:05:06
and button billy green up there to greet button i don't um uh i
00:05:11
do uh uh the same as with um uh you describe but um
00:05:17
after reading my whole which i uh put in forty five degrees in order to get some abduction
00:05:22
i also wrap it around the fax a copy read yellows and then only the men should this which i will put
00:05:27
in this part that is gonna be compressed because of the
00:05:31
sacking in here the inevitable sacking of the first macabre
00:05:37
okay it to make it easy we will call all of this l. r. t.
00:05:41
i. ligament reconstruction ten ten into position plus of course the tragic to me
00:05:47
what could we yeah uh go back to the to the the the actually
00:05:51
because i noticed some of you said it was the was so uh
00:05:58
a a sticky arthritis and somebody else at the once you said it was uh what what you think
00:06:05
what i would just say i need dynamic x. rays of the inner from procured d. c. t. joint
00:06:13
well okay we don't have that we go on uh with the yeah the rationale for doing this
00:06:21
i just want to just wanna make a quick comment via i don't get a lot of test i mean coming from america you think
00:06:26
that we waste money which we do try to save our country somebody because you're gonna be the removing the g. p. z. m.
00:06:31
and you can see the trappers lloyd join in this cave with very easily so why don't we live as we test i just call
00:06:37
and and actually look at the other joint be sure that that so i could trust them at the same time so true
00:06:45
oh
00:06:47
i cannot get away because i'm very worried about this question because um if you can show the next slide uh yeah
00:06:56
i was asked to show was asked me to get some data next slide the baylor recording be
00:07:01
uh got t. i. was a simple chip easy activity let's go to the next slide please
00:07:08
so this is a a slight i've made some some rights of a
00:07:11
lot essential can summarise for you that's simply the studies which war
00:07:14
for the indicating from the british group there's no difference in all count between begun reconstruction
00:07:21
it is yet to be except that's the legally construction has
00:07:24
obviously because it's more complicated as potentially more complications
00:07:29
but given that there's really no difference in all cons i think that's suitable
00:07:32
that you love choice depending on what the soldiers most competent doing
00:07:36
and the little reconstructing technique as opposed to the test of time it's a
00:07:40
reliable technique and my modification with that is i removed the radius that
00:07:45
keep your proximity switch or we would outgrow falls to the v. c. r. l. which make the op
00:07:50
which is so much more difficult when compared to let's say the whole f. c. r. reconstruction
00:07:57
i thank you and feel it
00:08:01
um if i mean there is of course a concern of john survival and then the
00:08:06
forty five year old i will not propose to do a prosthesis that's for sure
00:08:10
but uh we publish the results on a hundred and sixty uh patients that had to put joints and we have it
00:08:17
it's a ninety four percent on survivor read at seven years with a a minimal followup or five years
00:08:24
and going up to fifteen so i think this is a safe procedure so me and uh
00:08:29
uh each frame of this particular patient who's going to retirement
00:08:34
if you would be ten years younger i would indeed go for
00:08:38
that traps and ligaments suspension in my purse and keys
00:08:43
but now i understand you will you have arguments to do a a prosthesis
00:08:48
but if you are commenced against the trap rejected me or ligament reconstruction continued position
00:08:55
she will a lot faster be happy and basically uh the motion of
00:09:00
your meta carpal is different after trap exact me compared to
00:09:04
uh after joint are hopelessly for the very simple reason that you have created a joint
00:09:10
so it is going to put that on the uh on the joint surfaced
00:09:14
which means that meta carpal mobility is better after and more um
00:09:19
date if or physiological after john carter plastic compared to when you do a
00:09:25
uh traps act but if the patient is going to recognise that
00:09:30
that's depending on what the physical activities are that she's done
00:09:36
and and you have evidence for that in the literature
00:09:41
ah we're doing can dynamic city studies to to prove that but it's it's in the way
00:09:48
and and kevin uh now why why do you
00:09:52
prefer art pieces of tissue procedure to firstly
00:09:57
well some reasons prosthetics maybe bigger frosting colleagues that they have
00:10:02
the constipation in ten years i mean you'll be vision
00:10:05
i i think that the uh c. n. c. joint is so common lee arthritic
00:10:10
that's um but if we could revising these things after ten years ago and type act that's my practised
00:10:15
will feel would be visions another one to see visions for my patients and secondly
00:10:20
i think that's awful costly physically so much more difficult than becoming reconstruction interviews and excision
00:10:27
she's that's i think that's my colleagues here can be would beautifully but if everyone would would pop
00:10:32
up past the procedures i think that you can see one the number of complications the last
00:10:38
typical with a complex operation for common conditions such as c. m. c. i. think
00:10:42
that's simpler the better and not have the patient come back for another trip
00:10:48
and i think you have some uh uh evidence in the literature for these
00:10:55
so i was that i kinda synthesiser that sure showing that the joint replacements and of course all
00:11:00
these like case series is of that nature based on selects a look all our apartment
00:11:05
of course probably not the most sophisticated implants or these
00:11:08
implants have problems based on the series of literature
00:11:13
use and i think that invariably if it wanted doing get it would be a spectrum of different skill
00:11:18
sets and you're gonna see longing closing is you complications which i'm can be can be difficult street
00:11:26
trash you are running a database it tell us about that
00:11:31
still it's five years ago we started at database asking the
00:11:35
patients uh come full full of the primary interview
00:11:41
to to fill in a quick dash it's no run on the web space so that
00:11:50
you see here is an example and that the patient will will uh all the
00:11:56
way up she wilfully p. c. the put fashion for some reason ah
00:12:01
a database manager he thought that high school would be petted little
00:12:06
score so he forgot the the quick dash one but anyway
00:12:11
this allows us to to compare this particular ladies problem
00:12:15
with other similar patients same sex yeah average
00:12:19
h. about the same annex a preemptive score it's us you will probably this lady has been
00:12:27
uh compared with twenty one of the women undergoing surgery i had
00:12:32
answered the e. quest really add six months post op
00:12:38
and also they've been asked whether they were satisfied with the procedure on
00:12:42
so you can see this lady starts out with that a quick that's cool so it's
00:12:46
free and she will probably end up with a week that school of that
00:12:53
she has at probability of eighty six percent i uh three yes
00:12:57
to the question are you satisfied with the procedure i guess
00:13:00
so we're now running for the fifth yeah we haven't yeah the database two
00:13:04
hundred forty two patients so with this allows us to sort of
00:13:10
ah i object to give the patient platform to to discuss as to whether she should be operated on on on
00:13:19
and i understand this this is run a automatically online
00:13:24
and the patients in it do it at home or in to the waiting
00:13:28
room it was you could do it in the yeah i see
00:13:32
in the office which which comes for for the primary examination and she will agree to
00:13:39
i received an email with a link so she can answer the questions six months we have extended the yeah
00:13:47
the database still the pages will receive and they laughed windy and so forth
00:13:54
smart
00:13:56
the slide show we have a set of small summer here trio of
00:14:00
the panels will uh make a ligament reconstruction tending to position
00:14:05
uh to we'll do a no sorry we we forgot you uh no no uh_huh
00:14:12
you want the pursed easy to it that uh we'll do a prestigious nobody
00:14:17
would do a trap rejected me despite as you wrote once the overwhelming uh
00:14:22
evidence that it is as a good and that you have fewer complications
00:14:28
and maybe draw this solution so i would like to ask the audience who
00:14:32
is going to vote for a ligament reconstruction and taken into position
00:14:38
there are quite a few who would vote for pollen secure socket prostheses
00:14:45
not many not many simple trap rejected me
00:14:50
not many about the same as the four hours okay do you have any other solutions
00:14:57
maybe i picked up around but no there's somebody depletion um
00:15:03
there's what microphone you can give us a very quick comment
00:15:08
happen to lay i do something these cases but no
00:15:12
yeah for would be eh innovation of the joints it's a possibility yes also uh uh
00:15:19
what i was going to say maybe have a picked up the wrong generation
00:15:23
the younger people might do something across cropping but apparently not
00:15:28
of us that okay we move to the next case
00:15:34
the next case is a seventy two year old woman he's got the best
00:15:40
score two eighty eight or eighty out of hundred just got it
00:15:45
there's addressed it's forty two out of wondered like wood badge of sixty eight
00:15:53
makes trace looks like this with this that deformity
00:16:03
when i saw this is my first concern was the high dash course so when i
00:16:07
looked at this lady's x. rays and we don't have full espresso for rest
00:16:11
i was a little bit concerned that we might have uh some older concomitant pathology within the restore
00:16:17
within this three only joined that looks like to be our trading so that would be
00:16:21
um my first concern uh in terms of interpret interpreting her a clinical um
00:16:28
presentation she has obviously a very serious approximation
00:16:33
a very uh bad collapsible for and be joined with the m. p. joint hyper extensions actually
00:16:39
compensating for her collapse offered pump so because she cannot open read speech
00:16:44
she uses her and be joined as a pseudo science teacher
00:16:48
if you can do an archer plastic on these you bring them up to lengthen
00:16:51
you reduce that that's and and i have had cases in which i could
00:16:55
read use that and be hyper extension just by bringing them into lining
00:16:59
although i'm very reluctant to do it in this case because it would be very concerned on the bone stock that we
00:17:05
still have available in the uh in the trip easy so i would need to do c. t. scan up front
00:17:12
if i do a um ligament to plastic of some kind or project to me and the amount of nasty
00:17:19
i would uh no duty and peace stabilisation this same time because i wait uh
00:17:24
if it is a problem for the patient i will do it secondarily
00:17:28
um if you make them too stiff you risk that they and they don't get good
00:17:33
mobility in the n. b. level you risk that they cannot grab things probably
00:17:40
it it
00:17:42
but that could be uh this is actually a a home run operation but you saying here
00:17:47
a whole operation the sense that that's you can do lots to change the high mechanics make
00:17:51
the patient better in the in as it would've oh you're the reason that's the patients
00:17:56
had type extension and c. v. joints a compensatory happy extension because she wants to what
00:18:01
they had to quit fix a because the c. n. c. choice subplots enormous views
00:18:06
i cannot read this patient isn't extreme moldings to understand what the patients
00:18:10
able to adjust to the current situation even though looks kind of
00:18:13
not very pretty the patients so it it it just well that's that is not for the operation assume that
00:18:19
the patient comment to see with this deformity she's andy but it just because you cannot open
00:18:24
to hang sufficiently if that's the case in this is indeed it to double operation
00:18:28
i i do not want to um to mobile it's the c. and c. too i think that we're gonna be construction
00:18:34
which appeasing excision will free up the fancy and see joint however
00:18:39
if you go through the m. c. p. joints same time
00:18:42
by mostly fusion operation that hot extension also lost of with option the scenes each one
00:18:48
work or so i would remove the trapeze um i would do a p. or they can be construction
00:18:53
we've used the uh m. c. p. joints and once you've done that you have a stable will but um that's you can enjoy
00:19:02
john how um well this is a dell stage for try just
00:19:08
which is not an trapeze you apologise for this or or
00:19:11
uh what is wanted deformity um as pointed out by a few documents
00:19:16
the the ball and socket the implants might reduce your hyper extension
00:19:20
but since she has morphology of the rounds with a couple head it is a
00:19:25
possibility that it's uh not corrected by your prestigious and that you might need
00:19:31
a season we do mean the goblet with pieces of the radio says i'm woods
00:19:35
uh which i protect for six weeks with the you know to write system
00:19:43
we have seen the spaces in a number of times in the we have the opted for for the men to pass
00:19:50
the assessed is quite beautiful and a temporary out the fusion of the it's a couple until julie with that
00:19:57
why is sometimes we can take it out in five weeks
00:20:01
and to be hyper extension tendency will be minimal
00:20:10
i would i wouldn't choose for totally john carter plastic because there's a lot of separate station and as i yeah
00:20:18
it's an constraint implants this to mike chase of dissertation so i
00:20:22
would do a partial trap is yet to me and
00:20:26
to italian into position had again mentor construction and me i do intimidate and
00:20:31
then i'll graph i act whistling around diffraction crab ready out of hand
00:20:37
an abductor places long list of the front end and and then
00:20:41
if the empty page and is really an not off
00:20:44
uh if there's not of hyper extension i would do a
00:20:48
immediately nancy p. joined fusion at k. y. s.
00:20:57
yes so every ask why at partial trap a sector me rather anecdotal
00:21:03
and why don't we do it all to john card for pristine case of sip fixation
00:21:08
and next slide please snow if you do a partial travis actor may it was
00:21:13
also discussed and a and p. v. session that maybe not everybody was there
00:21:18
there is yes race of migration of the base of the
00:21:21
maker cartel and then you can add prevent impeachment
00:21:26
make the scan for it i think it's better to try to preserve the s. t. t. joins in case you
00:21:34
can i want to do later ever for corner fusion are of rock
00:21:38
summer are chiropractor mean and our that's maybe a rare chats
00:21:43
but i think most patients at a city arthritis r. f. informatics and if you
00:21:49
remove the trap easy and you then i start to complain
00:21:55
and then you can have even met cargo and stability
00:21:59
this is a patient to had a a total japanese act to me and their right hands rights and
00:22:06
r. t. i. procedure and and then left hand it was a partial for everything to me
00:22:12
and it's it can see she has a city arthritis and right hand i'll tell she doesn't
00:22:19
have any complaints you can see various uh ourselves helping of the known it on there
00:22:27
uh on the latter x-ray and that can maybe come more severe if you remove
00:22:32
all of the crap easy on you made east fabulous i might argo joints
00:22:38
which as as a case and i left address that's that a city designed to attract this is not something foolish
00:22:46
mm another slide and then uh that patient on the left hand she had the an don't don't represent
00:22:53
to me that's an r. t. i. procedure and got fed completely and know what to do
00:23:00
if you have a fair it's much more difficult to do
00:23:03
a a revision procedure if you have removed everything
00:23:08
and i accidentally i saw on her right hand she had an
00:23:11
operation there shouldn't have any complaint said oh also for
00:23:15
c. arthritis of the trapeze i make archetypal designed that they
00:23:19
dates and other hospital either c. n. c. joint fusion
00:23:24
and you see the giants have they not unites with bony few inventiveness
00:23:28
fibres fusion that's that's maybe the ideal solution you haven't biological
00:23:35
in back off oh no it's not really partial traffic jams
00:23:41
and then the second question i i why now uh
00:23:45
purses in case of separate station and patience that's
00:23:50
as it demands accent d. r. the space yeah the trap easy
00:23:54
and there's a higher risk of this location right and constraints
00:23:59
in price i don't have evidence for that that these are two cases who had
00:24:03
it also designed a implants that that fans and you can see there
00:24:10
yeah trapping him as a trainee their outer surface
00:24:14
after trap is a mess very high practical
00:24:19
may i ask you on the upper side um the problem
00:24:24
is yes the implant is uh indicated that um
00:24:28
it seems that the cup has a a subsided or
00:24:31
lucent isn't that the primary problem of that case
00:24:36
if that maybe that at i i remember it was a very difficult cases that may ninth
00:24:42
but i i really do it's may not always be i
00:24:46
i should not say it's the ligaments but h.
00:24:50
and something he puts in some patients you put the purses and it's
00:24:54
in the east devon and in this case it was if
00:24:57
a little bit problematic and that's maybe like never problems also that the cup fixation
00:25:03
okay and then back to the partial trapping check to me um yeah she you
00:25:08
maybe you avoid the problems if you later have to do for confusion
00:25:13
but understood you had this and number on the publications you added number off the operations
00:25:19
to convert it to a total a topic to me into because off a s. t. t. problems
00:25:30
i don't know if i might change if ah i ah
00:25:39
oh if it's
00:25:43
oh well yeah i'll before before now oh i don't think that's
00:25:50
i that's why i do my shortstop exact uh me and i'll come back to a total crap effect on me
00:25:57
there is one steady i found to compare twenty two
00:26:00
patients that opal versus twenty two rights are sure
00:26:06
and they're keep h. was better and are sure bets and that group five
00:26:10
patients needed cave into total that's yeah maybe like you meant yeah
00:26:18
that's a high if you're right now it's the problem is
00:26:21
you don't know in which patients your procedure well are
00:26:27
a hard to predict the future yes um can we go on a date to the sham really so
00:26:35
uh two of us seem to prefer a l. i. t. i. m. m. c. p. fusion
00:26:40
one uh uh l. i. t. i. and it can carry a fusion properties
00:26:45
one first uses n. says says m. o. d. s. and the
00:26:51
one oppressed eases and nothing in the m. c. p. that was
00:26:55
you fit so we are completely disagree we completely disagree
00:27:00
um what are the other solutions yeah somebody yeah have other
00:27:05
proposals for this case this uh younger patients no
00:27:12
okay um who votes for the l. r. t. i. and uh m. c. p. fusion
00:27:20
one third yeah who does uh the uh um
00:27:25
idea actually i mean temporary actor disease
00:27:28
very few who does the press cheeses and see some white pieces one
00:27:34
or two a prosthesis and nothing in the m. c. p.
00:27:40
also to yeah other solutions no so i think that if public will do a a
00:27:48
lot t. i. and at and t. p. fusion that's what they prefer okay
00:27:54
next click
00:27:57
okay case number three forty five year old woman he's of interest increasing
00:28:02
pain despite conservative treatment he's got a bus that activity or work
00:28:09
forty two out of one hundred as you got she's got a a dash to issue
00:28:14
of twenty five out of one word he's got a good bashing of thirty eight
00:28:22
this is how it looks and acts race
00:28:31
well this is of course a much more challenging case i mean she's a
00:28:35
young lady she has a high demand um not all the time if
00:28:39
she's just taking off your uh dental well i'm like for mission that's
00:28:44
not the main problem and when she's going to take out mowers
00:28:47
she has of she needs a lot of force and she'll put a lot of force
00:28:52
only your reconstructions so that is um the reason why would opt
00:28:56
in this case for the extension or still to me
00:29:00
because it's very well documented that works a good in this population that is only
00:29:06
also are tried his but has um specific activities that provokes hear me
00:29:12
um she's too young and too high demand to do
00:29:16
any um uh are two plastic with a prosthesis
00:29:21
and uh she's also too high demand to another guy i think
00:29:25
uh because you will lose too much uh awful force
00:29:29
i do feel susan this is with the plate unscrew and i tell them up front that i will take out the plate after
00:29:35
one year in case we need to do something down the road
00:29:38
um and also those based if frequent uh and your attention
00:29:47
like you know what this that really tricky situation because you have a a high function individual quite young forty five year
00:29:54
old lady was the tents it's so i think that's so important that you get to know this patient even better
00:30:00
i would do everything i can to do we conservatively with injection was pointing
00:30:04
'cause the behaviour modification everything i can to avoid doing anything to her
00:30:09
because if you do something was substantive and she cannot work is a career ending injury
00:30:16
and when i look at the um the x. rays i i
00:30:19
notice a few also fights but the article surface looks okay
00:30:22
if after i'm comfortable with our ensures fill all console treatments i'm gonna do the most simple thing possible which is
00:30:29
obvious topic that the premier of some select also fights and potentially the same time put it
00:30:34
almost substitute to cushion the joint base of whatever fine in a surgery but i would
00:30:39
i would definitely be very cautious with um this patient and get an over really
00:30:44
well understand the expectations and uh try to hire all focus of that
00:30:50
very quickly uh to more cushion or you can use that term assaults to the many different the most of the choose
00:30:56
for press reconstruction and so forth is off the shelf it's a term as you know from human or pick skin
00:31:01
you can actually it could affect enough piece that's hottest topic we could sort in between the
00:31:07
uh the p. z. m. about a couple it's that it's that that's the question
00:31:12
so uh could be an autographed also skin grafts or
00:31:16
yes telegraph up for somebody else somebody else
00:31:19
from not from the patient okay finally we are just copy you want the young generation
00:31:26
okay okay
00:31:29
um so this is a case of it with the trip dissimilar popular crisis stage too
00:31:34
for me the visual look scale is still tolerable since it's under fifty have his algorithm
00:31:40
people counsellors starting around when they're around fifty regarding the pain of the uh remote that some
00:31:47
but and the twenty the very happy when you're getting two seventy five they're ready for surgery
00:31:53
and if i would so the go for surgery i would just check to join to see what's going on
00:31:58
and making microscopic uh evaluation without promising any right
00:32:02
don't unless some some assigned effect to me
00:32:05
and if i see that a part of the um the joint this one off
00:32:11
i would consider we will slow sort of me i perform a wilson also
00:32:14
i mean with clear wires since it deals with in six weeks
00:32:19
wilson ah of just we i thought was something on the big toe
00:32:24
no no no wilson also we was described in the
00:32:27
uh nineteen seventy three by wilson uh he described
00:32:32
in extension or certainly when considering the base of the
00:32:35
first letter carpal were extended it's i mean
00:32:39
uh a couple degrees is enough that's not more less three maximum four millimetres of the
00:32:45
dorsal side of your cortex okay that's what you do want something like yeah
00:32:52
yeah i would be reluctant to to offer the spaces surgery she's she's strong hiding me and
00:32:58
and uh a contest cool appeal to people a little we found in our
00:33:03
uh see this of hundred fifty two patients uh that all the
00:33:08
half the patients had a reduction of the contests collect six months if they're pretty operative quick that's what's
00:33:15
the deal so she's uh she's not a candidate for surgery my p. centre to the remote dorchester
00:33:26
i i would propose error adults will jog africa state now she's young she's had high demand
00:33:32
she well we can't work irony here and met all the other procedures
00:33:37
that um what her there's a big risk should any division actor plastic if she embrace
00:33:44
yeah she doesn't want a it doesn't sound factor plus they of course it's
00:33:47
better not to operate that if she really has tried everything as
00:33:51
and you can sell you a partial travis said to me and and
00:33:55
then into position but that'll take a longer a recovery time
00:34:02
so uh the for the extension are still to me it's typically the um
00:34:06
early a highly painful younger patient uh that i would propose is to
00:34:12
and the prognosis is is is very good and um basically i
00:34:17
promise i try to promise them five to ten years
00:34:20
and after that they can still do something else okay next slide
00:34:24
so was proposed as a as a show set in seventy three actually one wilson described as
00:34:30
he called it an abduction hostile to me but it is an extension of still to
00:34:33
me depends on how you wanna look at it of course is a typical problem and
00:34:37
he proposed twenty five to thirty degrees of extensions tells me which i don't do
00:34:43
i am more in the twenty twenty five range if you go to thirty people will say
00:34:48
i it feels for putting in the beginning because my thumb has changed position
00:34:53
uh he did a follow up study after ten years ah with twenty three of still to me is and
00:34:59
this was of course in the old days all were good and you didn't have to prove any
00:35:03
evidence so that's you know that's how things were at that time the important paper his
00:35:08
here from france billy green where he did a compact stresses and to put a fuji films
00:35:14
into the joints and you see here on the top graph to see the normal distribution
00:35:19
the top graph is the area the lower graph is the uh force
00:35:24
and if you give the next slide you see that if you if you push again
00:35:29
uh you see that if you do an extension are still to me
00:35:31
that you're moving basically your contact forced to the dorsal side
00:35:35
but this was done in cadavers in normal joins the next slide
00:35:39
is showing you abnormal joints and on the left you have
00:35:42
moderate are tried this on the right side we have severe arthritis is very try to see that you have a big
00:35:49
uh we also have a peek to some extent in the moderate arthritis but look what happens if you change it
00:35:54
so you two year extension hostile to me i can have can you at the bottom
00:35:59
you see that you're shifting it nicely to uh to um the dorsal side
00:36:05
on the lower side you're on the lower panels have the area so the moment one
00:36:09
will still uh give you a predictable shift to the dorsal side it's like
00:36:14
hi to we'll still to me going from your meter camelot compile to unilateral come down here you go from your
00:36:20
folder trapeze into it or something easy so that a a is basically what it does and buy some time
00:36:27
and the last slide shows you um that i do always a. c. t. scan up front um
00:36:33
you can do an actress copy it depending on what you prefer to do you see also that there is some tilting and and if you
00:36:39
do the extension astronomy which is fixed with a little uh t. played
00:36:43
that you get uh some uh reduced distribution of the compact there
00:36:50
so one or maybe two maybe three options could be a yet to others after that cost just
00:36:59
to me to prostheses to avoid surgery or maybe one lottery i or notre project to me
00:37:08
uh what does the public's aorta solutions
00:37:12
yes
00:37:14
two
00:37:17
it must be brief i'm afraid i thank you for your home oh tons this high demand um
00:37:23
young patients somewhat probably consider the lie profiling yes
00:37:27
that crafting because the studies published so far
00:37:30
the show excellent results especially in great one one two mixed in three and that was results in grade four
00:37:37
but with the patient like this it's feasible option that it has
00:37:41
been shown to be better than a cortical steroids injections
00:37:44
and it doesn't burn any bridges the if it's not working under the peaceful by you sometime
00:37:50
yes and it was another solution
00:37:57
desire work well can like anybody mention not scott the cross
00:38:01
section not that this form element is the trip these
00:38:06
okay um who we are going to vote who does an artist copping get
00:38:11
break now what i program is actually yeah i'm sorry i was yeah
00:38:16
we we we must be creek yeah sure and nobody does that for this
00:38:21
and i didn't know yes oh yes this one uh an astronomy
00:38:28
yes for five people six maybe who testified surgery
00:38:35
oh yes i don't many remote adjusting room uh
00:38:41
they're not yeah
00:38:43
not really
00:38:44
okay a trap injected me
00:38:48
no okay we vote for austin to me today next case
00:38:55
case number four thirty year old man captain to sustain the
00:38:59
benefactor two years ago treated by poking tears pooling
00:39:03
yes now increasing pain at this injury jointly has the best at work at seventy
00:39:09
five or out of one hundred and the quick pace of forty eight
00:39:15
this is how the x. rays look
00:39:30
um so i can somewhat use too young and too high demand to do an
00:39:34
error to blast the and it doesn't need i'm not requests yet thing
00:39:38
um i would get the c. t. scan on him a high resolution c. t. scan
00:39:43
or scope and to get an idea of what to draw it looks light
00:39:46
i would again go for an extension are still to me but also in this particular
00:39:50
case and eaten palmer bleak ligament reconstruction ah is also a good option i think
00:39:56
uh it makes a joint also little bit stiffer and stable um
00:40:02
but um if the trapeze him still intact and it's only the whole
00:40:06
big which is off i would to a favour to eat and
00:40:10
i'm a ligament nasty with the total uh to the the vertical
00:40:14
tunnel to the base of the purple and f. c. r.
00:40:21
like the like fillets approach i think that um given given
00:40:25
that's the extra not really show lot of agency changes
00:40:29
you kind of wonder what is the apology whitey putting so much i think
00:40:33
this one a situation where it's like studies itself like thing that
00:40:36
people forget c. t. scan the find the optical surfaces the construct of
00:40:40
the choice we make at the front of a trip freeman
00:40:44
if and this is a construction worker young person i think that's the a fixation you
00:40:48
to be doable says this person is not someone actually have a trapeze yet again
00:40:52
because men which would be easier to me they will lose grip strength for three or
00:40:56
four months substantially and you may not be would be trying to construction work
00:41:01
so if i were to determine that particular service is one doubt business
00:41:06
all the trouble then it's quite some possible to do a year
00:41:11
a a c. n. c. joint fusion but since you joined fusion for the high rate of nonunion range of thirty to forty percent
00:41:18
in some series which means that we have to use the most sophisticated plating
00:41:22
system the law keeping system as shown promised to be able to
00:41:25
achieve higher with a fusion i think the mocking plate it's a single one for this patient for fusion is you have to join
00:41:35
this is a million that's two years old i mean there's always a discrepancy between
00:41:39
the symptoms and what you see on the x. rays can be very
00:41:43
painful and when you operate them uh they always have a lot of sign of right this uh
00:41:48
uh in the joint um i perform for having operated three cases you out last year not
00:41:54
woken beam c. t. going being because it has a high resolution than a normal city
00:41:59
unless irradiation uh to evaluate the quality of the cartilage
00:42:05
if the quite is of the strength is okay i performed in tropical are all still i mean
00:42:09
reducing the mel union unscrew putting an enter fragmentary screw it to interfering
00:42:16
theory screws between the two fragments that gives of a recruit these
00:42:20
are the first results um of uh the the pain and the
00:42:24
function with and that is a very easy procedure isn't it
00:42:30
a very easy percy no it it it's it requires a lot of preparation but it can be done without any
00:42:37
additional um technology i mean thing but you lies whatever you can do it
00:42:44
the this is dan rather on common case is problem seems to be real he is high school
00:42:52
i think that uh if he does not go away you end up with that fusion of e. c. it's one joint
00:43:02
in case of various cartilage deterioration already after i agree
00:43:06
that it's rare most people tolerate humans small mines
00:43:12
but i would go for an actual jesus um
00:43:19
so can you go to the next slide be uh this is as as slight
00:43:22
summarising the literature certainly not the latest but sure but something that's actually
00:43:27
it's actually as high quality the the conclusion to write i could just saw summarise for
00:43:32
you say c. m. c. confusion the traditional trading system has hybrid a non union
00:43:37
and the experience that myself which means that we have to file twenty ways
00:43:41
fuses yet see joy you the using block things place accommodation locking plates
00:43:46
and screws to achieve much more stable c. m. c. joint fusion
00:43:53
so
00:43:54
uh the summary issue i think we also must to conclude from what you have been to telling us
00:44:00
that c. a. c. t. scan in these cases is important yes to evaluate it uh yeah
00:44:07
atrocity yeah yeah yeah so uh uh one would choose an extension it it after to me one
00:44:14
maybe in turn one and in tropical us just to me and tree you would uh
00:44:20
go for fusion that makes each we only five although on the five
00:44:23
but that's because it several options depending on the c. t. exactly
00:44:29
um i would anybody use a prosthesis no apparently not not and a
00:44:35
lotta and even uh are the other solutions for these guys
00:44:41
mm not really there is one yes
00:44:52
um well thank you for that yet i just for this is the young patient
00:44:57
and a high demand patient uh why not offer airmen us ross copy
00:45:02
and informing them about the the options uh after finding a
00:45:07
the the the interjected a situation that if if the jarvis cocker and we can
00:45:14
uh well go for maybe an uh astronomy but if i have a
00:45:20
if the joint is a work so we think we could do a re section of the uh first the cup
00:45:27
at about and that that's that's maybe an option also is that of a um a fusion because the fusion
00:45:34
just that justin a nonunion into fruition does not that the that that uh i had that function
00:45:40
and i i think it's an invasive procedure
00:45:44
thank you thank you so we vote who is going to vote for an extension astronomy
00:45:50
there is one maybe if it would be the more i don't know what a
00:45:55
eaten like meant reconstruction three i think uh uh an inch optical astronomy
00:46:04
yes i've done and maybe ten
00:46:08
fusion
00:46:11
even more yes that would be the treatment of choice i think prestigious
00:46:17
yeah ah ah
00:46:20
uh other solutions without so this would be defined a
00:46:24
solution would be fusion for the majority thank you
00:46:33
case number for five sixty four year old woman suspension
00:46:36
onto plus the with the maybe it'll suspension
00:46:40
but this seems you one was before one year ago increasing pain despise glinting clinical examination
00:46:46
do is an infringement add up the first macabre on this gay for it
00:46:51
the infringement is unstable painful on examinations yes of the
00:46:56
s. q. inactivity of seventy out of hundreds
00:46:59
and uh there's a list of thirty out of one good liquidation of seventy eight
00:47:06
this are the x. rays look
00:47:10
and there's also cities again
00:47:14
looking like this
00:47:22
my first statement is politically correct on the slides in reality i would think
00:47:26
if that patient walks into my door to hand surgeon is next door
00:47:31
um it's a very difficult problem to treat and i don't think there
00:47:35
is an easy way out and certainly not the predictably out
00:47:39
um i have the impression that there was no a ligament that nasty down on the initial surgery
00:47:47
so i would like to do read to a ligament to pass the uh we have of the f. c. huh
00:47:53
two t. shaped stone do we unleash checker described that we you
00:47:56
reconstruct both the abduction but first reconstruct the internet a couple
00:48:02
a ligament between basement across one and he spent a couple too so that would be my first option but very often
00:48:09
the young patient and the skeleton seems to be a little bit on the on side so there's a young
00:48:14
patients very often they will end up with a fusion between the base of my purple one too
00:48:19
which is very uh only tolerated operation takes want to you
00:48:23
and it is a a prone to have competitions
00:48:29
thank you um unfortunately a form of a patient with this is that same problem
00:48:34
that was sent to me it was a technical features soft refuse the activity
00:48:38
is that's when the two whatnot strip the base another cop also confidentially
00:48:43
because you do need to preserve into market not a couple ligament which between the thumb index finger they
00:48:48
can provide additional stability and prevent the of not a couple from stop costing approximately in this case
00:48:54
based on what i ride a p. l. tending was use the f. c. attending was use soap
00:48:58
is really no additional become and that can be used x. m. a. b. c. r. l.
00:49:02
i think that after all this time the sixty four your women become
00:49:06
only difficult to get the mother couple but you came from
00:49:09
i think that although of forego fusion off the uh c. n. c. joined by
00:49:14
fusing the mother couple to the index mother couple the trap was already
00:49:18
simple graph thing and two screws can be helpful and i think that that
00:49:23
may be the only choice to keep the macabre exactly where this
00:49:31
um the filter project from is very very cumbersome problem um
00:49:36
steam pension i would like to i would try the mini tightrope between the first and second minute purple
00:49:42
uh if the this doesn't help when the patient is still painful uh would so
00:49:46
performers k. from it probably fusion would never crossed and the paper sources
00:49:55
if it's possible i would really do the tanning deposition and that's at ten an hour
00:50:01
and i would if they ever there are not enough tends to make
00:50:04
a stunning i would have probably feels that graph right on this
00:50:09
the last
00:50:12
to try to do it at the suspension awful plastic um if the effects a copy radius has
00:50:18
all right you used to be miked up for the extensive copy radius logos
00:50:23
and this supplement with the midi type we used to use
00:50:27
a few cases um into file with good results
00:50:31
but
00:50:33
oh
00:50:36
um okay next slide
00:50:39
next slide
00:50:42
is what we get when we perform a trip is it true mixed
00:50:47
is this into those eleven next
00:50:51
next
00:50:52
this is what you get about two years later which is painful
00:51:00
we perform we need tightrope in the uh around that they it next
00:51:08
again next next lines
00:51:11
okay probably
00:51:14
and it's what you get about one year now six months later i mean it has sack
00:51:20
as much as it was before but there is a difference she's not meaningful anymore next
00:51:28
so the tightrope uh what is prime indication in my previous following painful per
00:51:33
project too but it is often used as a primer in sobs procedure
00:51:39
it gives him prior intention sedative to two percent good results wouldn't
00:51:43
work on nine percent for results according to the creature next
00:51:49
it can enhanced ability but it does not always avoid personalisation of
00:51:54
the base of the first macabre one second secondary cases
00:51:58
and fracture of the base of the for this uh the segment a couple
00:52:02
have has been described as an important feature don't forget me tightrope
00:52:07
there's two packages with the hand package in the foot package be sure
00:52:13
when they delivered to you but you get the right stuff next
00:52:17
what is important next
00:52:20
whenever i perform your trip project you mean next spared that treatment because
00:52:26
that's gonna hold a big part of your first major problem
00:52:32
so the summary is that to the u. n. r. t. i. or treat you were
00:52:37
not t. i. and when you try to one and mini diaper problem one
00:52:42
and the other options we not adopted what does the public say a new l. r. t. i.
00:52:51
not many three four people a supplement it with the many tightrope
00:52:58
get a more uh not many tractor apollo
00:53:03
oh even more prestigious
00:53:08
no uh into beta kappa fusion the first and second it a couple not really giving
00:53:15
it was not convincing a sky format a couple fusion yes there is one
00:53:22
so many people i think don't really know what do you want a other solutions
00:53:27
yes okay uh we have no time to hear details about that i'm sorry so a
00:53:33
dish would be eh you actually i and when you try to fine yes
00:53:41
but
00:53:43
okay the last case number six sixty four euro roman retire and secretary
00:53:49
the total don't replacement was performed three years ago with an electra
00:53:54
she has increasing pain with a best you in a d. n. of
00:53:58
fifty six out of one hundred and a quick dash of eighty
00:54:03
and this is how it looks
00:54:06
see it before with electra
00:54:10
look up
00:54:13
so when i looked at the x. rays i think that it's very likely that chat the trapeze factor
00:54:19
at the time of insertion of that was the primary reason to get a cup loosening although
00:54:24
d. like propose teases has been a prone to have a problems with the with the cup
00:54:30
first choice in case of problems with our trip last the um
00:54:34
irrespective of this particular cases to to redo are protesting
00:54:39
um but if that is not feasible or there is a problem in
00:54:43
the anchoring when we try to put in a new cup
00:54:46
i would go for trapeze act to me and while the suspension for plastic
00:54:50
which works very well and a system in the mother carpal i don't take it out
00:54:56
in case the patient is fed up with our purposely which would
00:54:58
be perfectly understandable i would be immediately you for a while
00:55:03
for your information this is like this original drawing it that's what you meant yes yes good
00:55:13
the um remove whether implying this was suitable and you're gonna be construction does i'd be all for this patient
00:55:19
was there's really no need to make it more complicated the pistols them which spirit with another
00:55:23
couple can be left replace the proximal component can be moved with h. p. c.
00:55:29
but
00:55:32
um i would just perform a revision otter plus the and remove
00:55:37
plus these that has proven to be a baptist eases and put the prototype upon such prestigious
00:55:46
what we would be yeah and they hated me i got the distal
00:55:51
component and did too but but and a lot of t.
00:55:55
so uh it's just the corporate occult from top of i.
00:56:00
b. that he indeed it is operation it was
00:56:03
the swanson even up without swanson to this is the last remain up without like trap with it
00:56:12
and i would remove dad back up and actually this time and and put an ad
00:56:17
pan and have rafts but i would do partial trapeze act and he yeah
00:56:23
so the summary is that we almost on in agreement in you
00:56:28
remove the picnic in crap into and and actually ah
00:56:31
some of us might consider putting and a prestigious what does the bible say
00:56:36
who would do a removal of these components and do we do in a lotta guy
00:56:43
i think we have a match only to dan who would put in a new prostheses
00:56:50
some will do that yes other solutions
00:56:55
not really so we yes result solution please
00:57:01
it's actually not a solution that's a question to given a chance that usually would do it it's you or
00:57:07
would you still control the hole through the basically the couple or on the the the retains them all
00:57:13
would you just do some modification of the actual that doesn't have to go to the medical
00:57:20
like it all solomon with us them in the i guess you cannot really true also holes with another couple but
00:57:24
as i mentioned earlier controls another top anymore things not necessary so just
00:57:29
detached the a. p. l. with just the p. p. l. possibly
00:57:32
it's which will be to u. c. l. a. user bus attendant is into position something about special pretty well
00:57:40
just when a remark whenever i remove prosthesis hours remove also the system
00:57:44
it's a little bit cumbersome but you use very small k. wires and you use your
00:57:49
um your knife as a kind of awestruck so you go along and you manage to
00:57:55
remove every prestigious canals should enable since you want to put in a new
00:58:01
can i ask the experts why would would do and they largely on it what what why not just moves it to please you
00:58:12
get back to the trap injected me why do it and then
00:58:17
yes operation what's some patients have impinge we don't have that maybe if coming out a little bit
00:58:24
yeah but if i don't know yeah but if this them is
00:58:28
embedded into the mister cochran phone why do do a suspension i've vastly
00:58:34
i think i have an argument for that because i i i almost never do it
00:58:38
oh uh i have i have the basic experience with lucy like this
00:58:43
but i just i just take out that the p. c.
00:58:46
when you putting d. electra you remove the base of the uh make it past the cop you remove all the ligaments
00:58:54
gets completely unstable that's why map have it i would just
00:58:58
removing the top easy and now you're talking about your
00:59:04
experience with how you to see how we did it primarily operation yeah but
00:59:09
you have you haven't got any evidence that you have to put in a lassie i no evidence no real
00:59:16
and this it's they got a lot of fibrosis because they had the one uh_huh you got a point
00:59:21
yeah i mean there's one big difference you have to see the
00:59:24
delay between the primary procedure and your revision procedure yeah if
00:59:28
it is short you might mean r. t. i. if it's long couple years you don't need anything as you to
00:59:37
it is actually longer than the regular condition even if the cup with loops
00:59:44
because you remove the joint and then you put in a quite a long make so you won't have any problems with the length
00:59:51
i'm tying okay the time at the twin differs procedure yeah and your remote of
00:59:59
think we could go go on the talking for a long time but
01:00:02
we reached a seventeen thirty so we have to stop thank you
