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Pes Planus for Orthopaedic Exams
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Pes Planus for Orthopaedic Exams
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Language: EN.
Segment:0 .
Thank you. How do I one? Good evening, welcome to this teaching session, organized jointly by dfacs mentor group and the orthopedic Research UK amphoras, and I'll be moderating the session with my colleague Sean hinari. Ruth, head of education from our UK, is also the co-host tonight.
The speaker this evening is Mr Sunil bajaj, and he will be teaching us about pediatric, adult and pediatric and adult flat foot deformities. Mr Bajaj is a consultant, pediatric orthopedic surgeon at London at Lewisham and Greenwich NHS Trust. He gained his orthopedic training in the Southeast London, and he's done completed pediatric orthopedic fellowships at Sheffield Children's Hospital and Royal National Orthopedic Hospital in Stanmore.
Throughout his career, Mr Bajaj has been actively involved in teaching registrars and is highly acclaimed in the region for his teaching abilities. He's a convener of the UK, lower limb and pediatric of our case revision course and which runs twice a year. And I think the next one is in the autumn of this year here, and he's regularly invited as a faculty to various other FRC courses throughout the country.
We are very pleased that he's kindly accepted our invitation to present tonight, and I'm certain that each one of us will, will, will pick up many points from his session. This session, as you can see, will include the lecture presentation at the end of this presentation, there will be an emcee questions and that to check that you've all been focusing and listening to the presentation. So we will ask you all to answer these questions.
Mr Bajaj will tell us some tips for the FARC exam. And following that, there will be hardship and survival practice, and the places are limited, we only have about four or five questions prepared. So if anyone is interested, we ask you to express your interest by raising the hand symbol next to your name or sending us a message on the chat. We will prioritize those who are going for the exam in November.
But if there are no not enough candidates from November, we will take anyone else. So we try to keep these sessions as interactive as possible, so please ask you questions on the chat books and also raise your hand if you want to speak directly to Mr Bajaj. Our rules will get in touch with you regarding CPD certificates in due course. And if you missed any part of this presentation, don't worry.
It will be recorded and it will be posted on the FRCS mentor group YouTube channel and also on the UK site within a few days. Without further ado, I will leave you with Mr Bajaj. Over to you. Thank you for your kind introduction. Can everyone see it, please? Yes OK.
So hi, everyone, I'm Sunil Bajaj. I'm a pediatric and adult foot and ankle surgeon at Lewisham and Greenwich NHS Trust. So I thought we would take a very important topic today because, you know, at least it features a lot on their fashion. Thought it may be in clinical sessions. It meaning the wiwa to it features a lot in dfacs and that is a flat foot.
So I thought, let's discuss about the flat foot because the important thing about the flat foot is that, you know, it can affect all stages of life, right from pediatric, adolescent to adult. So this is the topic for today, flatfoot, and we are going to go in quite some depth. You know, obviously we can divide it into pediatric flatfoot, adolescent foot and adult foot and in pediatric foot.
Again, you've got flexible or physiological or postural and then you've got your fixed flat foot in adolescence. There are two main conditions Darcel coalitions and accessory navicula, which we'll discuss and in adult Blackfoot. Mainly, we'll discuss the posterior insufficiency because that's the most common which features in your exams. So, you know, we know that, you know, food has got multiple arches, you've got the medial arch, you've got a lateral arch, you've got your transverse toss a lot.
But probably the most important of those is the medial arch. So why do you need an arch? First of all, 1 May ask, why do we need a notch? This is because if you look at the foot, the foot is a segmented structure and to support the weight, a segmented structure requires an arch to support the very best. The second reason is it helps in shock absorption. And the third very important reason is propulsion.
So the three buzz words, if someone asked you what's the function of the medial arch support, absorption and propulsion, FRC is all it is all about buzzwords, and these buzzwords should come out in the answers. Now the important thing is the medial longitudinal arch. So what does it comprise of the bony structure? It's got the calcium, the tail is the navicula, the three uniforms and the three metatarsals. These comprise the medial longitudinal arch, and that's what we're going to focus on.
Now, obviously, you've got the structure to stabilize it, which can be divided into static and dynamic and static. Of course, it's got the bony and ligaments, and dynamic is the most important is the tip post. So amongst the static structures, probably you should. The most important you should know about is the spring ligament, and this is really important in the understanding of the management of foot.
So the spring ligament also called the plantar Calcasieu navicular ligament. And if you look at the diagram that you can see the two bands there. And these are the string ligament, they basically go from the substantial leg of the calcium right to the club, and they actually act like a hammock supporting the tails. So essentially, it is the plantar part of the tail navicular joint, the plant, the medial part of the tail ulnar claw joint.
And this is really important structure, which is a very important static stabilizer of the medial arch. So then, of course, the dynamic stabilizer, the dynamic stabilizer, as I said, is a tibial first year as everyone would know to be honest, consider inserts to all the bones of the foot, except the tailors and every insertion of the.
Rebels for Syria has got a role to play its insertion on in Africa is to elevate the medial margin of the foot. Its insertion on the sustainability line is to support the deal is its insertion to the third to the fifth metatarsal is to separate the foot. So basically it is basically got all the three parts has got a role in supine eating as well as elevating the media large and tip. And you know, we always talk when we talk about the gait and the stance phase of we always talk about and we talk about soldiers.
But you know what? The tip bolsters are another very important muscle, which actually plays a role in the stance of the G8. So what does the role of the tipples in the gait cycle? So before we actually get into foot individually, let's talk about the tip post because it is a functioning all flat feet. So if you look at the heel strike, so when you have the heel strike, there is, you know, there is an eccentric contraction of the tibial is a there, which prevents the foot slap down.
But as the heel strikes, the Sabella joint is analogous. And this causes the forefoot unlocking. So as a result, the forefoot is very flexible, and that's why it acts like a good shock absorber. So from the moment of the heel strike, the tibialis posterior starts to work. After the heel strike, the rebellious posterior comes to play, and most of its function is in mid. So there's an eccentric contraction of the tibial is possible in the stance.
So at the heel strike, the foot doesn't slide supination. But as you go to mid stance, the foot starts to plummet and the tibial Esposito is very important with this dysfunction so as to put your needs. The foot achieves a flat foot position. And this is very important the foot to be flat flattened, which stance? Because if it's flat, the weight bearing axis will go to the center of the foot, and that's very important.
It won't overload the medial or the lateral side. So that's uniform loading of the foot achieved because the tip post needs the foot and basically keeps the foot flat on which stands. And then during the terminal stunts, there's a concentric contraction of the post now, and as a result, the flexo-pronator again. And because the footstool beneath the heel inverts the forefoot, the tail of an ankle and the calkin occupied joins the midfoot, they become locked and the foot becomes a rigid lever.
And this gives you the push off during the terminal string. So this is a function you can see if the tip is not having this concentric contraction now, your foot will not be a very rigid lever and will not be an efficient push off. You'll lack an efficient push off. So that's what we said is the main function is during which stunts and turbulent stunts. That's the two phases of the gait cycle, where the tip is working initially with eccentric contraction and later as concentric contraction.
So the flatfoot, what are the effects of the flatfoot, so during which stunts we expect the foot to be flat, but if you have a flat foot, the weight bearing axis shifts to the inside of the foot rather than to the center of the foot. And because a weight bearing axis shifts to the inside, there's an internal rotation of the femur. There is an internal tradition of the knee. There's an interpretation of the tibia, which increases the angle and that increases pectoral patellofemoral pain.
And that's why flat foot just doesn't affect the foot. It also affects the knee, affects the hip and affects your lower back. So before again, going to individual feet, it's very important to understand the etiology of any foot. So, you know, foot is a trifling deformity. You know, there's a deformity in the sagittal plane where there's a sagging of the tailbone navicular joints, or there's a sagging in the surgical clean and you can determine the sagging by two important parameters immunities angle and the cranial pitch, which I am going to show you in the next slide.
The deformity in the frontal pain is the heel vagus and that you can look out for the tail of kalkilya angles and the deformity in the forefoot is in the transverse spleen, which is forefoot abduction. So there is a deformity in all three planes and forefoot abduction you get by the tail is first metatarsal angle and the tail coverage angle. I'm going to describe all three. So this is the miui's angle, which is a tolerance first metatarsal angle, so normally we expect the tailors and the first metatarsal to be in line.
This is a lateral view of the foot and the angle needs to be zero. However, in flatfoot, because of the sagging at the tiller navicular joint, you can see that the angle increases to above zero and it is convex plant outwards. So this is an important part of the media angle. So the mirror angle of 0 to 15 is mile, 15 to 30 is moderate and more than 30 severe flat foot. Then we are talking about the calculi pitch.
So calculated pitch is a line along the inferior border of the calcium and line along the plantar surface of the foot. And normally it ranges from about 25 to 40 feet. So here you can see that in the flat foot the calkin, which would mean be reduced. So that's the other important thing, which tells you there is a sagittal plane problem. Then if you look at the hind foot Vargas, this is by the tail of calculi angle kite.
He is the one who described the angle in the AP view. But you know, it's very difficult to demonstrate and calculate an AP view, so it's better to measure it in the lateral view. And so again, if the tail Tailhook angle is increased, so normally it's between 25 and 45. If it's increased, then it's analogous foot, and if it's decreased, it's about a foot. And then you got the forefoot abduction, or this is a very important part of foot and you guys should understand this part.
The midfoot subluxation laterally, there's a steal are uncovering and that produces four-foot abduction, and it's very important to identify this forward abduction. So there is the tailored Agricola coverage angle. So if you look at this, you draw a line along the articular surface of the. And along the articular surface of the navicular and the angle between these two, it should be 0 to 3 degrees.
So that's a normal. In other words, the navicular should completely cover the tail our head. Whereas if you look in this search, the next x-ray, you can see the navicular sublets laterally, so the tail won't have a cloud coverage until increases beyond three degrees. So this is uncovering of the dynamic of the tail. This is the tail coverage angle.
And then you've got the tail first metatarsal angle. So normally the tail is and the first metatarsal are called linear, but in the flat foot, because the tail is deviates medially and then goes laterally, the line through the tail is goes medial to the first metatarsal. So this is called the tail is first metatarsal angle. So these are some important angles which we need to know before we actually handle any flat foot.
So now we go to the first important part of the flat foot, the pediatric flatfoot, so the pediatric foot can be divided into two types, which could be either flexible or fixed, or it could be asymptomatic and symptomatic. So the flexible or the asymptomatic pediatric foot are two types the physiological foot or the postural foot or the calkin foot important calkin of is sometimes kept in the Viva and dfacs art, and it's very important to recognize this condition.
So this is a calculable guess, but essentially it's a packaging disorder. So then it's a packaging disorder. It is associated with other packaging disorders, which includes the idiot, which includes articles which includes metatarsal adaptors. So when they start to take you to the slides of the foot, please say that you want to examine the hips to rule out. So in this, what happens is, is the flexible type of foot.
In other words, both the reflection as well as the heel values are correctable. The heel is completely flexed here, but it is correctable. You can try to flex the foot and generally all it needs is just gentle manipulation, and majority of these will correct by the age of nine months. However, beware if you have a calculus value sport with this deformity in the leg called posterior medial tibial boing.
Then the posterior medial tibial bowing may result in the limb Allen discrepancy at maturity. So if there is a calkin of elegance with the posture medial bowing of the tibia, the children have to be followed until maturity. Because if the posterior medial bowing doesn't resolve on its own, they will have a difference of up to 3 to 11 centimeters. So beware calkin while his foot with posterior medial bowing of the tibia.
The other common foot in the child, which is asymptomatic, is the physiological slap for all children are born with flat feet. This is because the arch is absent at birth. They have generalized ligamentous laxity. They have got fat pads in their soul, so the arch is not very apparent and the arch can take up to 10 years to develop the first decade. So that's why when you get reference of a six year or a five-year-old child with a flat foot, you just have to reassure them because the arch can take up to 10 years to develop.
So the important thing about this foot is it's bilateral. It's asymptomatic and about 3% bas status in the adult population. So what are the screening tests? So you ask the child to go up on the toes. So you can see this is the flat foot, but as soon as the child goes up on the toes, the arts comes back and the heel goes into barrels, so it is completely correctable.
Similarly, you can ask the child to go on the inner and outer bottom of the foot, which means the supply joint is supple and you can see when the child is sitting down. That arch is present, but when you stands, the articles are be that shows it's a flexible foot and always check for in school. And please don't forget to study the Staley's rotational profile because foot can be associated with torsional deformities in the femur and the tibia.
So please test for the Staley's rotation profile, which is hip internal, external rotation, typekit angle, et cetera. So why can a flat foot, which is physiological, cause pain? Yes, it can, you know, majority of the time is asymptomatic, but minority of the times, it can cause pain. The reason being normally the dossey flexion when you dossey flex the foot, it occurs at the ankle. But because in these patients, the tendon Achilles is quite tight.
Those flexion bypasses the ankle and there is a midfoot break. And also flexion actually occurs at the midfoot, and that causes pain in the midfoot. And secondly, because of the high input values, you can get calcula fibula impingement. So they can get pain on the lateral side, impingement of the tenodesis and also because of the medial prominence of the talus, they can attack velocities on the medial side.
So beware heel cord or tender Achilles tightness in physiological flat feet. That's the only condition where physiological flat feet may need treatment because when they have tight heel cords. So how do you assess what he'll call tightness? It's very important that when you have a physiological foot to assess for tenodesis tightness before you do the silver sky test, you need to correct the heel values and correct the forefoot supervision that is very important.
Only then you should check for tender studies. Don't check the tender status with the heel and wielgus, because then the deflection may occur at the midpoint. So what is the treatment then asymptomatic, flexible flatfoot, nothing to do, just reassure them. I tell my patients that Usain Bolt had flat feet and he's the world's fastest man. So what is there to worry? So generally asymptomatic, flexible flat feet can be completely left alone.
You can do physiotherapy with Achilles tendon stretching and tibialis posterior strengthening and proprioception. And whether insoles or shoe modifications actually work in asymptomatic, flexible foot is a big mystery. And this mystery was solved by a gentleman called ringer a towel who did this prospective study on 129 people or children dividing them into four groups. Three, they had shoe modifications or heel inserts, and one where he did nothing.
And he found that there was no difference in the three year follow up. So therefore really giving them insoles when they are asymptomatic and flexible, it's a waste of time. On the other hand, if they become painful, there is a roll of the insults so you can give them either shoe modifications, insoles or earphones or of course, physiotherapy to do, he'll stretch or he'll call stretching.
But there are surgeries, obviously. You know, if it's a flexible, painful flat foot, it's painful and conservative treatment feels you can consider surgery is very rarely we have to do them, especially in the Black population, because you have got quite severe flat feet, which can be painful. And the problem in foot is a lateral column is shot so you can do lateral column lengthening. And in addition to that, you do a lot of soft tissue release.
You have to release the heel cord, that Achilles tendon. You have to advance the tibialis posterior because the balance procedure is very lax. So you need to tighten it. And you may have to lengthen the peritoneal tendons or the cultural osteotomy, which are sorted out for this condition is the lateral column lengthening how the lateral column lengthening axis is osteotomy done at the neck of the clerk and you Jack it open.
So basically the fulcrum of this osteotomy is axilo navicular joint. So what it does is it basically reduces the tailbone subluxation and restores the tail ulnar claw tenotomy and restores the arch of the foot. So as you can see here, this is where we do the lateral column opening. We make an osteotomy of the calcium. We Jack it open with the hinterland retractor.
And as you can see that as soon as you Jack it open, you see how the foot straightens out. The arch comes back and then you put a tri cortical iliac graft. Or you can do. Nowadays, you can put these tantalum wedges to open the calculi osteotomy, so thus it can collect your midfoot forefoot abduction. It can collect axilo, navicula, sac, and also it may even connect your heel.
While the heel doesn't correct by this procedure, then you may have to do a calkin and shift. The other thing which is actually coming into a lot of play now with flexible, painful flat feet is this is called the sinus Desai implant. So essentially what you do is it's called Art releases. So instead of doing a lateral cranial opening osteotomy you, you're actually producing putting an implant like a screw in the sinus Desai so that jacks open the sinus to side and prevents the lateral collapse of the sinus side and acts like a lateral column lengthening.
Its advantages are it's a very simple procedure, and it's sometimes done as a surgery. Sometimes it's done even at the local anesthesia in the US. But the disadvantages are you can do over stuffing of the sinus, or you can do under correction. So that's a problem and obviously you're putting a foreign material inside. So that's the disadvantages. So this was a patient who had a sinus ulcer implant, and you can see that it corrected uncovering corrected quite well, as seen on the x-rays on the right side.
And you can see these are the evidences to see that the scientists are saying blood actually works. So the next important topic is the pediatric six flatfoot, so we finish the pediatric flexible flatfoot, which was calkin of allergies and physiological, the pediatric flicks flatfoot, you mean you have to remove. Remember only one main condition and that is a congenital cortical talis. So it is also called the rock bottom foot.
So here, what happens is the hind foot is fixed ichinose. The midfoot is in fixed dose reflection. The forefoot isn't fixed abduction. So the mean pathology in this is a dorsal dislocation of the tail navicular joint. That's the mean pathology in CBT. So if you remember that what is the pathology in CBT is dorsal dislocation of the tail navicular joint, they have asked this next.
This has been asked in the exam what are the associations of CBT, the associations of CBT, neurological disorders and chromosomal or genetic syndromes? And the third thing obviously, it could be idiopathic. The neurological disorders like meningioma, Milo see lateral kyphosis and genetics in those trisomy 13, 15 and 18. And if it's idiopathic, it is also genetic and possibly an autism dominant inheritance.
So please remember associations of CBT, the two buzzwords you need to remember neurological disorders and genetic conditions. So what is the point problems in CCP so you can see the hind foot is in decline, as you can see on the X-ray. The tail is and the kalkilya both are in sequence. They are pointing down and the forefoot is industrial flexion that that's because of the dorsal dislocation of the tail on a regular joint and contracted anterior tibial muscles or the reflexes of the foot.
So this is why you get a rock bottom deformity because the forefoot is reflex and hind foot is equinix, so you get a convex plantar deformity. So the hind foot isn't fixed equine values, the forefoot is an abduction and deflection, and the planta surface of the foot is convex, and that's why it's called a rock bottom foot. It's very, very, very important to identify this at birth or very early in life because this needs immediate treatment.
So excuse for the CVT. I mean, obviously, you can do a lot, but the most important is the lateral actually of the foot and neutral position and the lateral actually of the foot in the force blind deflection position. So that's the lateral area of the foot in the neutral position. So you can see if you draw a line through the tail as it should normally be aligned with the metatarsals.
The navicular is not ossified until the age of 3. So you cannot see the Navy clad in this foot, so you just go with the metatarsals so you can see here the line to the tail is actually going plant up. It is not going to, but going plantar to the metatarsals. And then if you do a lateral view with the force maximal plant affliction, you can see the tail still goes planted to the metatarsal and it doesn't align with the metatarsals, even in maximum plantar flexion.
So this has to be differentiated by a condition called oblique tails and an oblique tail. As you can see that in maximum plantar flexion, you can see that the tail is actually aligned with the metatarsals, so management of the congenital oblique dealers is usually it. It was so far into surgery where you can do a one stage procedure or a two stage procedure, where you do a large Cincinatti incision and you have to do a lot of soft tissue and bony releases to reduce the tailbone articular joint.
But they found that surgery. Unfortunately results in a very stiff foot. So therefore now Dobbs that UBS has actually gone for serial casting, which is called the reverse Ponseti intraoperatively tuberosity. Here you've got Reverse quantity. So do you do the serial casting to reduce the tail ulnar claw joint and then an Achilles tenotomy to correct the decline in the ankle.
So it's a ponseti, a reverse. Ponseti is the order. So this was a child who presented lead, so he needed the one stage surgical release. You can see the Cincinnati incision on their finger, on the right, and you can see the correction. But remember, this is extreme. You can see preoperatively the vertical telescope and the X-ray on the right bottom lateral view shows that this corrected.
But remember now the treatment for CVD is reversed. Ponseti with at least tenotomy, you may need to do an open reduction of the ulnar claw joint, or it may reduce spontaneously. But remember it was Ponseti. So then we go to the adolescent foot adolescent Black for two important conditions the accessory navicular and also the calkin nunavik and the tassel coalition. These are the two conditions.
So the adolescent rigid foot is a very important short case in the exam, and it's a tacit coalition unless proved otherwise. It is a failure of segmentation. It is an autism dominant inheritance. It is also called a misnomer colonial spastic foot. That's a misnomer. The peroni are tight because the heel has been in Vegas for a long time, so actually they are not in spasm.
So that's a misnomer. And it's bilateral in 50% to 60% of the cases. So the commonest sight is the kalkilya navicular side and in the tail of calkin side, it's the middle facet of the tail. So this is a calcula navicula, and that's the middle facet of the case of kalkilya. There are other uncommon sites, but you don't need to know about them.
The most common is kalkilya, navicular and the medial facet of the tail of. The classification obviously depends on the degree of ossification, if it's fully ossified bar, then it's called a osteocytes. If it's a partially ossified bar, it's called a second ndrosis. And if it's a non ossified bar, it's called a syndesmosis and it's not generally associated with BFD and fibula.
So the symptoms are pain, and pain generally corresponds to the sight of the bar in Calcasieu navicular Mason in the Sinai star site and in the middle of the satellite, it's on the medial ankle joint. In addition, it also presents the presentation is when does when the bottle suffice? Calkin, kalkilya navicular. The pain is generally between 9 and 13 years, and they look in much later, 13 to 15 years.
This is when the bar justifies. And of course, the scientists are fixed flatfoot, so when you ask him to go up on the toes, the heel values will not correct. So radiographs you already described, but the important thing is, remember the 45 degree oblique views and axilo views. So the 45 degree oblique view shows the calcula navicular coalition best.
And of course, the lateral view for the tail of calculi coalition is seen in the lateral view. And there you see what you call is a C sign. The C sign is not typical for the coalition. Any Villegas foot can produce a C sign because the top of the tailors merges with the substance of the calculation analogous to an E foot can produce C sign. OK further investigations are secondary changes you can see, apart from the primary that is seeing the coalition, you can see secondary changes.
And one is a Taylor beating and you can see the anteater no sign, which is a prolongation of the anti the process of the calcium. I thought that imaging you can do with the CT scan, which shows you especially the local coalition's quite well. And you can do the MRI scans, especially for the cartilage installations. So most of the time, it can be an incidental finding, and it needs to be treated only if painful.
The important thing is treatment is always conservative. Remember, always try some insoles, try a plaster, sometimes 4, 3, 2 four weeks and then an insult. And if conservative treatment fails, then the Calcasieu navicular coalition, they do quite well. If you do early surgery on them where you reject the bar and you interposed the extent of the student service, and if it's a little adult, then you can still try excision of the coalition, but you may have to do a tailor fusion.
In axilo kalkilya coalition, on the other hand, you will see that the most important thing is they do quite badly with existence, though middle first coalitions do well with it can do well with exceptions posted official coalitions generally need subterfuge. So next we go to accessory navicula, so the incidence of that is 4 to 14% is generally bilateral. Most of the time, it's asymptomatic, just seen as a bulge on the medial side of the foot.
Now, obviously, there are three important types. The type 1 is a small article in the substance of the debate is posterior. It's got no connection with the navicular. Type 2 is about 1.1 to 1.3 centimeters size bone, which is connected to the navicular with the cartilage in this joint and type III is where fuses with the navicula, and you can't see it as a separate bone.
The communist is type 2. Now again, increase the lateral oblique view are quite good. You can see you can see the article there and you can even do MRI scans where you can see the high signal in the cloud as well as in the mean navicula, both in the 2002 rated images. So what happens is they produce immediate prominence, and they also medial the insertion of the tip post, and that's how they produce Blackfoot.
So most of the time, if they are asymptomatic, you don't need to do anything at all. But obviously, if there is an injury, then there is a pull on the second person so they can get symptomatic. And if they're symptomatic again, it's conservative, conservative, conservative and the siege baloney cost. And if a painful nonunion, especially in the type two, then you can do an exhibition.
When you do an exhibition, you basically split the deposit and excise it. Don't advance the depots, which is called the kingdom's procedure. Now, we don't need to do the procedure. All we need to do is just excise it. OK, it comes final topic. Adele foot. This is probably the most important topic because it features a lot on dfacs exam, and that's the tibialis posterior insufficiency.
So as we already said, the typical school student has got three important roles because of its multitude attachments to the foot, so through the attachment to the navicula, it raises the medial margin of the foot to the attachment to the substantial supports, the tailors and through the attachment to the metatarsals, beneath the foot. So the fact that what happens is because of The chronic overload of the tibial posterior, initially the tendon gets inflamed, later the tendon tears and later because of the deformity, you develop arthritis.
So these are the three stages of the tibialis posterior insufficiency. So it's a mighty plane, a deformity, as we said. You get the hind foot goes into Vegas, the forefoot starts abducting and flexo-pronator. And there's also medial column instability at the tail on or the first EMT joint. So classification of deposits asked in the exam and the earlier classification was Johnson Strom, who basically just classified it based on the presence of the hind foot deformity.
And later Mason added on the ankle involvement. So Mason did a modification of the Johnson stone. But now we actually also follow the blue men and Mason classification. We just don't look at the deformity, but look at the forefoot deformity, the ankle and the median column in stability, which is a more comprehensive classification. So the Johnson storm, you know, as we said, stage one, there's no deformity, stage two, there's a flexible hind foot deformity.
Stage three, there's a fixed hind foot deformity. And stage four added by Mason is when there is involvement of the ankle. But as blooming and Mason et Al defined this last vacation, and this is very good, you know, so he says stage one, no deformity. Stage two there's a flexible hind foot deformity, but it divides that into 2B and to C to B when there's a Whitford abduction to producing a foot abduction and to see when there is also first empty hypermobility.
And similarly, stage 3 is basically a rigid hind foot deformity, and stage 4 is the ankle deformity, which can be again forward if but flexible and forward be fixed. So I think this is a more comprehensive classification. So the risk factors of deposits generally in the fifth and sixth decade of life in usually obese ladies is very common in females. Pre-existing foot is a risk factor diabetes, corticosteroid use and sometimes zero negative inflammatory property.
So what happens, as we said in stage one, where there's only some inflammation of the post? You may notice some pain along the medial side of the post along the post and the medial ankle. There could be swelling there, so you can see you can see the swelling. Sometimes there, there could be swelling along the tip post. There may be also flattening of the arch, but most important is this is a correctable deformity so the patient can go on double heal and single heal.
It correct both. He can do the single heal. So even if you ask him to stand on one heel or the toes on one side, the deformity correct. Then it goes to stage two, where the tip pulls ruptures. So the result? You get a proper deformity. Here, the heel goes into bulges and in 2b, the forefoot starts abducting and in to see also the first hypomobility section.
So here the patient will not be able to do the single heel, but we'll be able to do the double heel. The reason he cannot do the single heel is because to in order to soften it, the foot. When you go up on your heel, you need the initiation to be done by post and subsequent ankle. Equinix is done by Achilles tendon, but because the post is not working in this stone, the topos cannot initiate this operation.
That's why you cannot do a single heel. But when he does a double heel, the initiation of slap lesion is done by the opposite foot. So then he can carry on with the tendon Achilles on the same side. And then, of course, the stage three where you get a fixed deformity and obviously with a stiff slap subtalar joint. So this is your stage three, as you can see, it's a fixed deformity doesn't correct and you have stiff slap de subtalar joint.
So what are the investigations you do? Well, you do, actually. We already talked about the miui's angle, the Taylors first metatarsal angle. And also you can see some kind of fibula impingement in the epp views, but you may also see more advanced stages where you can see arthritis in the DeLuna and the subtilis joints. So these are the extra features of advanced insufficiency.
And of course, you can do MRI scans within three to eight images, you can see a lot of inflammation or sometimes adipose ruptures, both on T1 and T2 weighted images. You can even do ultrasound scan. But the treatment, so you should stage one is just an inflammation of the post, so all you need to do is add the seeds and rest and you can give them supports like a deep post brace or you can do you, Cybill insert or you can also, of course, physiotherapy.
Very rarely, you can do a side effect of me, especially if it's 0 negative arthritis, according to both sinusitis. Now, stage two, as we said, we are divided into two way to be and to see throw in to e, where the heel is mainly a hind foot deformity. And the foot is OK. So you can't see too many toes sign. So there you can just do medial calkin cultural shift with FTL transfer to the post.
This is because the deformity is flexible and these people generally have been on the medial and lateral side of the ankle. So here you basically do a medial calculus shift to an extra articular oblique or shortening of the calcium. You're shifting the calkin immediately to correct the hind foot values. And you also using the FDL tendon? We are rooting it from the navicular from plantar to dorsal to augment the tip post.
It's going to be because there is a midfoot abduction. You need to correct them it foot abduction along with the hind foot deformity. So there you can do a lateral column lengthening, and it's great to see because there is also a first TMT hypermobility. You can do plan flexion or dorsal open, wedge osteotomy of the medial cuneiform.
This is because once you connect, the heel against the forefoot goes into supination. So in order to need the full foot, you may have to do a cotton osteotomy, which is a docile, open wedge osteotomy of the medial cuneiform. So these are the x-rays where we have done heel shift, FDL transfer, lateral column lengthening and accordions osteotomy to correct a stitch to see the pose insufficiency.
And of course, the stage three where you basically got arthritis at the tail joint. Now, normally we do. They used to do traditionally to pull out releases. But the disadvantage of the triple artery disease is the calkin occupied joint is not generally involved in flat foot. And because a lateral column is short, if you do a calkin occupied fusion, you further shortening the lateral column.
So nowadays we do a deep fusion and not a triple fusion, so we do need a double fusion, which is just a tail on having slap and calkin occupied fusion and not a solid subtilis fusion, not the calkin occupied fusion. So, conclusion, this poses a complex problem, it needs to be managed. Depending on what stage it is and what are the patient's symptoms, and you have to have an individualized treatment plan and results are quite good with conservative treatment, but obviously you need to go in early if you go into stage through two to prevent the stage three of stage four.
People haven't spoken about that, but stage four basically because of a long standing values producing a deltoid insufficiency. So in two, it produces a collectable and kill value. So you can do a deltoid deconstruction. But as in two th4t, whereas in 4b, it produces annual arthritis. So there you'll have to do a hind foot fusion. So this concludes the brief discussion about the pediatric adolescent and adult flatfoot, remember.
It features a lot as short and intermediate cases on their years, as well as why you are so pleased to play a lot of importance to this foot topic. So this concludes the topic on foot. We are open to questions. Thank you, Mr Death was very comprehensive lecture. Very focused. You covered the whole topic very beautifully. It's anything we all wish.
One of my mentors also said the same that we wish. We have listened to this before our exams, but I'm happy. Future candidates can take advantage of this now. So it's really, really a beautiful lecture. And as I say, it is a lot there and might not everyone might not have got the all in one go. So it will be, as I say, it's recorded and be posted later. So obviously there is. We have some basic questions, but before we go there, there is just a couple of small questions we have received.
I think the lecture was comprehensive enough is not covered everything, basically, but we have a question from Ahmad. He was asked about reverse Ponseti method. Is that a topic that could be asking if I should be worried about it? And yes, I think if it has now reversed, Ponseti is actually gaining a lot of popularity because surgical management of CBT is very difficult and it produces a very stiff foot because there's too much surgery involved.
So in reverse, ponseti, what we are doing is we are doing the reverse steps of the Ponseti. So here we are actually planned to flexing the ankle rather than flexing it. We have plantar flexing and inverting it. So the first five, six Cos we are plantar flexing the ankle and inverting the foot. And after fifth class, the foot actually resembles a clubfoot. It becomes like a clubfoot.
And then you do that Achilles tenotomy like you do in the Ponseti and you correct the ankle ichinose. And then you put it further into a plaster. But only thing is once you correct you, when you, when you, when you reduce the tailbone, have a joint. After five weeks, we put a key wire to hold the tailbone a joint reduced and then do an Achilles tenotomy and then put the final cast. And after that, we again put them in a brace, just like in clubfoot like that, we put them in a splint.
We here again put them in a dynamic brace so that for two years. And just like clockwork. So it's exactly like clubfoot. What is the reverse of it? So you should know about the worst ponseti? Yes, thank you. Thank you for explaining this. I think that answers the question.
Another question from us if he's asked if you do a CT scan that confirms there is bony coalition, you still have to do MRI scan or is it not? Well, I mean, the problem is I have been caught out in a few instances. What has happened is some of the patients, they have a bony coalition and in addition, they have got a fibrous coalition involving other joints.
So one of the patient had a medial facet, bony coalition of the subtilis joint and a fibrous coalition at the calcula. So I tend to do both. And the other important thing about the MRI is also it would highlight or show a high signal around the bony coalition telling you that the pain is actually coming from the coalition.
So it actually tells you that your pain points to you, that the problem is actually the coalition and not anything else. And also, it tells you the status of the satellite joint. If you do the MRI, so you can see if the satellite joint is already showing changes, then the prognosis is quite reserved for such individuals. So I tend to do both. Thank you very much.
That makes a lot of sense. And again, for the exam, for the exam, as long as you can explain your answer. I mean, in this manner, it'll be great, isn't it? One more questions from fikry is about the R36 screw and do you remove it and when do you remove it? If you see, autorisés is especially very good in pediatric population. When you have got two years of growth left.
So what we are doing in our tenodesis is we are jacking out the sinus to side with the sinus to say, jacked out. We allow the soft tissues to grow. So then what happens is once the child reaches maturity, you take the screw out. So by then, the soft tissue would have grown in the right tension. So that's the aim.
But you can now be also using an adults. It is using it use as an adjunct procedure. So for example, I do a post-reconstruction, then I can put in this implant. The support, my post-reconstruction, you see, so it doesn't allow the sinus are set to collapse and afterwards you can take it out in the future. So so it can be used either as an adjunct or it can be used as a corrective procedure in pediatrics.
It is used as a corrective procedure, but in adults it is used as an adjunct. Well, thank you so much. One more question from Mark ask, why is interposition sufficient to position mandatory after the coalition or doesn't coalition B grow again? Or why do you have to do that procedure? Well, the most important disadvantage of a calkin and articulate coalition is the currents of the coalition.
Unfortunately, the coalition going back is one of the most common complication. So we need to put something in the gap to prevent the coalition to grow again. And a good thing is just at the roof of the signers to say you've got this muscle extensiveness to embrace, which is completely a vestigial muscle based. So you can actually put it as a gap filler and that prevents a recurrence.
So it is definitely a good idea. After accession of the coalition to interpose the edb, which is present right there and prevent a recurrence of the coalition. That's very good, I think. I think that's all the questions, unless one of you, the questions are quite simple in terms of what they're asking. To be honest with you, one of the simplest questions is when you remove implants, when you do after is.
Know, you said, you know, in pediatrics are generally two or three years and adults as soon as the post stabilizes. OK one other question is there if there's hyper vulnerability in the medial column, you should do fusion rather than cotton. Would you do a fusion rather than cutting osteotomy? Well, I mean, the depends once you correct the heel bulges if the forefoot super niche, because generally that's what happens, then you have to do a cottons.
You actually need it. Otherwise, the foot won't reach the floor. Whereas if the forefoot doesn't urinate, then it's just a case of hypermobility at the TMT. But the forefoot supination is flexible and you can correct it. Then you can do first fusion. Thank you. Thank you for asking a good word.
Thank you. I just one more question before we move on to that is from art. If you ask, why do you use FHL and not FDL to transfer? So normally we use FDL for us, not FHL. So he's got it wrong. It's FDL, not the official that he didn't use. FDA lists FDL. If you look at the muscle, it's actually more comparable to the power of the post.
We look at it as a much bigger muscle belly, so it's actually the power of the FDL. It can match up to the tip was better than the official. And secondly, you know, if you sacrifice the FHL and you lose plantar flexion of the big toe, which is a bigger disability than losing plantar flexion of the lesser toes so that we have deal is more expendable. Thank you very much.
So will we move on now to the excuse if I could kindly put on the questions and Mr Bajaj will take us through him? You're doing what you are answering this question just to say we have about four or five five questions today. And we'll try to prioritize those going for the exam in November, and we try to prioritize those who didn't have chances before. And we can't.
We wish we could involve everyone. But due to time limitation, we will have to choose randomly a few people based on the exam dates. So bear with us and we'll try to be as fair as we can. I'm just saying that we do not record the Viva section of this. I'm going to end the polling now. Thank you. Thank you.
So, so. 157 of you answered. Thank you, everyone. So Mr Judge will take us now through the questions. OK, so the first question was the subtilis coalition is most common at which visit and answer for that is a middle facet of the kalkilya I think we have discussed during the talk and 52% of views, said the Middle East.
So majority of you did see the Middle East. So yes, I in the slap Taylor joint, you've got the anti-deficit deficit and poverty deficit. The middle deficit, fortunately, is most commonly involved because, you know, you can do an extension of the coalition, the middle to set the postwar deficit. Coalitions have got the worst prognosis and thank God they are not as common. So it is the middle deficit.
The second question is the perennial spastic foot is associated with what? And we did discuss in the topic that it was Darcel coalition is in spastic foot 40 percent, 30, 45% have said Darcel coalition. And again, that's a majority now, but only it's actually a misnomer, you know, because in a foot that he has been in Vegas for such a long time that the peroni muscles get shot.
And because of this, they appear to be in spasm. They are actually not in spasm. All they are, they are just tight. So when they try to invert the heel you, you know, you get pain and it appears as if the muscles have gone into spasm. So it is a misnomer. It is just a tight baronial muscle and not a spastic pattern in muscle, and it is associated with castle coalition.
And then the third important question was what is the surgical management of State Street insufficiency? So as we said, stage three to pose insufficiency was when there was arthritis at the tail of navicular and joint. And then we basically a majority of the answer to that is a deep infusion. And I'm quite pleasantly surprised because 58% of you have said the perfusion.
I did cover it in the topic. Now, even if you see triple fusion, it's not wrong. Now, why do we go for deep fusion and not triple fusion? Because if you look at flatfoot, the foot has got a short lateral column, and a long medial column. So when you do a triple fusion, you fuse the calkin occupied joint, which means that you can shorten the lateral column further. And moreover, in a flat foot, most of the weight bearing is on the medial side, so the calculated vijan is not involved.
The wife used the calcium occupied joint to just fuse the tailbone ulnar claw in the joint, and you can do that through a single medial approach. You don't even need to do two incisions. And this has been well popularized by Professor tenotomy from Switzerland. So I do the double fusion through the single medial approach and the image. I do not want to further shorten the lateral column.
So that's the answer for the fusion stage 3% efficiency. That concludes the Viva. Congrats, most of you got it wrong, correct? It Yeah. These are very challenging questions, I have to say. Foot and ankle topics tend to be challenging, so I think candidates did very well. Yes so many people have been actually focusing on listening. That's good to know.
And thank you so well, Mr bajaj, if you would like to proceed with your case. Chair, the slides now, so this is a key discussion. So this is a child. Essentially, now he's now five years of age and he comes presents to us with an intervening date. There is a past history of having a plaster or serial casting for metatarsals adapters.
And obviously, that field. And finally, the child has got problems in the sense that he's having problems with shoe wear and also he's also having problems. He's got a clumsy gait and obviously he's in towing. So this is a picture of the child and obviously because it's a metatarsals addict, it's generally it's a normal variation and it should correct.
But you can see in this child, it hasn't corrected. So what do I do? Do I ask anyone that what would you do further? Obviously, what you can't see in this child is the hind foot, and you can. I can tell you that the hind foot is in slight Vargas, and he's got a collapsed arch and the forefoot is adapted. So could I ask anyone what thoughts are going on in the head and what further investigations would they need?
A five-year-old child who has a deformity of his foot with a four foot abduction amid foot collapse and a hind foot while just. And he has had treatment for metatarsals and doctors as a child, which has failed, and he has got symptoms in the form of an unsteady gait and problems with you wear. And in doing. Yes who is with us now?
Totally, or. Yes Yes. OK so who's answering? I have a future. It's me. Yes Oh yes, you are telling me this is a clinical photograph of both feet in a standing position. I see the photo in abducted and abducted position, but I need to see how in the food position, correct?
So I'm telling you, I don't have time for it, but I'm telling you the food is in Vegas and you can actually see the collapse of the arch in the foot here. OK this looks as obscure food where the food is abducted and the right food is in Vegas. And this is what you do. What? what do you want to do now?
I need to do an after history examination, I put on weight bearing X-ray for the full interview. So this is a weight bearing X-ray. You can see the AP and the lateral weight bearing X-ray. So what can you see? I see I see the combined government, in spite of the presence of Taylor hit and coverage, the four-foot is in abduction, all footage in what is a four British abducted four people that did indeed ADD yes, forfeited abducted when he was abducted.
It is not at all subluxation of the picture over the head of the Taylor's. And what is it like to debut in the lateral views, which I think is less than 10 degrees or this collapse of the medial epicondyle arch, even in the middle east, angle is negative. Very good, very good, very good, very, very good. So, yes, this is a really rare condition which is called skew foot, as you said, where the forefoot is in adduction and midfoot is laterally translated and the hind foot is in dialogue.
It's also called the serpentine foot or the foot. So what are you going to do for this child then? Literally, what are you going to do for them? This combined to correct the deformity of the handful and corrected the form of the four also. OK I think it needs to lateral column listening to it before that in the clinical examination. What else you want to examine in the ankle in the child? This in this case, I have to assess the rotational profile of the lower limb, and I need to assess the fitness of the Achilles.
Very good. Very good. I'm very happy to use the. Yes, because they tend to have a tight Achilles tendon, especially a tight gas truck. OK, so so how are you going to manage him? Obviously, his failed conservative treatment is now coming up to five years of age. So what is how would you approach this?
But how are you going to manage it? This is surgically. I need to increase the coverage, no, I need to increase the coverage of the joint, I need to do another column lengthening. Good they I have full off the collection of the little things the forefoot will be in more abduction, more abduction. It could be more affection. Most of all, it is mainly metatarsal osteotomy is to correct the forefoot abduction.
OK, so you so do you think all is that significant abduction at the metatarsal level? You think you want to do multiple metatarsal osteotomy? Or can you do something that could be open with a medial open, which is certain of the medial cf.? Fantastic so if you do a medial open wedge of the medial cuneiform and the lateral open wedge of the calcium or lateral column lengthening, you should be able to correct the midfoot and forefoot.
What about the hind foot? While guess that kind of progress can be corrected by medial displacement of tenotomy? Very good, but usually when you do the lateral column lengthening the hind foot, Bulger's also generally, you know, because what happens is, so how does lateral column lengthening work? How does it work? Can you explain?
How can you correct the uncovering of the tolerance bilateral column lengthening? How does it work? Lateral column lengthening? It means the foot. From the lateral side, based on along through the center of the head of the taylors, it of the meat fruit over time. Very good.
So basically the fulcrum of this osteotomy is a tail ulnar claw joint or the head of the tail. So when you open it laterally, it basically rotates around the tail ulnar claw joint, and that's how you get the tail covering back. I'm really, really are. Congratulations it's a very good answer. And you did very well, so that's good. OK, so this finishes at this discussion.
The next we go to the Viva. So for this, I'd like to thank Mr. Bajaj again for this wonderful session presentation, case discussions and M6. It's just been amazing. And we all enjoyed it and we all learned a lot and I could see your students have learned a lot and extended well. This answer reflects how much he learns from your lecture.
Very, very good. And thank you for offering to take a few candidates through the vyver, so we will do that next. So I'll stop recording now. Thank you.
Segment:0 .
Thank you. How do I one? Good evening, welcome to this teaching session, organized jointly by dfacs mentor group and the orthopedic Research UK amphoras, and I'll be moderating the session with my colleague Sean hinari. Ruth, head of education from our UK, is also the co-host tonight.
The speaker this evening is Mr Sunil bajaj, and he will be teaching us about pediatric, adult and pediatric and adult flat foot deformities. Mr Bajaj is a consultant, pediatric orthopedic surgeon at London at Lewisham and Greenwich NHS Trust. He gained his orthopedic training in the Southeast London, and he's done completed pediatric orthopedic fellowships at Sheffield Children's Hospital and Royal National Orthopedic Hospital in Stanmore.
Throughout his career, Mr Bajaj has been actively involved in teaching registrars and is highly acclaimed in the region for his teaching abilities. He's a convener of the UK, lower limb and pediatric of our case revision course and which runs twice a year. And I think the next one is in the autumn of this year here, and he's regularly invited as a faculty to various other FRC courses throughout the country.
We are very pleased that he's kindly accepted our invitation to present tonight, and I'm certain that each one of us will, will, will pick up many points from his session. This session, as you can see, will include the lecture presentation at the end of this presentation, there will be an emcee questions and that to check that you've all been focusing and listening to the presentation. So we will ask you all to answer these questions.
Mr Bajaj will tell us some tips for the FARC exam. And following that, there will be hardship and survival practice, and the places are limited, we only have about four or five questions prepared. So if anyone is interested, we ask you to express your interest by raising the hand symbol next to your name or sending us a message on the chat. We will prioritize those who are going for the exam in November.
But if there are no not enough candidates from November, we will take anyone else. So we try to keep these sessions as interactive as possible, so please ask you questions on the chat books and also raise your hand if you want to speak directly to Mr Bajaj. Our rules will get in touch with you regarding CPD certificates in due course. And if you missed any part of this presentation, don't worry.
It will be recorded and it will be posted on the FRCS mentor group YouTube channel and also on the UK site within a few days. Without further ado, I will leave you with Mr Bajaj. Over to you. Thank you for your kind introduction. Can everyone see it, please? Yes OK.
So hi, everyone, I'm Sunil Bajaj. I'm a pediatric and adult foot and ankle surgeon at Lewisham and Greenwich NHS Trust. So I thought we would take a very important topic today because, you know, at least it features a lot on their fashion. Thought it may be in clinical sessions. It meaning the wiwa to it features a lot in dfacs and that is a flat foot.
So I thought, let's discuss about the flat foot because the important thing about the flat foot is that, you know, it can affect all stages of life, right from pediatric, adolescent to adult. So this is the topic for today, flatfoot, and we are going to go in quite some depth. You know, obviously we can divide it into pediatric flatfoot, adolescent foot and adult foot and in pediatric foot.
Again, you've got flexible or physiological or postural and then you've got your fixed flat foot in adolescence. There are two main conditions Darcel coalitions and accessory navicula, which we'll discuss and in adult Blackfoot. Mainly, we'll discuss the posterior insufficiency because that's the most common which features in your exams. So, you know, we know that, you know, food has got multiple arches, you've got the medial arch, you've got a lateral arch, you've got your transverse toss a lot.
But probably the most important of those is the medial arch. So why do you need an arch? First of all, 1 May ask, why do we need a notch? This is because if you look at the foot, the foot is a segmented structure and to support the weight, a segmented structure requires an arch to support the very best. The second reason is it helps in shock absorption. And the third very important reason is propulsion.
So the three buzz words, if someone asked you what's the function of the medial arch support, absorption and propulsion, FRC is all it is all about buzzwords, and these buzzwords should come out in the answers. Now the important thing is the medial longitudinal arch. So what does it comprise of the bony structure? It's got the calcium, the tail is the navicula, the three uniforms and the three metatarsals. These comprise the medial longitudinal arch, and that's what we're going to focus on.
Now, obviously, you've got the structure to stabilize it, which can be divided into static and dynamic and static. Of course, it's got the bony and ligaments, and dynamic is the most important is the tip post. So amongst the static structures, probably you should. The most important you should know about is the spring ligament, and this is really important in the understanding of the management of foot.
So the spring ligament also called the plantar Calcasieu navicular ligament. And if you look at the diagram that you can see the two bands there. And these are the string ligament, they basically go from the substantial leg of the calcium right to the club, and they actually act like a hammock supporting the tails. So essentially, it is the plantar part of the tail navicular joint, the plant, the medial part of the tail ulnar claw joint.
And this is really important structure, which is a very important static stabilizer of the medial arch. So then, of course, the dynamic stabilizer, the dynamic stabilizer, as I said, is a tibial first year as everyone would know to be honest, consider inserts to all the bones of the foot, except the tailors and every insertion of the.
Rebels for Syria has got a role to play its insertion on in Africa is to elevate the medial margin of the foot. Its insertion on the sustainability line is to support the deal is its insertion to the third to the fifth metatarsal is to separate the foot. So basically it is basically got all the three parts has got a role in supine eating as well as elevating the media large and tip. And you know, we always talk when we talk about the gait and the stance phase of we always talk about and we talk about soldiers.
But you know what? The tip bolsters are another very important muscle, which actually plays a role in the stance of the G8. So what does the role of the tipples in the gait cycle? So before we actually get into foot individually, let's talk about the tip post because it is a functioning all flat feet. So if you look at the heel strike, so when you have the heel strike, there is, you know, there is an eccentric contraction of the tibial is a there, which prevents the foot slap down.
But as the heel strikes, the Sabella joint is analogous. And this causes the forefoot unlocking. So as a result, the forefoot is very flexible, and that's why it acts like a good shock absorber. So from the moment of the heel strike, the tibialis posterior starts to work. After the heel strike, the rebellious posterior comes to play, and most of its function is in mid. So there's an eccentric contraction of the tibial is possible in the stance.
So at the heel strike, the foot doesn't slide supination. But as you go to mid stance, the foot starts to plummet and the tibial Esposito is very important with this dysfunction so as to put your needs. The foot achieves a flat foot position. And this is very important the foot to be flat flattened, which stance? Because if it's flat, the weight bearing axis will go to the center of the foot, and that's very important.
It won't overload the medial or the lateral side. So that's uniform loading of the foot achieved because the tip post needs the foot and basically keeps the foot flat on which stands. And then during the terminal stunts, there's a concentric contraction of the post now, and as a result, the flexo-pronator again. And because the footstool beneath the heel inverts the forefoot, the tail of an ankle and the calkin occupied joins the midfoot, they become locked and the foot becomes a rigid lever.
And this gives you the push off during the terminal string. So this is a function you can see if the tip is not having this concentric contraction now, your foot will not be a very rigid lever and will not be an efficient push off. You'll lack an efficient push off. So that's what we said is the main function is during which stunts and turbulent stunts. That's the two phases of the gait cycle, where the tip is working initially with eccentric contraction and later as concentric contraction.
So the flatfoot, what are the effects of the flatfoot, so during which stunts we expect the foot to be flat, but if you have a flat foot, the weight bearing axis shifts to the inside of the foot rather than to the center of the foot. And because a weight bearing axis shifts to the inside, there's an internal rotation of the femur. There is an internal tradition of the knee. There's an interpretation of the tibia, which increases the angle and that increases pectoral patellofemoral pain.
And that's why flat foot just doesn't affect the foot. It also affects the knee, affects the hip and affects your lower back. So before again, going to individual feet, it's very important to understand the etiology of any foot. So, you know, foot is a trifling deformity. You know, there's a deformity in the sagittal plane where there's a sagging of the tailbone navicular joints, or there's a sagging in the surgical clean and you can determine the sagging by two important parameters immunities angle and the cranial pitch, which I am going to show you in the next slide.
The deformity in the frontal pain is the heel vagus and that you can look out for the tail of kalkilya angles and the deformity in the forefoot is in the transverse spleen, which is forefoot abduction. So there is a deformity in all three planes and forefoot abduction you get by the tail is first metatarsal angle and the tail coverage angle. I'm going to describe all three. So this is the miui's angle, which is a tolerance first metatarsal angle, so normally we expect the tailors and the first metatarsal to be in line.
This is a lateral view of the foot and the angle needs to be zero. However, in flatfoot, because of the sagging at the tiller navicular joint, you can see that the angle increases to above zero and it is convex plant outwards. So this is an important part of the media angle. So the mirror angle of 0 to 15 is mile, 15 to 30 is moderate and more than 30 severe flat foot. Then we are talking about the calculi pitch.
So calculated pitch is a line along the inferior border of the calcium and line along the plantar surface of the foot. And normally it ranges from about 25 to 40 feet. So here you can see that in the flat foot the calkin, which would mean be reduced. So that's the other important thing, which tells you there is a sagittal plane problem. Then if you look at the hind foot Vargas, this is by the tail of calculi angle kite.
He is the one who described the angle in the AP view. But you know, it's very difficult to demonstrate and calculate an AP view, so it's better to measure it in the lateral view. And so again, if the tail Tailhook angle is increased, so normally it's between 25 and 45. If it's increased, then it's analogous foot, and if it's decreased, it's about a foot. And then you got the forefoot abduction, or this is a very important part of foot and you guys should understand this part.
The midfoot subluxation laterally, there's a steal are uncovering and that produces four-foot abduction, and it's very important to identify this forward abduction. So there is the tailored Agricola coverage angle. So if you look at this, you draw a line along the articular surface of the. And along the articular surface of the navicular and the angle between these two, it should be 0 to 3 degrees.
So that's a normal. In other words, the navicular should completely cover the tail our head. Whereas if you look in this search, the next x-ray, you can see the navicular sublets laterally, so the tail won't have a cloud coverage until increases beyond three degrees. So this is uncovering of the dynamic of the tail. This is the tail coverage angle.
And then you've got the tail first metatarsal angle. So normally the tail is and the first metatarsal are called linear, but in the flat foot, because the tail is deviates medially and then goes laterally, the line through the tail is goes medial to the first metatarsal. So this is called the tail is first metatarsal angle. So these are some important angles which we need to know before we actually handle any flat foot.
So now we go to the first important part of the flat foot, the pediatric flatfoot, so the pediatric foot can be divided into two types, which could be either flexible or fixed, or it could be asymptomatic and symptomatic. So the flexible or the asymptomatic pediatric foot are two types the physiological foot or the postural foot or the calkin foot important calkin of is sometimes kept in the Viva and dfacs art, and it's very important to recognize this condition.
So this is a calculable guess, but essentially it's a packaging disorder. So then it's a packaging disorder. It is associated with other packaging disorders, which includes the idiot, which includes articles which includes metatarsal adaptors. So when they start to take you to the slides of the foot, please say that you want to examine the hips to rule out. So in this, what happens is, is the flexible type of foot.
In other words, both the reflection as well as the heel values are correctable. The heel is completely flexed here, but it is correctable. You can try to flex the foot and generally all it needs is just gentle manipulation, and majority of these will correct by the age of nine months. However, beware if you have a calculus value sport with this deformity in the leg called posterior medial tibial boing.
Then the posterior medial tibial bowing may result in the limb Allen discrepancy at maturity. So if there is a calkin of elegance with the posture medial bowing of the tibia, the children have to be followed until maturity. Because if the posterior medial bowing doesn't resolve on its own, they will have a difference of up to 3 to 11 centimeters. So beware calkin while his foot with posterior medial bowing of the tibia.
The other common foot in the child, which is asymptomatic, is the physiological slap for all children are born with flat feet. This is because the arch is absent at birth. They have generalized ligamentous laxity. They have got fat pads in their soul, so the arch is not very apparent and the arch can take up to 10 years to develop the first decade. So that's why when you get reference of a six year or a five-year-old child with a flat foot, you just have to reassure them because the arch can take up to 10 years to develop.
So the important thing about this foot is it's bilateral. It's asymptomatic and about 3% bas status in the adult population. So what are the screening tests? So you ask the child to go up on the toes. So you can see this is the flat foot, but as soon as the child goes up on the toes, the arts comes back and the heel goes into barrels, so it is completely correctable.
Similarly, you can ask the child to go on the inner and outer bottom of the foot, which means the supply joint is supple and you can see when the child is sitting down. That arch is present, but when you stands, the articles are be that shows it's a flexible foot and always check for in school. And please don't forget to study the Staley's rotational profile because foot can be associated with torsional deformities in the femur and the tibia.
So please test for the Staley's rotation profile, which is hip internal, external rotation, typekit angle, et cetera. So why can a flat foot, which is physiological, cause pain? Yes, it can, you know, majority of the time is asymptomatic, but minority of the times, it can cause pain. The reason being normally the dossey flexion when you dossey flex the foot, it occurs at the ankle. But because in these patients, the tendon Achilles is quite tight.
Those flexion bypasses the ankle and there is a midfoot break. And also flexion actually occurs at the midfoot, and that causes pain in the midfoot. And secondly, because of the high input values, you can get calcula fibula impingement. So they can get pain on the lateral side, impingement of the tenodesis and also because of the medial prominence of the talus, they can attack velocities on the medial side.
So beware heel cord or tender Achilles tightness in physiological flat feet. That's the only condition where physiological flat feet may need treatment because when they have tight heel cords. So how do you assess what he'll call tightness? It's very important that when you have a physiological foot to assess for tenodesis tightness before you do the silver sky test, you need to correct the heel values and correct the forefoot supervision that is very important.
Only then you should check for tender studies. Don't check the tender status with the heel and wielgus, because then the deflection may occur at the midpoint. So what is the treatment then asymptomatic, flexible flatfoot, nothing to do, just reassure them. I tell my patients that Usain Bolt had flat feet and he's the world's fastest man. So what is there to worry? So generally asymptomatic, flexible flat feet can be completely left alone.
You can do physiotherapy with Achilles tendon stretching and tibialis posterior strengthening and proprioception. And whether insoles or shoe modifications actually work in asymptomatic, flexible foot is a big mystery. And this mystery was solved by a gentleman called ringer a towel who did this prospective study on 129 people or children dividing them into four groups. Three, they had shoe modifications or heel inserts, and one where he did nothing.
And he found that there was no difference in the three year follow up. So therefore really giving them insoles when they are asymptomatic and flexible, it's a waste of time. On the other hand, if they become painful, there is a roll of the insults so you can give them either shoe modifications, insoles or earphones or of course, physiotherapy to do, he'll stretch or he'll call stretching.
But there are surgeries, obviously. You know, if it's a flexible, painful flat foot, it's painful and conservative treatment feels you can consider surgery is very rarely we have to do them, especially in the Black population, because you have got quite severe flat feet, which can be painful. And the problem in foot is a lateral column is shot so you can do lateral column lengthening. And in addition to that, you do a lot of soft tissue release.
You have to release the heel cord, that Achilles tendon. You have to advance the tibialis posterior because the balance procedure is very lax. So you need to tighten it. And you may have to lengthen the peritoneal tendons or the cultural osteotomy, which are sorted out for this condition is the lateral column lengthening how the lateral column lengthening axis is osteotomy done at the neck of the clerk and you Jack it open.
So basically the fulcrum of this osteotomy is axilo navicular joint. So what it does is it basically reduces the tailbone subluxation and restores the tail ulnar claw tenotomy and restores the arch of the foot. So as you can see here, this is where we do the lateral column opening. We make an osteotomy of the calcium. We Jack it open with the hinterland retractor.
And as you can see that as soon as you Jack it open, you see how the foot straightens out. The arch comes back and then you put a tri cortical iliac graft. Or you can do. Nowadays, you can put these tantalum wedges to open the calculi osteotomy, so thus it can collect your midfoot forefoot abduction. It can collect axilo, navicula, sac, and also it may even connect your heel.
While the heel doesn't correct by this procedure, then you may have to do a calkin and shift. The other thing which is actually coming into a lot of play now with flexible, painful flat feet is this is called the sinus Desai implant. So essentially what you do is it's called Art releases. So instead of doing a lateral cranial opening osteotomy you, you're actually producing putting an implant like a screw in the sinus Desai so that jacks open the sinus to side and prevents the lateral collapse of the sinus side and acts like a lateral column lengthening.
Its advantages are it's a very simple procedure, and it's sometimes done as a surgery. Sometimes it's done even at the local anesthesia in the US. But the disadvantages are you can do over stuffing of the sinus, or you can do under correction. So that's a problem and obviously you're putting a foreign material inside. So that's the disadvantages. So this was a patient who had a sinus ulcer implant, and you can see that it corrected uncovering corrected quite well, as seen on the x-rays on the right side.
And you can see these are the evidences to see that the scientists are saying blood actually works. So the next important topic is the pediatric six flatfoot, so we finish the pediatric flexible flatfoot, which was calkin of allergies and physiological, the pediatric flicks flatfoot, you mean you have to remove. Remember only one main condition and that is a congenital cortical talis. So it is also called the rock bottom foot.
So here, what happens is the hind foot is fixed ichinose. The midfoot is in fixed dose reflection. The forefoot isn't fixed abduction. So the mean pathology in this is a dorsal dislocation of the tail navicular joint. That's the mean pathology in CBT. So if you remember that what is the pathology in CBT is dorsal dislocation of the tail navicular joint, they have asked this next.
This has been asked in the exam what are the associations of CBT, the associations of CBT, neurological disorders and chromosomal or genetic syndromes? And the third thing obviously, it could be idiopathic. The neurological disorders like meningioma, Milo see lateral kyphosis and genetics in those trisomy 13, 15 and 18. And if it's idiopathic, it is also genetic and possibly an autism dominant inheritance.
So please remember associations of CBT, the two buzzwords you need to remember neurological disorders and genetic conditions. So what is the point problems in CCP so you can see the hind foot is in decline, as you can see on the X-ray. The tail is and the kalkilya both are in sequence. They are pointing down and the forefoot is industrial flexion that that's because of the dorsal dislocation of the tail on a regular joint and contracted anterior tibial muscles or the reflexes of the foot.
So this is why you get a rock bottom deformity because the forefoot is reflex and hind foot is equinix, so you get a convex plantar deformity. So the hind foot isn't fixed equine values, the forefoot is an abduction and deflection, and the planta surface of the foot is convex, and that's why it's called a rock bottom foot. It's very, very, very important to identify this at birth or very early in life because this needs immediate treatment.
So excuse for the CVT. I mean, obviously, you can do a lot, but the most important is the lateral actually of the foot and neutral position and the lateral actually of the foot in the force blind deflection position. So that's the lateral area of the foot in the neutral position. So you can see if you draw a line through the tail as it should normally be aligned with the metatarsals.
The navicular is not ossified until the age of 3. So you cannot see the Navy clad in this foot, so you just go with the metatarsals so you can see here the line to the tail is actually going plant up. It is not going to, but going plantar to the metatarsals. And then if you do a lateral view with the force maximal plant affliction, you can see the tail still goes planted to the metatarsal and it doesn't align with the metatarsals, even in maximum plantar flexion.
So this has to be differentiated by a condition called oblique tails and an oblique tail. As you can see that in maximum plantar flexion, you can see that the tail is actually aligned with the metatarsals, so management of the congenital oblique dealers is usually it. It was so far into surgery where you can do a one stage procedure or a two stage procedure, where you do a large Cincinatti incision and you have to do a lot of soft tissue and bony releases to reduce the tailbone articular joint.
But they found that surgery. Unfortunately results in a very stiff foot. So therefore now Dobbs that UBS has actually gone for serial casting, which is called the reverse Ponseti intraoperatively tuberosity. Here you've got Reverse quantity. So do you do the serial casting to reduce the tail ulnar claw joint and then an Achilles tenotomy to correct the decline in the ankle.
So it's a ponseti, a reverse. Ponseti is the order. So this was a child who presented lead, so he needed the one stage surgical release. You can see the Cincinnati incision on their finger, on the right, and you can see the correction. But remember, this is extreme. You can see preoperatively the vertical telescope and the X-ray on the right bottom lateral view shows that this corrected.
But remember now the treatment for CVD is reversed. Ponseti with at least tenotomy, you may need to do an open reduction of the ulnar claw joint, or it may reduce spontaneously. But remember it was Ponseti. So then we go to the adolescent foot adolescent Black for two important conditions the accessory navicular and also the calkin nunavik and the tassel coalition. These are the two conditions.
So the adolescent rigid foot is a very important short case in the exam, and it's a tacit coalition unless proved otherwise. It is a failure of segmentation. It is an autism dominant inheritance. It is also called a misnomer colonial spastic foot. That's a misnomer. The peroni are tight because the heel has been in Vegas for a long time, so actually they are not in spasm.
So that's a misnomer. And it's bilateral in 50% to 60% of the cases. So the commonest sight is the kalkilya navicular side and in the tail of calkin side, it's the middle facet of the tail. So this is a calcula navicula, and that's the middle facet of the case of kalkilya. There are other uncommon sites, but you don't need to know about them.
The most common is kalkilya, navicular and the medial facet of the tail of. The classification obviously depends on the degree of ossification, if it's fully ossified bar, then it's called a osteocytes. If it's a partially ossified bar, it's called a second ndrosis. And if it's a non ossified bar, it's called a syndesmosis and it's not generally associated with BFD and fibula.
So the symptoms are pain, and pain generally corresponds to the sight of the bar in Calcasieu navicular Mason in the Sinai star site and in the middle of the satellite, it's on the medial ankle joint. In addition, it also presents the presentation is when does when the bottle suffice? Calkin, kalkilya navicular. The pain is generally between 9 and 13 years, and they look in much later, 13 to 15 years.
This is when the bar justifies. And of course, the scientists are fixed flatfoot, so when you ask him to go up on the toes, the heel values will not correct. So radiographs you already described, but the important thing is, remember the 45 degree oblique views and axilo views. So the 45 degree oblique view shows the calcula navicular coalition best.
And of course, the lateral view for the tail of calculi coalition is seen in the lateral view. And there you see what you call is a C sign. The C sign is not typical for the coalition. Any Villegas foot can produce a C sign because the top of the tailors merges with the substance of the calculation analogous to an E foot can produce C sign. OK further investigations are secondary changes you can see, apart from the primary that is seeing the coalition, you can see secondary changes.
And one is a Taylor beating and you can see the anteater no sign, which is a prolongation of the anti the process of the calcium. I thought that imaging you can do with the CT scan, which shows you especially the local coalition's quite well. And you can do the MRI scans, especially for the cartilage installations. So most of the time, it can be an incidental finding, and it needs to be treated only if painful.
The important thing is treatment is always conservative. Remember, always try some insoles, try a plaster, sometimes 4, 3, 2 four weeks and then an insult. And if conservative treatment fails, then the Calcasieu navicular coalition, they do quite well. If you do early surgery on them where you reject the bar and you interposed the extent of the student service, and if it's a little adult, then you can still try excision of the coalition, but you may have to do a tailor fusion.
In axilo kalkilya coalition, on the other hand, you will see that the most important thing is they do quite badly with existence, though middle first coalitions do well with it can do well with exceptions posted official coalitions generally need subterfuge. So next we go to accessory navicula, so the incidence of that is 4 to 14% is generally bilateral. Most of the time, it's asymptomatic, just seen as a bulge on the medial side of the foot.
Now, obviously, there are three important types. The type 1 is a small article in the substance of the debate is posterior. It's got no connection with the navicular. Type 2 is about 1.1 to 1.3 centimeters size bone, which is connected to the navicular with the cartilage in this joint and type III is where fuses with the navicula, and you can't see it as a separate bone.
The communist is type 2. Now again, increase the lateral oblique view are quite good. You can see you can see the article there and you can even do MRI scans where you can see the high signal in the cloud as well as in the mean navicula, both in the 2002 rated images. So what happens is they produce immediate prominence, and they also medial the insertion of the tip post, and that's how they produce Blackfoot.
So most of the time, if they are asymptomatic, you don't need to do anything at all. But obviously, if there is an injury, then there is a pull on the second person so they can get symptomatic. And if they're symptomatic again, it's conservative, conservative, conservative and the siege baloney cost. And if a painful nonunion, especially in the type two, then you can do an exhibition.
When you do an exhibition, you basically split the deposit and excise it. Don't advance the depots, which is called the kingdom's procedure. Now, we don't need to do the procedure. All we need to do is just excise it. OK, it comes final topic. Adele foot. This is probably the most important topic because it features a lot on dfacs exam, and that's the tibialis posterior insufficiency.
So as we already said, the typical school student has got three important roles because of its multitude attachments to the foot, so through the attachment to the navicula, it raises the medial margin of the foot to the attachment to the substantial supports, the tailors and through the attachment to the metatarsals, beneath the foot. So the fact that what happens is because of The chronic overload of the tibial posterior, initially the tendon gets inflamed, later the tendon tears and later because of the deformity, you develop arthritis.
So these are the three stages of the tibialis posterior insufficiency. So it's a mighty plane, a deformity, as we said. You get the hind foot goes into Vegas, the forefoot starts abducting and flexo-pronator. And there's also medial column instability at the tail on or the first EMT joint. So classification of deposits asked in the exam and the earlier classification was Johnson Strom, who basically just classified it based on the presence of the hind foot deformity.
And later Mason added on the ankle involvement. So Mason did a modification of the Johnson stone. But now we actually also follow the blue men and Mason classification. We just don't look at the deformity, but look at the forefoot deformity, the ankle and the median column in stability, which is a more comprehensive classification. So the Johnson storm, you know, as we said, stage one, there's no deformity, stage two, there's a flexible hind foot deformity.
Stage three, there's a fixed hind foot deformity. And stage four added by Mason is when there is involvement of the ankle. But as blooming and Mason et Al defined this last vacation, and this is very good, you know, so he says stage one, no deformity. Stage two there's a flexible hind foot deformity, but it divides that into 2B and to C to B when there's a Whitford abduction to producing a foot abduction and to see when there is also first empty hypermobility.
And similarly, stage 3 is basically a rigid hind foot deformity, and stage 4 is the ankle deformity, which can be again forward if but flexible and forward be fixed. So I think this is a more comprehensive classification. So the risk factors of deposits generally in the fifth and sixth decade of life in usually obese ladies is very common in females. Pre-existing foot is a risk factor diabetes, corticosteroid use and sometimes zero negative inflammatory property.
So what happens, as we said in stage one, where there's only some inflammation of the post? You may notice some pain along the medial side of the post along the post and the medial ankle. There could be swelling there, so you can see you can see the swelling. Sometimes there, there could be swelling along the tip post. There may be also flattening of the arch, but most important is this is a correctable deformity so the patient can go on double heal and single heal.
It correct both. He can do the single heal. So even if you ask him to stand on one heel or the toes on one side, the deformity correct. Then it goes to stage two, where the tip pulls ruptures. So the result? You get a proper deformity. Here, the heel goes into bulges and in 2b, the forefoot starts abducting and in to see also the first hypomobility section.
So here the patient will not be able to do the single heel, but we'll be able to do the double heel. The reason he cannot do the single heel is because to in order to soften it, the foot. When you go up on your heel, you need the initiation to be done by post and subsequent ankle. Equinix is done by Achilles tendon, but because the post is not working in this stone, the topos cannot initiate this operation.
That's why you cannot do a single heel. But when he does a double heel, the initiation of slap lesion is done by the opposite foot. So then he can carry on with the tendon Achilles on the same side. And then, of course, the stage three where you get a fixed deformity and obviously with a stiff slap subtalar joint. So this is your stage three, as you can see, it's a fixed deformity doesn't correct and you have stiff slap de subtalar joint.
So what are the investigations you do? Well, you do, actually. We already talked about the miui's angle, the Taylors first metatarsal angle. And also you can see some kind of fibula impingement in the epp views, but you may also see more advanced stages where you can see arthritis in the DeLuna and the subtilis joints. So these are the extra features of advanced insufficiency.
And of course, you can do MRI scans within three to eight images, you can see a lot of inflammation or sometimes adipose ruptures, both on T1 and T2 weighted images. You can even do ultrasound scan. But the treatment, so you should stage one is just an inflammation of the post, so all you need to do is add the seeds and rest and you can give them supports like a deep post brace or you can do you, Cybill insert or you can also, of course, physiotherapy.
Very rarely, you can do a side effect of me, especially if it's 0 negative arthritis, according to both sinusitis. Now, stage two, as we said, we are divided into two way to be and to see throw in to e, where the heel is mainly a hind foot deformity. And the foot is OK. So you can't see too many toes sign. So there you can just do medial calkin cultural shift with FTL transfer to the post.
This is because the deformity is flexible and these people generally have been on the medial and lateral side of the ankle. So here you basically do a medial calculus shift to an extra articular oblique or shortening of the calcium. You're shifting the calkin immediately to correct the hind foot values. And you also using the FDL tendon? We are rooting it from the navicular from plantar to dorsal to augment the tip post.
It's going to be because there is a midfoot abduction. You need to correct them it foot abduction along with the hind foot deformity. So there you can do a lateral column lengthening, and it's great to see because there is also a first TMT hypermobility. You can do plan flexion or dorsal open, wedge osteotomy of the medial cuneiform.
This is because once you connect, the heel against the forefoot goes into supination. So in order to need the full foot, you may have to do a cotton osteotomy, which is a docile, open wedge osteotomy of the medial cuneiform. So these are the x-rays where we have done heel shift, FDL transfer, lateral column lengthening and accordions osteotomy to correct a stitch to see the pose insufficiency.
And of course, the stage three where you basically got arthritis at the tail joint. Now, normally we do. They used to do traditionally to pull out releases. But the disadvantage of the triple artery disease is the calkin occupied joint is not generally involved in flat foot. And because a lateral column is short, if you do a calkin occupied fusion, you further shortening the lateral column.
So nowadays we do a deep fusion and not a triple fusion, so we do need a double fusion, which is just a tail on having slap and calkin occupied fusion and not a solid subtilis fusion, not the calkin occupied fusion. So, conclusion, this poses a complex problem, it needs to be managed. Depending on what stage it is and what are the patient's symptoms, and you have to have an individualized treatment plan and results are quite good with conservative treatment, but obviously you need to go in early if you go into stage through two to prevent the stage three of stage four.
People haven't spoken about that, but stage four basically because of a long standing values producing a deltoid insufficiency. So in two, it produces a collectable and kill value. So you can do a deltoid deconstruction. But as in two th4t, whereas in 4b, it produces annual arthritis. So there you'll have to do a hind foot fusion. So this concludes the brief discussion about the pediatric adolescent and adult flatfoot, remember.
It features a lot as short and intermediate cases on their years, as well as why you are so pleased to play a lot of importance to this foot topic. So this concludes the topic on foot. We are open to questions. Thank you, Mr Death was very comprehensive lecture. Very focused. You covered the whole topic very beautifully. It's anything we all wish.
One of my mentors also said the same that we wish. We have listened to this before our exams, but I'm happy. Future candidates can take advantage of this now. So it's really, really a beautiful lecture. And as I say, it is a lot there and might not everyone might not have got the all in one go. So it will be, as I say, it's recorded and be posted later. So obviously there is. We have some basic questions, but before we go there, there is just a couple of small questions we have received.
I think the lecture was comprehensive enough is not covered everything, basically, but we have a question from Ahmad. He was asked about reverse Ponseti method. Is that a topic that could be asking if I should be worried about it? And yes, I think if it has now reversed, Ponseti is actually gaining a lot of popularity because surgical management of CBT is very difficult and it produces a very stiff foot because there's too much surgery involved.
So in reverse, ponseti, what we are doing is we are doing the reverse steps of the Ponseti. So here we are actually planned to flexing the ankle rather than flexing it. We have plantar flexing and inverting it. So the first five, six Cos we are plantar flexing the ankle and inverting the foot. And after fifth class, the foot actually resembles a clubfoot. It becomes like a clubfoot.
And then you do that Achilles tenotomy like you do in the Ponseti and you correct the ankle ichinose. And then you put it further into a plaster. But only thing is once you correct you, when you, when you, when you reduce the tailbone, have a joint. After five weeks, we put a key wire to hold the tailbone a joint reduced and then do an Achilles tenotomy and then put the final cast. And after that, we again put them in a brace, just like in clubfoot like that, we put them in a splint.
We here again put them in a dynamic brace so that for two years. And just like clockwork. So it's exactly like clubfoot. What is the reverse of it? So you should know about the worst ponseti? Yes, thank you. Thank you for explaining this. I think that answers the question.
Another question from us if he's asked if you do a CT scan that confirms there is bony coalition, you still have to do MRI scan or is it not? Well, I mean, the problem is I have been caught out in a few instances. What has happened is some of the patients, they have a bony coalition and in addition, they have got a fibrous coalition involving other joints.
So one of the patient had a medial facet, bony coalition of the subtilis joint and a fibrous coalition at the calcula. So I tend to do both. And the other important thing about the MRI is also it would highlight or show a high signal around the bony coalition telling you that the pain is actually coming from the coalition.
So it actually tells you that your pain points to you, that the problem is actually the coalition and not anything else. And also, it tells you the status of the satellite joint. If you do the MRI, so you can see if the satellite joint is already showing changes, then the prognosis is quite reserved for such individuals. So I tend to do both. Thank you very much.
That makes a lot of sense. And again, for the exam, for the exam, as long as you can explain your answer. I mean, in this manner, it'll be great, isn't it? One more questions from fikry is about the R36 screw and do you remove it and when do you remove it? If you see, autorisés is especially very good in pediatric population. When you have got two years of growth left.
So what we are doing in our tenodesis is we are jacking out the sinus to side with the sinus to say, jacked out. We allow the soft tissues to grow. So then what happens is once the child reaches maturity, you take the screw out. So by then, the soft tissue would have grown in the right tension. So that's the aim.
But you can now be also using an adults. It is using it use as an adjunct procedure. So for example, I do a post-reconstruction, then I can put in this implant. The support, my post-reconstruction, you see, so it doesn't allow the sinus are set to collapse and afterwards you can take it out in the future. So so it can be used either as an adjunct or it can be used as a corrective procedure in pediatrics.
It is used as a corrective procedure, but in adults it is used as an adjunct. Well, thank you so much. One more question from Mark ask, why is interposition sufficient to position mandatory after the coalition or doesn't coalition B grow again? Or why do you have to do that procedure? Well, the most important disadvantage of a calkin and articulate coalition is the currents of the coalition.
Unfortunately, the coalition going back is one of the most common complication. So we need to put something in the gap to prevent the coalition to grow again. And a good thing is just at the roof of the signers to say you've got this muscle extensiveness to embrace, which is completely a vestigial muscle based. So you can actually put it as a gap filler and that prevents a recurrence.
So it is definitely a good idea. After accession of the coalition to interpose the edb, which is present right there and prevent a recurrence of the coalition. That's very good, I think. I think that's all the questions, unless one of you, the questions are quite simple in terms of what they're asking. To be honest with you, one of the simplest questions is when you remove implants, when you do after is.
Know, you said, you know, in pediatrics are generally two or three years and adults as soon as the post stabilizes. OK one other question is there if there's hyper vulnerability in the medial column, you should do fusion rather than cotton. Would you do a fusion rather than cutting osteotomy? Well, I mean, the depends once you correct the heel bulges if the forefoot super niche, because generally that's what happens, then you have to do a cottons.
You actually need it. Otherwise, the foot won't reach the floor. Whereas if the forefoot doesn't urinate, then it's just a case of hypermobility at the TMT. But the forefoot supination is flexible and you can correct it. Then you can do first fusion. Thank you. Thank you for asking a good word.
Thank you. I just one more question before we move on to that is from art. If you ask, why do you use FHL and not FDL to transfer? So normally we use FDL for us, not FHL. So he's got it wrong. It's FDL, not the official that he didn't use. FDA lists FDL. If you look at the muscle, it's actually more comparable to the power of the post.
We look at it as a much bigger muscle belly, so it's actually the power of the FDL. It can match up to the tip was better than the official. And secondly, you know, if you sacrifice the FHL and you lose plantar flexion of the big toe, which is a bigger disability than losing plantar flexion of the lesser toes so that we have deal is more expendable. Thank you very much.
So will we move on now to the excuse if I could kindly put on the questions and Mr Bajaj will take us through him? You're doing what you are answering this question just to say we have about four or five five questions today. And we'll try to prioritize those going for the exam in November, and we try to prioritize those who didn't have chances before. And we can't.
We wish we could involve everyone. But due to time limitation, we will have to choose randomly a few people based on the exam dates. So bear with us and we'll try to be as fair as we can. I'm just saying that we do not record the Viva section of this. I'm going to end the polling now. Thank you. Thank you.
So, so. 157 of you answered. Thank you, everyone. So Mr Judge will take us now through the questions. OK, so the first question was the subtilis coalition is most common at which visit and answer for that is a middle facet of the kalkilya I think we have discussed during the talk and 52% of views, said the Middle East.
So majority of you did see the Middle East. So yes, I in the slap Taylor joint, you've got the anti-deficit deficit and poverty deficit. The middle deficit, fortunately, is most commonly involved because, you know, you can do an extension of the coalition, the middle to set the postwar deficit. Coalitions have got the worst prognosis and thank God they are not as common. So it is the middle deficit.
The second question is the perennial spastic foot is associated with what? And we did discuss in the topic that it was Darcel coalition is in spastic foot 40 percent, 30, 45% have said Darcel coalition. And again, that's a majority now, but only it's actually a misnomer, you know, because in a foot that he has been in Vegas for such a long time that the peroni muscles get shot.
And because of this, they appear to be in spasm. They are actually not in spasm. All they are, they are just tight. So when they try to invert the heel you, you know, you get pain and it appears as if the muscles have gone into spasm. So it is a misnomer. It is just a tight baronial muscle and not a spastic pattern in muscle, and it is associated with castle coalition.
And then the third important question was what is the surgical management of State Street insufficiency? So as we said, stage three to pose insufficiency was when there was arthritis at the tail of navicular and joint. And then we basically a majority of the answer to that is a deep infusion. And I'm quite pleasantly surprised because 58% of you have said the perfusion.
I did cover it in the topic. Now, even if you see triple fusion, it's not wrong. Now, why do we go for deep fusion and not triple fusion? Because if you look at flatfoot, the foot has got a short lateral column, and a long medial column. So when you do a triple fusion, you fuse the calkin occupied joint, which means that you can shorten the lateral column further. And moreover, in a flat foot, most of the weight bearing is on the medial side, so the calculated vijan is not involved.
The wife used the calcium occupied joint to just fuse the tailbone ulnar claw in the joint, and you can do that through a single medial approach. You don't even need to do two incisions. And this has been well popularized by Professor tenotomy from Switzerland. So I do the double fusion through the single medial approach and the image. I do not want to further shorten the lateral column.
So that's the answer for the fusion stage 3% efficiency. That concludes the Viva. Congrats, most of you got it wrong, correct? It Yeah. These are very challenging questions, I have to say. Foot and ankle topics tend to be challenging, so I think candidates did very well. Yes so many people have been actually focusing on listening. That's good to know.
And thank you so well, Mr bajaj, if you would like to proceed with your case. Chair, the slides now, so this is a key discussion. So this is a child. Essentially, now he's now five years of age and he comes presents to us with an intervening date. There is a past history of having a plaster or serial casting for metatarsals adapters.
And obviously, that field. And finally, the child has got problems in the sense that he's having problems with shoe wear and also he's also having problems. He's got a clumsy gait and obviously he's in towing. So this is a picture of the child and obviously because it's a metatarsals addict, it's generally it's a normal variation and it should correct.
But you can see in this child, it hasn't corrected. So what do I do? Do I ask anyone that what would you do further? Obviously, what you can't see in this child is the hind foot, and you can. I can tell you that the hind foot is in slight Vargas, and he's got a collapsed arch and the forefoot is adapted. So could I ask anyone what thoughts are going on in the head and what further investigations would they need?
A five-year-old child who has a deformity of his foot with a four foot abduction amid foot collapse and a hind foot while just. And he has had treatment for metatarsals and doctors as a child, which has failed, and he has got symptoms in the form of an unsteady gait and problems with you wear. And in doing. Yes who is with us now?
Totally, or. Yes Yes. OK so who's answering? I have a future. It's me. Yes Oh yes, you are telling me this is a clinical photograph of both feet in a standing position. I see the photo in abducted and abducted position, but I need to see how in the food position, correct?
So I'm telling you, I don't have time for it, but I'm telling you the food is in Vegas and you can actually see the collapse of the arch in the foot here. OK this looks as obscure food where the food is abducted and the right food is in Vegas. And this is what you do. What? what do you want to do now?
I need to do an after history examination, I put on weight bearing X-ray for the full interview. So this is a weight bearing X-ray. You can see the AP and the lateral weight bearing X-ray. So what can you see? I see I see the combined government, in spite of the presence of Taylor hit and coverage, the four-foot is in abduction, all footage in what is a four British abducted four people that did indeed ADD yes, forfeited abducted when he was abducted.
It is not at all subluxation of the picture over the head of the Taylor's. And what is it like to debut in the lateral views, which I think is less than 10 degrees or this collapse of the medial epicondyle arch, even in the middle east, angle is negative. Very good, very good, very good, very, very good. So, yes, this is a really rare condition which is called skew foot, as you said, where the forefoot is in adduction and midfoot is laterally translated and the hind foot is in dialogue.
It's also called the serpentine foot or the foot. So what are you going to do for this child then? Literally, what are you going to do for them? This combined to correct the deformity of the handful and corrected the form of the four also. OK I think it needs to lateral column listening to it before that in the clinical examination. What else you want to examine in the ankle in the child? This in this case, I have to assess the rotational profile of the lower limb, and I need to assess the fitness of the Achilles.
Very good. Very good. I'm very happy to use the. Yes, because they tend to have a tight Achilles tendon, especially a tight gas truck. OK, so so how are you going to manage him? Obviously, his failed conservative treatment is now coming up to five years of age. So what is how would you approach this?
But how are you going to manage it? This is surgically. I need to increase the coverage, no, I need to increase the coverage of the joint, I need to do another column lengthening. Good they I have full off the collection of the little things the forefoot will be in more abduction, more abduction. It could be more affection. Most of all, it is mainly metatarsal osteotomy is to correct the forefoot abduction.
OK, so you so do you think all is that significant abduction at the metatarsal level? You think you want to do multiple metatarsal osteotomy? Or can you do something that could be open with a medial open, which is certain of the medial cf.? Fantastic so if you do a medial open wedge of the medial cuneiform and the lateral open wedge of the calcium or lateral column lengthening, you should be able to correct the midfoot and forefoot.
What about the hind foot? While guess that kind of progress can be corrected by medial displacement of tenotomy? Very good, but usually when you do the lateral column lengthening the hind foot, Bulger's also generally, you know, because what happens is, so how does lateral column lengthening work? How does it work? Can you explain?
How can you correct the uncovering of the tolerance bilateral column lengthening? How does it work? Lateral column lengthening? It means the foot. From the lateral side, based on along through the center of the head of the taylors, it of the meat fruit over time. Very good.
So basically the fulcrum of this osteotomy is a tail ulnar claw joint or the head of the tail. So when you open it laterally, it basically rotates around the tail ulnar claw joint, and that's how you get the tail covering back. I'm really, really are. Congratulations it's a very good answer. And you did very well, so that's good. OK, so this finishes at this discussion.
The next we go to the Viva. So for this, I'd like to thank Mr. Bajaj again for this wonderful session presentation, case discussions and M6. It's just been amazing. And we all enjoyed it and we all learned a lot and I could see your students have learned a lot and extended well. This answer reflects how much he learns from your lecture.
Very, very good. And thank you for offering to take a few candidates through the vyver, so we will do that next. So I'll stop recording now. Thank you.
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