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Cavo-Varus Foot for Postgraduate Orthopaedic Exams
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Cavo-Varus Foot for Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
Thank you so much, Abdullah, that was a very kind and very generous introduction. It's my pleasure to get to talk to you all this evening. So the topic that I'm going to try and talk to you about is pesky. It's quite a complex topic. And to understand pez is properly, we actually have to an awful lot about the foot and ankle.
So I'm going to try and go through that as best I can. This is going to be at the level for those sitting the FLDS exam, and if anybody has any specific questions at the end, we can go through that. So pez caves caves is a descriptive term which just talks about how high the arches in the foot. But it covers a whole host of different foot shapes. It's often associated with a various position of the hind foot, and it may also be associated with an acquaintance.
To understand it properly takes excellent three dimensional anatomy several mechanical models all in your head at one time and also a great deal of flexibility of thought. So to understand how the foot works, we're going to look at multiple different mechanical models as we go through. But to understand how a normal foot works when a normal foot requires going up onto the tip toes to allow you to push off the tibialis posterior fires, along with the gas stroke and salacious through the Achilles.
And as the heel comes up, it swings around the tail adjoining joint inverts. This does two things. first thing it does is it stretches the plantar fascia around the metatarsal heads, pulling them around a further distance. And that tension is the plantar fascia, but it also locks the shape our joint. So this is windless mechanism, which we'll go through again shortly.
But when this mechanism is something that's very commonly talked about in the foot and ankle and you can see that the pictures at the bottom, the way when we go up onto our tiptoes, it actually tensions. The plantar fascia, which shortens the distance between the metatarsal head and the calcaneus. And that actually tensions the whole sole of the foot and turns.
It's very floppy and supple when it lands on the floor and something that's rigid and allows us to push off this inversion of the hind foot through the plant. Fashion tip post locks the mid portion of the foot and actually makes it more rigid, allowing us to push off. So keep virus I want to just stay right. At the start is a condition of stiffness, which is the complete opposite of the flat foot, which nine times out of 10 is a condition of sloppiness.
Kalybos can be a normal shape of the foot, so a lot of people have arresting cable various position when the foot is not on the floor. You will see that some people have a high arch in a vigorous position of the hind foot, and it can also be advantageous. Many sports players and those that are quick at running will actually have a mild case over this foot. Every single foot is completely individual, and you must approach it as a 3D puzzle that you have to solve to figure out the treatment specific and bespoke to that patient's foot.
Try and consider the following as you go through any 3D deformities, such as virus. So that will include trying to think as you go through the examination about the cause of the kevo virus, the deformity from top to bottom, and also those corrective options. And this is what we talk about in the exam is higher order thinking. And this is exactly what you have to do when you are consultant, when you see a patient, as soon as you start seeing that patient, you're actually thinking about your treatment and how you're going to apply that in that patient.
So what causes the virus? Well, the first thing that you should think about is that 60% to 70% of Rivera's feet have a neurological cause, and this could be something peripheral nerve problems such as Charcot Murray teeth. It could be a cerebral palsy, which although the lesion in the brain is static, the actual deformities that occur in the foot are not static.
It could be something such as Friedreich's ataxia, which is something we quote in the exam, but we rarely see it could be a spinal cord injury, a peripheral nerve injury, or something higher up like a stroke. Diagnosing a neurological cause is extremely important to understand the process that you might accept. Expect this foot to go through and also the prognosis of the condition and their reaction to the treatment that you might provide.
It's worth thinking about whether this is a bilateral problem as well. You will see some feet that are bilateral and this could be Charcot Murray's tooth. It could be a paraplegic or a quadriplegic. It could be Friedreich's ataxia, a spinal cord injury, cts-v or Imtiaz. There are also unilateral causes, such as shark tooth. Cerebral palsy can be unilateral in a hemiplegia polio.
Friedrichs ataxia a spinal cord injury. CTV volkmann contracture and stroke, and they are also associated things that you might see during your examination. Are any of the arms affected? If so, is it one arm or two arms are the legs shortened? Is one leg shorter than the other? Is this a champagne bottle type leg where you get peripheral wasting of?
Muscles, but proximal retention of muscle size, and that's usually a mnemonic finding in shark tooth is the IQ affected as well as this? Is this a global pathology? So there are a couple of anatomical things that we need to be aware of when looking at k Rivera's, and the first is the peronist longest activity, and this usually confuses people. So peronist longest is a muscle that sits on the lateral aspect of the leg.
So it's a lateral muscle, but it runs underneath the foot towards the medial plantar surface of the first metatarsal. If your foot's not on the floor, tensioning through the peronist longest will plan to flex your first metatarsal and also either the foot. But as soon as you're standing on that foot due to the fact that your first ray is now planned to flex down as you stand on it like a kickstand, the foot will rock over into an inverted position.
And I'm going to talk about that more shortly. To be honest, posterior tendon is a medially based muscle. It runs behind the medial EO to the navicula, where it inserts in a non standing foot. This will cause planta flexion through the telenav joint, and it will add up to the midfoot around the town of axilo joined in a standing foot. It will actually lift the heel up and invert the heel, and it forms part of that action, which allows you to lock your mid foot and create a stiff foot for push off mechanical concepts.
You're going to have to keep in your head when you're looking at a reverse foot. Our first of all, the tripod theory. A tripod can't be wonky. That's why we make barstools tripods so that when you're feeling a little bit squishy after too many days, you don't fall off the chair. It will always be stable. All three legs will share the force, and those three legs in the foot are a calcaneus in the first metatarsal head and the fifth metatarsal head to toe in foot.
That's how it looks. There are those three points that we talk about. Now this theory only really stands when you're looking at the foot from a global perspective. If you want to just consider the four, the forces are very different. When we're looking at a whole foot position, the tripod theory is very important. I've tried to use my hand here to show and this is what I was, what I did in the exam when I had to look at one of these.
And that was to show the medial arch with my index finger being the first metatarsal, my thumb being the Calcasieu arm and my middle finger being the fifth metatarsal. And you can see that a normal foot from a medial side and posterior. As soon as we planned to flex the first metatarsal, what we're essentially doing is lengthening one of those tripod legs towards the floor. And then when we went back through that, the foot will tip onto the other two legs.
And that's how when you've got a planet, a flexed first ray, the foot will actually tip into a various position with a higher arch. And that's because all of the foot is loading through that one kickstand position. Plantar flexed first metatarsal. If we then look at that same foot from the back as it lands on the first strain tips into various, you will actually see the heel come into a various position purely driven by that for folks to flex first metatarsal.
The windless mechanism is also very important when we look at acabou various foot and as we described before, would you go up onto the tip toes that actually stretches the punter flat plantar fascia around the metatarsal heads tensions the sole of the foot, and this elevates the arch and pushes the heel into a various pulled over by a tight plantar fascia. When you look at a cave virus, you need to consider, is this a problem of the soft tissues?
Is this that the soft tissues are too stiff? Is this that there is a muscular weakness? Is this that there is muscular or soft tissue contracture? Is it due to spasticity or overactivity of certain muscles or an imbalance or under activity of other muscles? Is this a bone or joint problem created by asymmetrical arthritis of the ankle or a previous fracture? Maui union in the history?
You want to know whether this has been present since birth or this is a progressive problem. Do they have a colostomy or an ulcer on the lateral border of the foot? Is there worsening mobility? Is that their main complaint? Do they have pain from joints, which are becoming degenerate? Is there a recurrent instability problem or do they have associated problems that are also going on?
And also what's been tried so far? Assessing deformity involves looking at the patient as a whole from the global aspect and then looking at the actual foot itself approximately and working your way down so purposefully. Make yourself consider the hind foot position, then the midfoot and then the forefoot. Try and go in an order of inspection, examination and special tests.
As we always do. Consider the following as you're going. As I've said before, think about what's causing this, what's driving this deformity? Where is the deformity occurring and what's the deformity specific to this foot? And what are the corrective options and whether they're appropriate in this patient? First of all, inspection does the patient walk, get them up and walk them in a young patient?
You can use the GMFCS if they have cerebral palsy, you want to be looking at whether they're using walking aids, whether they have splints and inspect their shoes to look for asymmetrical wear or insoles. Look at their gait so the gait pattern can tell you an awful lot if they have a high step, that's to clear a foot drop away from the floor. And then when their heel hits, they will have a foot slap because they don't have that eccentric slowing of time out, and that tells you that it's not working or is weak.
Are they recruiting their extensor tendons of the toes? So as they try and pick their foot up, can you see their extensor tendons pulling on the skin as they try and use their toes to lift the foot and also their toe Walker with tightness and spasticity in the posterior aspect of the calf? Is it a bilateral problem? Other associated deformities of proximal proximal issues in the legs.
Champagne bottles. Arm involvement, such as posturing or spasticity of the arms. And are there surgical scars from previous procedures? Overall, is the leg smaller? Is is the foot smaller and this would recommend to you that this has been present since birth and is more likely to be something such as CTV polio. Look at the skin, the nails, the hair.
This can all give you good aspects of whether there's something going on globally in this limb. When you're looking at the hind foot, there are a few things you want to comment on. The first thing is a cabinet position is the serious Achilles complex tight is that pulling the heel up and the toes down from the front aspect, you might see a peekaboo heel and that's a various position of the heel, which you can see sneaking out from the front.
Peekaboo heel purely tells you that the cocaine is in a various position and is then is visible posterior, sometimes quite difficult to actually see what alignment the heel is in. So one thing I always do is run my thumb down the back of the Achilles tendon, and that seems to draw a blanching line down the heel, and that can actually delineate whether this heel is straight. In slight, there is slight violence.
Just by running, you thumb down the back, then inspect the midfoot. Is there a kivus? A high arch position is the forefoot abducted. So is the forefoot actually beyond the line where you think it would be towards the midline of the body? Inspecting the forefoot, is there plantar Es of that first metatarsal when the foot's off the floor?
Can you actually see a punter flexed first? Ray is there clawing of the toes or clawing of the toes? Remember is that the empty PJs a hyperextended by overactive expenses? And are those expenses being recruited when the patient tries to lift their foot? And in that bottom picture, you can actually see these both stringing tendons that are visible. The BJ's always inspect.
The sole of the foot calyces will tell you exactly where the foot is weight bearing. A normal foot will weight that on the heel the first metatarsal. And then a shared colostomy under the lesser metatarsals. If you've got a large closet over the fifth metatarsal head or on the lateral border, you know they're putting too much weight through their. Still, a skilled test is something that's important in every single foot examination, and that's a test for one thing and one thing alone, it purely tests for gastronomy.
This tightness is a very difficult thing to explain quickly, and I'm going to help you to do that. So basically, you have to know the anatomy that pulls the heel up, and that's gastrectomy. And it's attaching together to a combined tendon called the Achilles, which inserts on the calcaneus. The gastric originates on the back of the femur, so it crosses the knee and the ankle. The silliest originates on the back of the tib and fib, so it only crosses the ankle.
So the difference between the two is just that. The gastric crosses the knee and there's the anatomy where the knee strikes. The gastric is engaged. When the knee is flexed, the gas is relaxed. The silliest is the same regardless of what the knee is doing. If you straighten the knee and also flex the ankle and look at the lateral side of the foot, you're then tensioning gastric sleeve and Achilles all together.
You look at the border of the lateral side of the foot. This is a straight surface, and this will give you the angle between the back of the leg and the lateral border of the foot. What you don't want to do is look at the medial side because the arch will give you a false reading. Ben, if you keep pressure on the foot and flex the knee, you're relaxing the gas stroke, the silliest Achilles complex and the ankle motion are all exactly the same.
All you're doing is taking gastric out of the equation. If there is a significant increase in the range of motion and the creases on the front of the ankle, then the test is positive. The positive test means gastric malleus tightness. There is a dire grammatical representation. I do it is this show, so I do it with the knees straight and then I bend the knee and see if the range of motion increases.
And here's a picture representation of an ankle and full dorsiflexion with a straight knee. And then with a bent me, you can see the creases occurring on the front of the ankle. And that's one of the key signs I look for. That's a much easier thing to look for than looking around the corner at the lateral border to see the angle, which is just something that we ballpark.
So if you've got a silver scale positive that tells you that you've got a gastric sleeve, this tightness, if you've got a silver scale negative and there is reduced dose deflection, that could mean one of several things Achilles tightness, Stelios FHO or FDL tightness, such as the ones contracture, posterior ankle, capsule tightness, ankle arthritis or a previous ankle fusion. If you've got a negative silver skill test with normal dorsal flexion, you have a normal ankle.
So when you're looking at a reverse, the next thing to look at is whether you've got a passively correctable deformity. Passively correctable means the joints move so they're not so arthritic they've become locked. The ligaments aren't so contracted that they're locking joints and you've not had previous fusions.
So you want to see whether the virus is correctable. Make sure you bend the knee to relax the and just see if you can passively shift that heel into a analogous position. Is there a method for kivus? And if there is, can you correct that by positioning the heel and push up on the first rate? Is that is there that plantar x, which is correctable as well and is there core?
So if you actually bring the anti-bjp down, can you correct that? Muscle function is something to look at as well, and this is going to be the next part of your examination. So first of all, cilia, you're going to plan to flex. This is a plan to flex the ankle and you're going to test the strength of gastric sleeve and see if it's tight using a silver scale test. The next thing you're going to look at.
Is Tim out if you don't deflects the ankle against resistance is about working? To post, you're going to plan to flex an adult than midfoot and you're going to resist against the medial border of the first metatarsal feeling over that tendon, which you can feel coming around the back of the medial mallet is to post working because this might be needed for correction is peronist prévus working to get them to forcefully abducts the foot.
So what I usually do is I put the foot in an abducted position and then I say, don't let me move your foot. And then with one finger, I'll come towards the fifth metatarsal. And try and add up to the foot and in the foot. And if they can resist that, peronist reverses working the peronist longest. I will plan to flex the foot and put it in an inverted position, and that will be my first metatarsal down.
And again, I'll say, don't let me move your foot now or push up under the first metatarsal head and get them to resist. And you can feel pollicis longus tendon tension on the lateral side of the foot. Then you want to look for needle, FHL and FDL tendons, whether they're working and is the Power Five out five. All of these muscles need to be tested because they might be required to correct this foot, and it will also point you towards the possible diagnosis.
Common block test is something that is going to be asked if you get a reverse foot and you need to be able to explain this very succinctly and clearly. Clearly, this is a test that relied completely on the tripod that we talked about before. So for that, you've got to remember that a tripod can't be wonky. All three aspects of a Three Legged anything that has three legs and wants to stand on the floor won't be wonky.
The force will be shared between those three points. The Kessler cranium first met head with my head and there are those ports. It's a dynamic test of a rigorous but first we stand the patient with the whole foot on a block. Wait by the foot. Examine the hind foot alignment from behind the patient. Is it straight or is it in a reverse foot? You'd expect it to be vigorous.
Then what are you going to do? Is twist the foot slightly so that the first metatarsal head is just hanging off the medial border of that block and you're going to wait there, the patient. So you can see now that first metatarsal is now off the block. But the other two aspects of the tripit tripod are on the block. If you now wait by the foot. Your weight bearing through those two other legs of the tripod, allowing that first metatarsal to drop into thin air, reexamine for alignment and see if it has been corrected.
So here you can see foot flat on the floor with a heel and a foot standing with the first metatarsal free. Tipping into a neutral or more vigorous alignment. And you can see it again a positive test. Whether heel correct when you wait there without the first metatarsal on the block tells you two things. The deformity is 4 foot driven, and that means that plan to flex first, ray is actually tipping the foot into a Reverse position.
The second thing it shows you is that the hind foot is supple, and that means that if you take away that deforming force from the front of the foot, the hind four will correct. There is also an aspect of instability and a lot of patients with Cairo, various you've got a varied position of the handful already and that's already in a partially inverted position. So they're already halfway across to having an inversion injury.
So it's very common to have ATF Allen CFL injuries. Remember, ATF is another anatomical thing we're going to have to be aware of in these patients and that the insertion of the ATF actually ticks upwards as it goes from the fibula to the neck of the Taylors. The CFL heads backwards as it goes onto the cranium. ATF is tested with the anterior drawer test and for this, what you're going to do is have the ankle 20 degrees plummet to flex, and that will bring that ligament, which is facing upwards into its most tension position.
So 20 degree plan to flexed foot. Then you're going to stabilize the tibia, hold the heel and translate the heel forwards. If they have a big leg or you have small hands, put the foot on the bed and translate the tibia backwards. If you see an increased glide and the tibia over the tolerance or the tail end under the tibia or a sulcus sign just in front of the fibula, then this is positive.
So here is the anterior drawer test and you'd see a sort of sign just in front of the fibula there as you slide it forwards. And here is the second way which I find very useful in people with larger legs, and you can see a nice big sulcus and you actually get a bigger range of motion in this as well, especially because the gastric malleus allows the foot to slide forwards under the tibia or the tibia to slide over because the knee is flexed.
So this is a very useful way to do that test. The CFL runs in the opposite direction, so you're actually going to have to forcefully dorsiflex the ankle on your forearm and apply various force to the heel, and you're looking for an equal range of motion to the opposite side or increased, whether there's a solid end point. And if you can feel that CFL tension against your thumb underneath the peroneal tendons where it runs.
So this is the way I do it with the forefoot running up my forearm. I hold the heel and I use the thumb of my hand on the heel and put it in just underneath the fibula here over the peroneal tendons. As you tick to various, you will feel the CFL push against those peroneal tendons underneath the thumb. And that's one of the aspects I look for. So I'm looking at radiographs of the cave overexposed.
There are several things to look at. And this is where you can start to really understand a foot on an X-ray is a 3D problem. So looking at just the deep view of the door, so point of view, you can actually see what position the hind foot sailing angle is a very useful thing in a normal foot. You have the Taylor sitting on top of the Calcasieu. But there is a slight angle to them as the calculus goes towards the lateral column, and the tolerance goes towards the medial column in a flat floor.
They unravel and the tolerance tips off the kalkilya. This is measured by Kate's angle, and that will be increased in a flat foot in a cave in various foot. The tailors will be right on top of the cocaine, so you get a decreased rectangle. Katanga is the angle between the tolerance and the cranium when you're looking at the foot from above. Tailor coverage is another thing to look at, and this looks at purely how much of a navicular is over the tolerance.
If you have an increased Taylor coverage so navicular is hanging over the medial side of the Taylor head, this tells you that you actually have an abducted forefoot and which may be associated with post overactivity because you actually have something pulling them immediately. How can you pitch is another aspect to look at, and that tells you the height of the cocaine that tells you how high that table's position is likely to be.
And if there is a cocaine use aspect to that. Mary's angles very, very useful, and this is something that you can generally just eyeball when you look at an X-ray and that's the line running down the talus, down the mid body and the neck of the tolerance and a line running down the first task. And they should be aligned perfectly. They should be two parallel lines, normally from minus 4 to plus 4.
Canvas is way off. There's more than 4 degrees positive, and that's where you take. This is actually slightly up and metatarsals slightly down where those lines cross tells you something else as well. It tells you where the center of rotation angle is. This is good. Good for considering where the deformity apex is in a flat or occasionally very spots.
And look where those lines cross, not just what the angle is. Sinus Thomas, I see 3 sine is also useful looking at harmful virus, and this is something that's slightly more common in a CTV typekit virus position of the first metatarsal stacking is something that can be seen just by glancing at a foot. You can tell whether this is a cable spot or a flat foot. So in a high, arched or kivus, you will see the metatarsals all visible, like the picture on the top in a flat foot.
All of these metatarsals line up a normal foot will kind of be like this. So if you're looking for the medial aspect of a foot, a normal foot will be like that. Rivera's position? It's almost like a hand facing towards you, and it is flat on the desk. Are the findings that you might see on an extra cable, there is something such as a fifth metatarsal based fracture because this patient is overloading the lateral border of their foot, which isn't designed to take that much force.
The CCTV typekit, you will see some other aspects, the first thing you'll see is that the fibular is very posterior in relation to the tibia. That's because cts-v patient is a three dimensional twisting rotational deformity, so they actually have an externally rotated ankle. So they will actually face very, very lateral in terms of their trans malleable axis. And then the foot rotates through the tail neck back to Face forwards on this patient, so you will see a very posterior fibula.
You'll also see an abnormally flattened tail of a Taylor body will run straight into the neck, and very often the tail and neck are butts on the front of the tibia. He you might also see something such as a congenital vertical talus, which can present as an extremely slap or a very high arch support, depending on the position of the rest of the bones and whether this is lost or dislocated. So non-surgical options are always the first thing we're going to talk about, and that's going to be an MDT approach.
Firstly, we need to reassure the patient and diagnose the cause 60% to 70% will be neurological. Physiotherapy can be useful to stretch the pressure, stretch the gastro, stretch out the post and balance muscles that are now weak. Also, orthotics can come in useful to accommodate or correct the position of the foot, depending on whether it's correctable or a fixed deformity.
Custom made insoles, custom made shoes, a foot drop splint or an AFO splint like the one pictured podiatry will be very useful to look after the health of the skin on the foot, such as Department of curiosities and monitor, and they can also they can also access orthotics, and some podiatry services will make those in house. We may also need neurology, neurophysiology, a spinal surgeon or a genetic geneticist, depending on what you think of the underlying cause might be.
Then we get to the surgical corrective options of a Eric's foot. So option one is do we need to lengthen any muscles gastric meaning a slide if we've got a silver scale positive? And that's why we release the fracture over the gas rock and allow the muscle to stretch out. If silver's field is negative, then we may need to release or lengthen the Achilles tendon to allow the heel to come back underneath the tibia is post overly tight.
Does this need lengthening these Edl contracted? Is this causing some of that flooring that's been there for so long is also pulling the first toe up into the air that needs lengthening? Ask them ligaments contracted and do these need releasing as well, such as the deltoid, the spring ligament, the subtalar ligaments, the plantar fascia, whenever we see a flat foot, we think of these structures as completely important.
But remember the k virus, especially if it's been present for a long time, it is an issue of stiffness and over contraction. You can very often release multiple tight ligaments and tight structures various foot, and it still won't correct as much as you would expect. So don't be afraid to release these structures if that's needed to get correction. Ligament reconstruction might be required, such as the lateral ligaments.
If they're chronically unstable. And one of the most beautiful procedures in the k Rivera is a tendon transfer because you get a double benefit. Not only do you remove a deforming force of an overactive or tendon, which isn't balanced out by an eccentric pull, but you're also going to implant that somewhere else to get a corrective force. But you do need a power that has five after five, or at the very least, in good 4 out of five.
This can include something like a tip post transfer, where we take the tip post off the navicular. We've put it through the interosseous membrane to pass it over the dorsal aspect of the ankle or the anterior ankle, and we insert it literally and laterally so axes and dorsal flexor of the ankle to balance not working and also an active inverter. If the post isn't working, you can use FDL, but it's not going to be as strong as stiff post.
And like I said before, you can get a double correction here. Post is causing you both errors. So if there's an equation, OK, reverse type position and there's an adopted forefoot on that dorsal point of view of the X-ray with too much Taylor coverage releasing, this will allow the foot to come back and then give you some active dorsiflexion and inversion of the foot. Maybe there's some pictures of the post tendon, which has been performed with splitting the tendon.
This is to give a more balanced Dorsett flexion of the foot. It's also do apparently its longest to transfer, which is a very beneficial procedure as these tendons lie right next to each other. Very straightforward to pull this horse so it to the brevis and slit along with just beyond where you've sewn it. It does take you about five minutes to convince yourself that you're cutting the correct tendon after you've seen them together.
It's worth marking one and hoping that the pen doesn't work from one to the other. It's always a slightly nervous time in the operation. And that could be seen here, and it's a very nice procedure because it's done through one small incision. We could also do something like an oil transfer where we take the child off the toe, which is causing that clawed position of the hallux we release that allows the tow to come back down.
We then implant the shell tendon into the metatarsal neck, so the X doors deflects the first metatarsal. If that's the deforming force, if this is a four foot driven cave, us with a supple hind foot because we've taken the HL7 off the toe, we will then need to use the IPA. Otherwise, we'll get a mallet deformity of the toe. We've still got extensive loosest crevice attached to the proximal five, so we will still have enough to lift that big toe off the floor.
Osteotomy very useful procedure because we can actually move the legs of the tripod into a beneficial position to help correct the foot calculi osteotomy can be done without sliding the calcaneus laterally or doing a lateral closing wedge, which I actually prefer more. It's a more stable procedure. If you cut a wedge out with a lateral base of the wedge and then you actually leave a medial cortex intact.
You can actually swing the weight bearing aspect of the calcaneus into a Lateral position and that actually lateral eases or Valdez's your heel part of the tripod, and that will actually cause some correction. You can also do a dorsal flexing first metatarsal osteotomy so you could have cuts in the metatarsal over parallel to the floor with the dorsal closing wedge. Or you can cut through the joint and fuse the first metatarsal TJ with a dorsal flexing, dorsal closing wedge and also form a super muscular osteotomy.
If there is asymmetrical arthritis or a previous fracture Mount Union. Here is a naturalizing balcony sliding type osteotomy, and here is the procedure that I prefer, which is a closing lateral wedge such as a Dwyer procedure or a crack of, I think is the other name for its lateral closing wedge. And you can see that it actually positions the heel more centrally under the tibia.
And that actually lateral eases your weight bearing point to the tripod. Here are some of the dorsal closing wedge osteotomy cyber through the joint with A10 fusion. If you think that that's an unstable or an arthritic, painful joint, or you can avoid the joint altogether, you can either do it as a vertical closing wedge, or you can do it parallel to the floor, which gives you a more stable closing wedge.
The final option in a nonsurgical non corrective deformity where there's arthritis present or you've got a very severe correction that's required is to either fuse the ankle. If the ankle is driving this virus or perform a triple fusion if you're doing a triple fusion or a keV virus. You have to address the lateral column. This is not a time to do it before where you just go immediately into a tailor and a tailor individually joint fusion.
Because if you do that, you're actually going to swing the foot into for more adapted, more Canvas and more various position. You are going to have to address all three parts of the triple and you're going to have to bone grafts. The medial side may slightly and take slightly more off the lateral side to get that correction. You may also need to do a fairly substantial midfoot osteotomy or a rotational osteotomy or fusions, depending on what that foot needs.
So to put it all together, one of the easiest ways to do that is to look at a sharp konmari tooth, which is probably one of the more common aspects of a cave over its position foot. So sharp motif is a hereditary motor sensory neuropathy, and if you can remember that name, then you can talk. You can say everything you need to say about shark tooth to pass the exam, and that is that this is an inherited condition and hereditary.
It affects the peripheral motor and sensory nerves, motor and sensory loss. And then if you want extra bonus points, you can say the main two types are the cause a demyelination of the nerves or Lariam type degeneration is progressive. It can affect the arms. It affects the longer peripheral nerves first, and it affects the nerves at different rates and by different amounts, so it causes an imbalanced weakness.
So this is very important to specify. It does not cause spasticity of certain muscles. It does not cause certain muscles to be overactive or tight. It causes all muscles to become weak, but at different rates, so some will be stronger than others. When you examine the foot. So this is a shellcode married tooth type foot, and you might get something like this in the exam and be asked to describe the deformity if you are looking at the foot on the left to the patient's left foot.
You might say looking from the front, there's a peekaboo heel. I can see sense of recruitment and I can see drawing of the toes. Looking from behind the foot, I can see a various position of the hind foot. Midfoot abduction and an increased arch. I can see that the first ray is planned to flex and I can also see from this side the coring makes sense. Recruitment sort of discussed.
It appears as an acquaintance position and mix, and then you can go on to examine it. Remember that this is muscles that are weakened by differing amounts. So any shark tooth typekit Rivera, you will find it peronist brevis will be more weak, so they will have loss for very weak, active evasion of the foot. What they will have is retention of the Pyrenees longer.
So remember that this is not strong or overactive. This is just last week, so you will get that classic plantar flexed first metatarsal. So this will be a four foot driven cave, various type foot that plan to flexed first ray caused by apparently its longest. We'll give you that arch shape, and it will also tip you into various when you stand on that front of flexed first ray.
They will also have a weakened Taliban, so they'll have a foot drop. They'll have that high stepping foot slap and gate, and they will also start to use their extensor tendons of the forefoot to lift the front of the foot off the floor when they try and clear the floating foot in the swing stance of gait. This claw of the toes actually causes several problems to do with the cave of their sport and shock.
The first thing is it will extend the CPGs. When you hyper send the MTB gs, the flexor tendons are being pulled around a further distance, which causes that flexed position of the PIP Jays and Jays. Because the toe is now sitting on top of the metatarsal. Whenever you stand, you wait there through the flexes and that drives the toe vertically down on the metatarsal head. And this is called the plunger effect.
If you have a toe, that's cord and the base of the proximal flexes on top of the metatarsal head. It will be driving that metatarsal into the floor when that patient walks. It will also exacerbate that windless mechanism by pulling the plantar fascia, which is inserted into the base of the planter aspect to the proximal phalanx around the metatarsal head, which will tighten your plans flush and more, stiffening the foot and raising the arch even higher.
As the hill sets off center, it's in a shortened position, so a Solis securities complex will be sitting slightly immediately and not completely open positions that will be contracted over time. If it becomes too long, it came a very sorry, if he's been left there for too long, you will start to get stiff or arthritic joints in that position, and it stops being correctable through soft tissues or osteotomy, and then you're looking at fusing joints.
So starting at the top and working down for a Charcot Murray tooth typekit covariance, you would say something like, I would first assess the serious Achilles complex doing a silver scale test if it's positive. I'd do a gastric slide. If it's negative, I do an Achilles lengthening. Then look at the hill position, the hill is in a medial various position, so I would do a lateral closing wedge, Kilkenny or osteotomy.
This lateral eases the weight bearing position of the heel, which applies a corrective force through the hind foot. If it's fixed for a subtitled subtitle is arthritic, you do a tame effusion. Working forwards, you can assess the perennial tensions and most likely, you'll need to transfer longest to brevis, so you're going to need to actually release the longest off that first metatarsal, which is going to allow correction on the one, which is to allow your plan to flex first metatarsal to come away from the floor mat will help through the tripod theory.
You're then going to transfer up to the Revit so you have an active inversion force on the lateral ball of the foot. Releasing the tape post again will take away some of that adoption plantar flexion of the medial column force, taking it through the intereses membrane and plumbing it in the top lateral aspect of the foot will give you some active dorsiflexion and inversion. And then you can consider the force looking at whether you're still going to need to do a Dorset flexing first, ray osteotomy, if releasing peronist long off the first rate hasn't done enough.
Are you going to have to lift that first rate up in the air? Are you going to do a generous procedure? And are you going to need to balance your lesser toes? And you'll only really know that once we corrected your hind foot and that's why we start at the top and work down. So we're going to lengthen the serious Achilles complex, either through gastric or Achilles that will allow your heel to come back in its correct position.
Then you're going to lateralize your heel, then you're going to remove the deforming forces and use those deforming forces to correct the foot, such as tip post transfer to the dorsolateral foot. And apparently as longest of reverse transfer, then we can correct the forefoot in the fourth. That's probably the most complex part of all this in balancing those toes and getting them to sit where they want to.
The easiest thing you could possibly say is I'll do a dorsal flexing first metatarsal osteotomy, and I'll probably need to do an extensive tenotomy and MTPA releases in most toes that will allow the toes to come down, but you might need to do things like flaps to extend the transfer. If we look at that foot, we just looked at a few seconds ago. We'll actually see on the right foot.
There are already some scars from correction, so this isn't a case of mine. This is just one I got off the internet for descriptive purposes, but you can see here this is a perfect case that you will get in the past. Yes, you say here is a patient with bilateral deformities. They've got a cable, various position with the left foot and you describe all those things.
We talked about peekaboo heel high arch with recruitment of expenses, pulling toes, various hand foot position and Achilles tightness and on the right foot. They've had previous surgical correction. You can see three stab incisions from a percutaneous triple release of Achilles. You can see a lateral based scar from the peronist longest transfer to brevis. There may also be that calculi osteotomy has been performed through this incision.
And there's also some formidable scars, potentially from the dorsal flexing, first rate osteotomy or a journalist procedure. And then there's some small scars over the lesser toes, suggesting there's been soft tissue balancing of the lesser toes. So I hope I've given you a bit of a whistle stop tour as to all the aspects that are involved in a cave various assessment, and you will see that to understand the 3D deformity of foot, you have to know very well the anatomy.
You have to understand the biomechanics of the foot and you're looking at three or four different models in the foot to talk about the various and how you get it. Correct it and then you've got a multitude of surgical options available to you, and you're going to have to design this operation around this patient. Now we talk about an Carte operation, and it really does mean a La Carte. So if you went to a menu, you would order exactly what you felt like on that day.
And that's exactly what you do for a foot like this is not an algorithm based assessment. You're going to look at the hind foot and say, how various is the hind foot? How it is the hind foot, how calcaneus is the hand foot? How high is the arch? Is this just a vertical elevation of the arch? Or is there some rotation? Is there a corrective rotation of the forefoot?
Is the first rate blunt to flex is the tail. It's more covered by the navicula, and you're going to have to use all those X-rays and all these assessments to figure out what you're going to do for this spot. It's not a straightforward thing, but it is a beautiful thing once you start to understand it. I hope I've given you a little bit of an overview, and I'm happy to take any questions that you might have.
Thank you very much, Mr G. That was really nice. Although I've done that before I there are certain aspects that I've learned, especially this stepwise management plan, which I really, really liked. I have some questions that has been put by the audience. The first one is about the silver skilled test and whether there is any difference, whether when, when, whether it is done with the patient sitting or lying.
And that probably is, but the only difference, really, that crosses all those joints would be sciatic nerve. So if you're going to do it with a patient sitting, you're going to have some tension on the sciatic nerve. So I always you've seen me in the clinic, Abdullah, I always sit-in my chair down at its lowest point. And if the patient can get their foot onto my knee, then I know already that the sciatic nerve is OK.
On the odd occasion, when I Dorset flex and ankle of a patient, they might say, oh, it's a bit tight down the back of which case I can do it with the foot in a lower position so I can take the foot off my knee onto the floor and do it again. So if you want to get the patient on the bed, then yes, that can be beneficial in some patients who have sciatica.
But I don't see it as a problem. I usually do it with the patient sitting. I can do my whole examination with the patient standing and sitting. Excellent fine. The questions they have is about the investigation whenever you get the first case of kivus. Would you always do a neurological assessment and a neurological investigation in the form of MRI of the spine or the brain or any such or not?
You assume that it's been done already as a foot and ankle orthopedic consultant. It's rare that I would get a referral of a patient that doesn't have a diagnosis, so most patients that would come to me with a caving various foot will have a history of CTV type treatment as a child, or they will have shark tooth running in the family and they will have been assessed at childhood because their mom has it.
Or this will be something that's been known about or there will be a known cerebral palsy. In the odd case that I do get where this is a first presentation of a case where there is a foot, then absolutely you would do a full assessment from top to toe. You would be asking neurological type questions. Has your gait worsened? Have you become more clumsy?
How is your walking pattern changed? How? how are your other senses? Do you have any pain radiating down your leg and you're going to have to think, is this brain? Is this peripheral nerve? Is this spine? Is this a neurological, muscular type problem? So I've seen patients with NewCo polysaccharide oasis with various type position and mcquinn okigbo various type position.
And there are so many different things that present as a cave to various foot, and they're all totally different and must be managed completely independently. But in answer to your question, yes, if there is no diagnosis and this is the first presentation, you're going to have to do a holistic top to toe approach. And that may require several months of I'm going to get an MRI scan of the spine of the whole spine, plus or minus the head are going to send you to see a neurologist.
We're going to get nerve conduction studies. You might need to speak to multiple people before you go anywhere near this foot with an eye because it will affect how the foot behaves accordingly. So, for instance, with a polysaccharide oasis, the muscles don't become spastic, they become stiff. So the muscles still have some activity, but the muscles can't stretch. They become stiff with the laying down of the gag proteins in the muscle so they don't stretch.
So your muscles can't stretch out for that Stallings curve to contract back down. So you're going to treat that very differently to something like a chakra motif. And if this is a progressive problem, you're going to treat it differently. If you think you can rely on muscle power to stay there, then you can use the muscles that are working for transfers. If you think that all muscles are going to become weak over time, then you're going to be looking for more definitive bony options, such as osteotomy or fusions.
The next question is mid is first metatarsal driven. Should you always do a dorsal metatarsal osteotomy, or will you as a new plan for it beforehand? Or will you go with an open mind and assess how it is in the operatively because you've mentioned this proximal to distal approach? Absolutely that's absolutely correct. So there is no always and there is no never. You're going to do each aspect of this operation and you're going to see how the foot responds to what you've done.
If you release the peronist longest off that base of that first metatarsal and attach it to your peronist crevice, that may be enough that the foot will correct how to phrase what you've said in the exam. So in the exam you've got in the clinical situation, a patient with us. And how would you say that I will go with an open mind? How would you phrase it in the exam in a way that conveys that what you're talking about, but at the same time, you know, you appreciate how complex the issue is.
So if my screen is still up? Yes so if we take the patient's left foot, that's in a reverse position here. What I would say is so before we have got a patient with bilateral foot problems, this patient has a preoperative left foot and a post-operative right foot on the left foot from a anterior position. I can see a peekaboo heel, a high arch and flooring of the toes of extensive recruitment.
Looking behind the foot, I can see that there is both straining of the Achilles tendon with a vigorous heel position and to correct this foot. First of all, I've discussed with the patient what they've tried previously, what their main complaints are, and if they're willing to consider surgical correction, surgical correction would be in the form of a 3D deformity correction starting proximally and distally. I will do a silver scale test to assess whether this needs.
The gas rock lengthening or Achilles, if it's positive gas dropping its negative Achilles. I will then laterals the position of the heel using a lateral closing wedge that will give me a Lateral position of the posterior aspect of the tripod, giving the foot. Some correction. As part of my assessment, I would do a Coleman block test. If that's positive.
That tells me two things. One, that it is a four foot driven deformity caused by blunt flexion of my first metatarsal two that the hind foot is supple. If I have a positive common block test, I would then do peronist longest to Revit transfer. I would see the position of the first metatarsal if it correct after this all well and good, if it does not. My next option would be to do a flexing closing wedge osteotomy the first metatarsal or if the X-rays showed arthritis of the TJ or do a dorsal closing wedge fusion of the first TNT to elevate the first metatarsal, then I would balance the soft tissues of the forefoot.
Other options for the first metatarsal would be a joans procedure. So it's a very difficult thing to put succinctly because there are so many options, but it's just having these things available, but you'd have to assess the whole thing and then talk about it from top to bottom. But it's able to use appropriate surgical options for a foot like this is very important.
So the key ones you really need to know are you going to do something for salis Achilles complex? Definitely that's an absolute. You will. If the heel is virus, you're going to want to put that into Vegas. If your first rate is down, your options are long to brabus transfer, if longest works. And your next option is Jones, if you want to do something dynamic.
Don't forget, if you're doing a Jones, you've got to fuse the IPA. You may need to Dorset reflects the first metatarsal through a non fuse and also flexing, closing and closing wedge on the dorsal aspect or fuse the TTMT. If you think that's painful and arthritic, then you're going to balance your forefoot and they're really the ones that you should definitely know for a cave that's supple.
If it's not supple and it doesn't correct on a Coleman block, you want to see X-rays to probably got home for arthritis, in which case, you're probably going to do a triple. That's the easiest I can make it. Absolutely as you mentioned, it's a three dimensional deformity, and unless you understand the anatomy and the biomechanics, it's very difficult to give answers something.
Another question I have here, which is related to the post-op protocol for these patients. Now I'm assuming that again, it depends on what you did exactly, because that with the aim of the management. Have you done first, ray as well, fusion or not? But in general, what is your routine post-op for the cases? So I try and make things as simple as I can. And for most 3D corrections, so something like a virus or a flat foot, I will usually do six weeks non weight bearing in a cast, followed by 6 weeks weight bearing in a boot.
That's just a general run of the mill thing when I've got osteotomy to heel and tendon transfers to heel. Mm-hmm And there are other things I might look at, so there are certain things I can do in a flat foot to speed things up if I'm going to do synthetic ligament reconstructions. But on the whole, six weeks non weight bearing, followed by 6 weeks weight bearing and a boot. Excellent and for the physiotherapy, when do you start that and what is the aim of it?
It just depends. So it really depends. If I've done, if I've gone for effusion, then I'm going to go minimally on my physiotherapy and I'm just going to be doing a little bit of sagittal range once I'm at the cast so the patient can remove it. So if I've done a triple, I would say six weeks non weight bearing, followed by 6 weeks without burying a boot and.
I might get the patient out after the first six weeks and starting doing a range of the motion of the ankle. With something like a more complicated correction, random transfers, I might want to get those patients going a little bit quicker, so I might actually put them in a boot at around four weeks and just start some gentle range of motion exercises. But it's patient by patient basis. It depends on the patient factors, operative factors, surgical factors, load loads and loads of aspects would really come into that compliance and tissue situation and exactly what you did and how the field was during the operation.
Excellent OK, so again, next question is, how would you correct the forefoot adduction? Abduction is usually driven by tip post, though post is what adopts the forefoot. Unless you've got unless you've got one of these very skewed feet like a TV where the ankles are facing off laterally and the forefoot is facing very immediately, the usual case is that it's a post type adoption and you'd see this on the door.
So planet of you as Taylor covering. So if I just skip back to that view, you will actually see over covering of the four foot, so you'll actually see that the picture is being pulled around the tail ahead. So in that one, if they've got a foot drop as well, you've got the perfect option of releasing the tip post from the navicular. And because you actually need to pull it through the intereses membrane to the anterior aspect and insert it.
You are actually going to have to take that as long as possible. So it's worth taking off to post with a sliver of curiosity and running down to the cuneiform to give you a little bit of extra length. The worst thing you ever want to see in the world is when you take it off and you can't quite get it to the bone where you want to insert it. So keeping as much length as you can there with a sliver of curiosity and then pulling it through intereses membrane onto the lateral dorsal surface of the foot.
So the lateral cuneiform or the voyage that will release that, that deforming force of the post and by plumbing it in on the top and lateral aspect, it will give you that active Dorset collection and the version of the foot. So you actually get a removal of a reformer and an addition of a character. And there the beautiful options where you get buy one, get one free.
Yep yep, beautiful. Fine I have another question here. But shall we do these surgeries just for because Mrs. No, no, that's what plastic surgery is for. So I do these. These are big surgeries. They do not, give someone a normal foot. They give someone improved biomechanics. So for any foot surgery, what you're looking for is a stable, weight bearing platform and something that's pain free and chewable.
Are the things you're looking for stable, weight bearing platform, pain free, chewable. So if they walk in and they're wearing the boot hands and they just don't like the look of a certain bump on their foot, then they're not going to want major reconstructive surgery of osti, optimizing the bones and releasing tendons and transferring them elsewhere. You're not going to get this back to a normal foot, but you can improve things.
And so surgery is really for when there's weight bearing issues or when there's pain. And that pain might be due to the weight going through the aspect of the foot overloading the soft tissues or arthritis. So it could be related to fractures and things that are associated instability. The people that aren't appropriate for surgery, usually the simple task of explaining what the surgery entails will make them realize that this is quite a substantial task for them as well as you.
And they will usually self-select and say, actually, you know, don't worry about it, it's fine. I'm quite who remain solid. Excellent there is a question that I didn't fully understand from Cynthia Kumar. Now I will say it. If you if you understand it, then fine. If not, then will invite Mr synthy Kumar to say it. So in case a fixed Guevara's painless foot can we follow non operative?
I think he means, can we go with this conservative treatment? Of course, of course. So non-offensive is always a viable option in surgery, in my mind is a last resort option. So doing nothing has very few risks, but doing something does put the patient through a substantial risk in the post-operative period. And I only do that if there are clear gains to be made. So there's only there's only reason to put the patient through the risk of surgery.
You think that there are substantial gains that are likely to be made. So if you have a patient who has a K Rivera's position of the foot and they can see you and say, oh, it's deformed doctor, I don't I don't like the look of it. Does it hurt? No, it doesn't hurt. It just annoys me.
Then you can say, well, let's get you some good, good going insoles and some shoes that fit your thought rather than making your foot fit the shoes. And let's see where we get to. And a good thing to say to these patients is that surgery is always there. My favorite thing that I like telling the patients is I'm going to be working there for 30 or 40 years, so I'm not going to go anywhere.
And they can come back whenever they like and have the surgery. But you can't then do the surgery, so you exhaust all of their aspects for an operation like this before you, before you jump for the NIPE. Excellent well, thank you very much for your time and your presentation, and I'm sure everyone has learned a lot. I certainly have.
Thank you again for giving us the time and putting it so succinctly and nice. Make it towards the exam.
Segment:0 .
Thank you so much, Abdullah, that was a very kind and very generous introduction. It's my pleasure to get to talk to you all this evening. So the topic that I'm going to try and talk to you about is pesky. It's quite a complex topic. And to understand pez is properly, we actually have to an awful lot about the foot and ankle.
So I'm going to try and go through that as best I can. This is going to be at the level for those sitting the FLDS exam, and if anybody has any specific questions at the end, we can go through that. So pez caves caves is a descriptive term which just talks about how high the arches in the foot. But it covers a whole host of different foot shapes. It's often associated with a various position of the hind foot, and it may also be associated with an acquaintance.
To understand it properly takes excellent three dimensional anatomy several mechanical models all in your head at one time and also a great deal of flexibility of thought. So to understand how the foot works, we're going to look at multiple different mechanical models as we go through. But to understand how a normal foot works when a normal foot requires going up onto the tip toes to allow you to push off the tibialis posterior fires, along with the gas stroke and salacious through the Achilles.
And as the heel comes up, it swings around the tail adjoining joint inverts. This does two things. first thing it does is it stretches the plantar fascia around the metatarsal heads, pulling them around a further distance. And that tension is the plantar fascia, but it also locks the shape our joint. So this is windless mechanism, which we'll go through again shortly.
But when this mechanism is something that's very commonly talked about in the foot and ankle and you can see that the pictures at the bottom, the way when we go up onto our tiptoes, it actually tensions. The plantar fascia, which shortens the distance between the metatarsal head and the calcaneus. And that actually tensions the whole sole of the foot and turns.
It's very floppy and supple when it lands on the floor and something that's rigid and allows us to push off this inversion of the hind foot through the plant. Fashion tip post locks the mid portion of the foot and actually makes it more rigid, allowing us to push off. So keep virus I want to just stay right. At the start is a condition of stiffness, which is the complete opposite of the flat foot, which nine times out of 10 is a condition of sloppiness.
Kalybos can be a normal shape of the foot, so a lot of people have arresting cable various position when the foot is not on the floor. You will see that some people have a high arch in a vigorous position of the hind foot, and it can also be advantageous. Many sports players and those that are quick at running will actually have a mild case over this foot. Every single foot is completely individual, and you must approach it as a 3D puzzle that you have to solve to figure out the treatment specific and bespoke to that patient's foot.
Try and consider the following as you go through any 3D deformities, such as virus. So that will include trying to think as you go through the examination about the cause of the kevo virus, the deformity from top to bottom, and also those corrective options. And this is what we talk about in the exam is higher order thinking. And this is exactly what you have to do when you are consultant, when you see a patient, as soon as you start seeing that patient, you're actually thinking about your treatment and how you're going to apply that in that patient.
So what causes the virus? Well, the first thing that you should think about is that 60% to 70% of Rivera's feet have a neurological cause, and this could be something peripheral nerve problems such as Charcot Murray teeth. It could be a cerebral palsy, which although the lesion in the brain is static, the actual deformities that occur in the foot are not static.
It could be something such as Friedreich's ataxia, which is something we quote in the exam, but we rarely see it could be a spinal cord injury, a peripheral nerve injury, or something higher up like a stroke. Diagnosing a neurological cause is extremely important to understand the process that you might accept. Expect this foot to go through and also the prognosis of the condition and their reaction to the treatment that you might provide.
It's worth thinking about whether this is a bilateral problem as well. You will see some feet that are bilateral and this could be Charcot Murray's tooth. It could be a paraplegic or a quadriplegic. It could be Friedreich's ataxia, a spinal cord injury, cts-v or Imtiaz. There are also unilateral causes, such as shark tooth. Cerebral palsy can be unilateral in a hemiplegia polio.
Friedrichs ataxia a spinal cord injury. CTV volkmann contracture and stroke, and they are also associated things that you might see during your examination. Are any of the arms affected? If so, is it one arm or two arms are the legs shortened? Is one leg shorter than the other? Is this a champagne bottle type leg where you get peripheral wasting of?
Muscles, but proximal retention of muscle size, and that's usually a mnemonic finding in shark tooth is the IQ affected as well as this? Is this a global pathology? So there are a couple of anatomical things that we need to be aware of when looking at k Rivera's, and the first is the peronist longest activity, and this usually confuses people. So peronist longest is a muscle that sits on the lateral aspect of the leg.
So it's a lateral muscle, but it runs underneath the foot towards the medial plantar surface of the first metatarsal. If your foot's not on the floor, tensioning through the peronist longest will plan to flex your first metatarsal and also either the foot. But as soon as you're standing on that foot due to the fact that your first ray is now planned to flex down as you stand on it like a kickstand, the foot will rock over into an inverted position.
And I'm going to talk about that more shortly. To be honest, posterior tendon is a medially based muscle. It runs behind the medial EO to the navicula, where it inserts in a non standing foot. This will cause planta flexion through the telenav joint, and it will add up to the midfoot around the town of axilo joined in a standing foot. It will actually lift the heel up and invert the heel, and it forms part of that action, which allows you to lock your mid foot and create a stiff foot for push off mechanical concepts.
You're going to have to keep in your head when you're looking at a reverse foot. Our first of all, the tripod theory. A tripod can't be wonky. That's why we make barstools tripods so that when you're feeling a little bit squishy after too many days, you don't fall off the chair. It will always be stable. All three legs will share the force, and those three legs in the foot are a calcaneus in the first metatarsal head and the fifth metatarsal head to toe in foot.
That's how it looks. There are those three points that we talk about. Now this theory only really stands when you're looking at the foot from a global perspective. If you want to just consider the four, the forces are very different. When we're looking at a whole foot position, the tripod theory is very important. I've tried to use my hand here to show and this is what I was, what I did in the exam when I had to look at one of these.
And that was to show the medial arch with my index finger being the first metatarsal, my thumb being the Calcasieu arm and my middle finger being the fifth metatarsal. And you can see that a normal foot from a medial side and posterior. As soon as we planned to flex the first metatarsal, what we're essentially doing is lengthening one of those tripod legs towards the floor. And then when we went back through that, the foot will tip onto the other two legs.
And that's how when you've got a planet, a flexed first ray, the foot will actually tip into a various position with a higher arch. And that's because all of the foot is loading through that one kickstand position. Plantar flexed first metatarsal. If we then look at that same foot from the back as it lands on the first strain tips into various, you will actually see the heel come into a various position purely driven by that for folks to flex first metatarsal.
The windless mechanism is also very important when we look at acabou various foot and as we described before, would you go up onto the tip toes that actually stretches the punter flat plantar fascia around the metatarsal heads tensions the sole of the foot, and this elevates the arch and pushes the heel into a various pulled over by a tight plantar fascia. When you look at a cave virus, you need to consider, is this a problem of the soft tissues?
Is this that the soft tissues are too stiff? Is this that there is a muscular weakness? Is this that there is muscular or soft tissue contracture? Is it due to spasticity or overactivity of certain muscles or an imbalance or under activity of other muscles? Is this a bone or joint problem created by asymmetrical arthritis of the ankle or a previous fracture? Maui union in the history?
You want to know whether this has been present since birth or this is a progressive problem. Do they have a colostomy or an ulcer on the lateral border of the foot? Is there worsening mobility? Is that their main complaint? Do they have pain from joints, which are becoming degenerate? Is there a recurrent instability problem or do they have associated problems that are also going on?
And also what's been tried so far? Assessing deformity involves looking at the patient as a whole from the global aspect and then looking at the actual foot itself approximately and working your way down so purposefully. Make yourself consider the hind foot position, then the midfoot and then the forefoot. Try and go in an order of inspection, examination and special tests.
As we always do. Consider the following as you're going. As I've said before, think about what's causing this, what's driving this deformity? Where is the deformity occurring and what's the deformity specific to this foot? And what are the corrective options and whether they're appropriate in this patient? First of all, inspection does the patient walk, get them up and walk them in a young patient?
You can use the GMFCS if they have cerebral palsy, you want to be looking at whether they're using walking aids, whether they have splints and inspect their shoes to look for asymmetrical wear or insoles. Look at their gait so the gait pattern can tell you an awful lot if they have a high step, that's to clear a foot drop away from the floor. And then when their heel hits, they will have a foot slap because they don't have that eccentric slowing of time out, and that tells you that it's not working or is weak.
Are they recruiting their extensor tendons of the toes? So as they try and pick their foot up, can you see their extensor tendons pulling on the skin as they try and use their toes to lift the foot and also their toe Walker with tightness and spasticity in the posterior aspect of the calf? Is it a bilateral problem? Other associated deformities of proximal proximal issues in the legs.
Champagne bottles. Arm involvement, such as posturing or spasticity of the arms. And are there surgical scars from previous procedures? Overall, is the leg smaller? Is is the foot smaller and this would recommend to you that this has been present since birth and is more likely to be something such as CTV polio. Look at the skin, the nails, the hair.
This can all give you good aspects of whether there's something going on globally in this limb. When you're looking at the hind foot, there are a few things you want to comment on. The first thing is a cabinet position is the serious Achilles complex tight is that pulling the heel up and the toes down from the front aspect, you might see a peekaboo heel and that's a various position of the heel, which you can see sneaking out from the front.
Peekaboo heel purely tells you that the cocaine is in a various position and is then is visible posterior, sometimes quite difficult to actually see what alignment the heel is in. So one thing I always do is run my thumb down the back of the Achilles tendon, and that seems to draw a blanching line down the heel, and that can actually delineate whether this heel is straight. In slight, there is slight violence.
Just by running, you thumb down the back, then inspect the midfoot. Is there a kivus? A high arch position is the forefoot abducted. So is the forefoot actually beyond the line where you think it would be towards the midline of the body? Inspecting the forefoot, is there plantar Es of that first metatarsal when the foot's off the floor?
Can you actually see a punter flexed first? Ray is there clawing of the toes or clawing of the toes? Remember is that the empty PJs a hyperextended by overactive expenses? And are those expenses being recruited when the patient tries to lift their foot? And in that bottom picture, you can actually see these both stringing tendons that are visible. The BJ's always inspect.
The sole of the foot calyces will tell you exactly where the foot is weight bearing. A normal foot will weight that on the heel the first metatarsal. And then a shared colostomy under the lesser metatarsals. If you've got a large closet over the fifth metatarsal head or on the lateral border, you know they're putting too much weight through their. Still, a skilled test is something that's important in every single foot examination, and that's a test for one thing and one thing alone, it purely tests for gastronomy.
This tightness is a very difficult thing to explain quickly, and I'm going to help you to do that. So basically, you have to know the anatomy that pulls the heel up, and that's gastrectomy. And it's attaching together to a combined tendon called the Achilles, which inserts on the calcaneus. The gastric originates on the back of the femur, so it crosses the knee and the ankle. The silliest originates on the back of the tib and fib, so it only crosses the ankle.
So the difference between the two is just that. The gastric crosses the knee and there's the anatomy where the knee strikes. The gastric is engaged. When the knee is flexed, the gas is relaxed. The silliest is the same regardless of what the knee is doing. If you straighten the knee and also flex the ankle and look at the lateral side of the foot, you're then tensioning gastric sleeve and Achilles all together.
You look at the border of the lateral side of the foot. This is a straight surface, and this will give you the angle between the back of the leg and the lateral border of the foot. What you don't want to do is look at the medial side because the arch will give you a false reading. Ben, if you keep pressure on the foot and flex the knee, you're relaxing the gas stroke, the silliest Achilles complex and the ankle motion are all exactly the same.
All you're doing is taking gastric out of the equation. If there is a significant increase in the range of motion and the creases on the front of the ankle, then the test is positive. The positive test means gastric malleus tightness. There is a dire grammatical representation. I do it is this show, so I do it with the knees straight and then I bend the knee and see if the range of motion increases.
And here's a picture representation of an ankle and full dorsiflexion with a straight knee. And then with a bent me, you can see the creases occurring on the front of the ankle. And that's one of the key signs I look for. That's a much easier thing to look for than looking around the corner at the lateral border to see the angle, which is just something that we ballpark.
So if you've got a silver scale positive that tells you that you've got a gastric sleeve, this tightness, if you've got a silver scale negative and there is reduced dose deflection, that could mean one of several things Achilles tightness, Stelios FHO or FDL tightness, such as the ones contracture, posterior ankle, capsule tightness, ankle arthritis or a previous ankle fusion. If you've got a negative silver skill test with normal dorsal flexion, you have a normal ankle.
So when you're looking at a reverse, the next thing to look at is whether you've got a passively correctable deformity. Passively correctable means the joints move so they're not so arthritic they've become locked. The ligaments aren't so contracted that they're locking joints and you've not had previous fusions.
So you want to see whether the virus is correctable. Make sure you bend the knee to relax the and just see if you can passively shift that heel into a analogous position. Is there a method for kivus? And if there is, can you correct that by positioning the heel and push up on the first rate? Is that is there that plantar x, which is correctable as well and is there core?
So if you actually bring the anti-bjp down, can you correct that? Muscle function is something to look at as well, and this is going to be the next part of your examination. So first of all, cilia, you're going to plan to flex. This is a plan to flex the ankle and you're going to test the strength of gastric sleeve and see if it's tight using a silver scale test. The next thing you're going to look at.
Is Tim out if you don't deflects the ankle against resistance is about working? To post, you're going to plan to flex an adult than midfoot and you're going to resist against the medial border of the first metatarsal feeling over that tendon, which you can feel coming around the back of the medial mallet is to post working because this might be needed for correction is peronist prévus working to get them to forcefully abducts the foot.
So what I usually do is I put the foot in an abducted position and then I say, don't let me move your foot. And then with one finger, I'll come towards the fifth metatarsal. And try and add up to the foot and in the foot. And if they can resist that, peronist reverses working the peronist longest. I will plan to flex the foot and put it in an inverted position, and that will be my first metatarsal down.
And again, I'll say, don't let me move your foot now or push up under the first metatarsal head and get them to resist. And you can feel pollicis longus tendon tension on the lateral side of the foot. Then you want to look for needle, FHL and FDL tendons, whether they're working and is the Power Five out five. All of these muscles need to be tested because they might be required to correct this foot, and it will also point you towards the possible diagnosis.
Common block test is something that is going to be asked if you get a reverse foot and you need to be able to explain this very succinctly and clearly. Clearly, this is a test that relied completely on the tripod that we talked about before. So for that, you've got to remember that a tripod can't be wonky. All three aspects of a Three Legged anything that has three legs and wants to stand on the floor won't be wonky.
The force will be shared between those three points. The Kessler cranium first met head with my head and there are those ports. It's a dynamic test of a rigorous but first we stand the patient with the whole foot on a block. Wait by the foot. Examine the hind foot alignment from behind the patient. Is it straight or is it in a reverse foot? You'd expect it to be vigorous.
Then what are you going to do? Is twist the foot slightly so that the first metatarsal head is just hanging off the medial border of that block and you're going to wait there, the patient. So you can see now that first metatarsal is now off the block. But the other two aspects of the tripit tripod are on the block. If you now wait by the foot. Your weight bearing through those two other legs of the tripod, allowing that first metatarsal to drop into thin air, reexamine for alignment and see if it has been corrected.
So here you can see foot flat on the floor with a heel and a foot standing with the first metatarsal free. Tipping into a neutral or more vigorous alignment. And you can see it again a positive test. Whether heel correct when you wait there without the first metatarsal on the block tells you two things. The deformity is 4 foot driven, and that means that plan to flex first, ray is actually tipping the foot into a Reverse position.
The second thing it shows you is that the hind foot is supple, and that means that if you take away that deforming force from the front of the foot, the hind four will correct. There is also an aspect of instability and a lot of patients with Cairo, various you've got a varied position of the handful already and that's already in a partially inverted position. So they're already halfway across to having an inversion injury.
So it's very common to have ATF Allen CFL injuries. Remember, ATF is another anatomical thing we're going to have to be aware of in these patients and that the insertion of the ATF actually ticks upwards as it goes from the fibula to the neck of the Taylors. The CFL heads backwards as it goes onto the cranium. ATF is tested with the anterior drawer test and for this, what you're going to do is have the ankle 20 degrees plummet to flex, and that will bring that ligament, which is facing upwards into its most tension position.
So 20 degree plan to flexed foot. Then you're going to stabilize the tibia, hold the heel and translate the heel forwards. If they have a big leg or you have small hands, put the foot on the bed and translate the tibia backwards. If you see an increased glide and the tibia over the tolerance or the tail end under the tibia or a sulcus sign just in front of the fibula, then this is positive.
So here is the anterior drawer test and you'd see a sort of sign just in front of the fibula there as you slide it forwards. And here is the second way which I find very useful in people with larger legs, and you can see a nice big sulcus and you actually get a bigger range of motion in this as well, especially because the gastric malleus allows the foot to slide forwards under the tibia or the tibia to slide over because the knee is flexed.
So this is a very useful way to do that test. The CFL runs in the opposite direction, so you're actually going to have to forcefully dorsiflex the ankle on your forearm and apply various force to the heel, and you're looking for an equal range of motion to the opposite side or increased, whether there's a solid end point. And if you can feel that CFL tension against your thumb underneath the peroneal tendons where it runs.
So this is the way I do it with the forefoot running up my forearm. I hold the heel and I use the thumb of my hand on the heel and put it in just underneath the fibula here over the peroneal tendons. As you tick to various, you will feel the CFL push against those peroneal tendons underneath the thumb. And that's one of the aspects I look for. So I'm looking at radiographs of the cave overexposed.
There are several things to look at. And this is where you can start to really understand a foot on an X-ray is a 3D problem. So looking at just the deep view of the door, so point of view, you can actually see what position the hind foot sailing angle is a very useful thing in a normal foot. You have the Taylor sitting on top of the Calcasieu. But there is a slight angle to them as the calculus goes towards the lateral column, and the tolerance goes towards the medial column in a flat floor.
They unravel and the tolerance tips off the kalkilya. This is measured by Kate's angle, and that will be increased in a flat foot in a cave in various foot. The tailors will be right on top of the cocaine, so you get a decreased rectangle. Katanga is the angle between the tolerance and the cranium when you're looking at the foot from above. Tailor coverage is another thing to look at, and this looks at purely how much of a navicular is over the tolerance.
If you have an increased Taylor coverage so navicular is hanging over the medial side of the Taylor head, this tells you that you actually have an abducted forefoot and which may be associated with post overactivity because you actually have something pulling them immediately. How can you pitch is another aspect to look at, and that tells you the height of the cocaine that tells you how high that table's position is likely to be.
And if there is a cocaine use aspect to that. Mary's angles very, very useful, and this is something that you can generally just eyeball when you look at an X-ray and that's the line running down the talus, down the mid body and the neck of the tolerance and a line running down the first task. And they should be aligned perfectly. They should be two parallel lines, normally from minus 4 to plus 4.
Canvas is way off. There's more than 4 degrees positive, and that's where you take. This is actually slightly up and metatarsals slightly down where those lines cross tells you something else as well. It tells you where the center of rotation angle is. This is good. Good for considering where the deformity apex is in a flat or occasionally very spots.
And look where those lines cross, not just what the angle is. Sinus Thomas, I see 3 sine is also useful looking at harmful virus, and this is something that's slightly more common in a CTV typekit virus position of the first metatarsal stacking is something that can be seen just by glancing at a foot. You can tell whether this is a cable spot or a flat foot. So in a high, arched or kivus, you will see the metatarsals all visible, like the picture on the top in a flat foot.
All of these metatarsals line up a normal foot will kind of be like this. So if you're looking for the medial aspect of a foot, a normal foot will be like that. Rivera's position? It's almost like a hand facing towards you, and it is flat on the desk. Are the findings that you might see on an extra cable, there is something such as a fifth metatarsal based fracture because this patient is overloading the lateral border of their foot, which isn't designed to take that much force.
The CCTV typekit, you will see some other aspects, the first thing you'll see is that the fibular is very posterior in relation to the tibia. That's because cts-v patient is a three dimensional twisting rotational deformity, so they actually have an externally rotated ankle. So they will actually face very, very lateral in terms of their trans malleable axis. And then the foot rotates through the tail neck back to Face forwards on this patient, so you will see a very posterior fibula.
You'll also see an abnormally flattened tail of a Taylor body will run straight into the neck, and very often the tail and neck are butts on the front of the tibia. He you might also see something such as a congenital vertical talus, which can present as an extremely slap or a very high arch support, depending on the position of the rest of the bones and whether this is lost or dislocated. So non-surgical options are always the first thing we're going to talk about, and that's going to be an MDT approach.
Firstly, we need to reassure the patient and diagnose the cause 60% to 70% will be neurological. Physiotherapy can be useful to stretch the pressure, stretch the gastro, stretch out the post and balance muscles that are now weak. Also, orthotics can come in useful to accommodate or correct the position of the foot, depending on whether it's correctable or a fixed deformity.
Custom made insoles, custom made shoes, a foot drop splint or an AFO splint like the one pictured podiatry will be very useful to look after the health of the skin on the foot, such as Department of curiosities and monitor, and they can also they can also access orthotics, and some podiatry services will make those in house. We may also need neurology, neurophysiology, a spinal surgeon or a genetic geneticist, depending on what you think of the underlying cause might be.
Then we get to the surgical corrective options of a Eric's foot. So option one is do we need to lengthen any muscles gastric meaning a slide if we've got a silver scale positive? And that's why we release the fracture over the gas rock and allow the muscle to stretch out. If silver's field is negative, then we may need to release or lengthen the Achilles tendon to allow the heel to come back underneath the tibia is post overly tight.
Does this need lengthening these Edl contracted? Is this causing some of that flooring that's been there for so long is also pulling the first toe up into the air that needs lengthening? Ask them ligaments contracted and do these need releasing as well, such as the deltoid, the spring ligament, the subtalar ligaments, the plantar fascia, whenever we see a flat foot, we think of these structures as completely important.
But remember the k virus, especially if it's been present for a long time, it is an issue of stiffness and over contraction. You can very often release multiple tight ligaments and tight structures various foot, and it still won't correct as much as you would expect. So don't be afraid to release these structures if that's needed to get correction. Ligament reconstruction might be required, such as the lateral ligaments.
If they're chronically unstable. And one of the most beautiful procedures in the k Rivera is a tendon transfer because you get a double benefit. Not only do you remove a deforming force of an overactive or tendon, which isn't balanced out by an eccentric pull, but you're also going to implant that somewhere else to get a corrective force. But you do need a power that has five after five, or at the very least, in good 4 out of five.
This can include something like a tip post transfer, where we take the tip post off the navicular. We've put it through the interosseous membrane to pass it over the dorsal aspect of the ankle or the anterior ankle, and we insert it literally and laterally so axes and dorsal flexor of the ankle to balance not working and also an active inverter. If the post isn't working, you can use FDL, but it's not going to be as strong as stiff post.
And like I said before, you can get a double correction here. Post is causing you both errors. So if there's an equation, OK, reverse type position and there's an adopted forefoot on that dorsal point of view of the X-ray with too much Taylor coverage releasing, this will allow the foot to come back and then give you some active dorsiflexion and inversion of the foot. Maybe there's some pictures of the post tendon, which has been performed with splitting the tendon.
This is to give a more balanced Dorsett flexion of the foot. It's also do apparently its longest to transfer, which is a very beneficial procedure as these tendons lie right next to each other. Very straightforward to pull this horse so it to the brevis and slit along with just beyond where you've sewn it. It does take you about five minutes to convince yourself that you're cutting the correct tendon after you've seen them together.
It's worth marking one and hoping that the pen doesn't work from one to the other. It's always a slightly nervous time in the operation. And that could be seen here, and it's a very nice procedure because it's done through one small incision. We could also do something like an oil transfer where we take the child off the toe, which is causing that clawed position of the hallux we release that allows the tow to come back down.
We then implant the shell tendon into the metatarsal neck, so the X doors deflects the first metatarsal. If that's the deforming force, if this is a four foot driven cave, us with a supple hind foot because we've taken the HL7 off the toe, we will then need to use the IPA. Otherwise, we'll get a mallet deformity of the toe. We've still got extensive loosest crevice attached to the proximal five, so we will still have enough to lift that big toe off the floor.
Osteotomy very useful procedure because we can actually move the legs of the tripod into a beneficial position to help correct the foot calculi osteotomy can be done without sliding the calcaneus laterally or doing a lateral closing wedge, which I actually prefer more. It's a more stable procedure. If you cut a wedge out with a lateral base of the wedge and then you actually leave a medial cortex intact.
You can actually swing the weight bearing aspect of the calcaneus into a Lateral position and that actually lateral eases or Valdez's your heel part of the tripod, and that will actually cause some correction. You can also do a dorsal flexing first metatarsal osteotomy so you could have cuts in the metatarsal over parallel to the floor with the dorsal closing wedge. Or you can cut through the joint and fuse the first metatarsal TJ with a dorsal flexing, dorsal closing wedge and also form a super muscular osteotomy.
If there is asymmetrical arthritis or a previous fracture Mount Union. Here is a naturalizing balcony sliding type osteotomy, and here is the procedure that I prefer, which is a closing lateral wedge such as a Dwyer procedure or a crack of, I think is the other name for its lateral closing wedge. And you can see that it actually positions the heel more centrally under the tibia.
And that actually lateral eases your weight bearing point to the tripod. Here are some of the dorsal closing wedge osteotomy cyber through the joint with A10 fusion. If you think that that's an unstable or an arthritic, painful joint, or you can avoid the joint altogether, you can either do it as a vertical closing wedge, or you can do it parallel to the floor, which gives you a more stable closing wedge.
The final option in a nonsurgical non corrective deformity where there's arthritis present or you've got a very severe correction that's required is to either fuse the ankle. If the ankle is driving this virus or perform a triple fusion if you're doing a triple fusion or a keV virus. You have to address the lateral column. This is not a time to do it before where you just go immediately into a tailor and a tailor individually joint fusion.
Because if you do that, you're actually going to swing the foot into for more adapted, more Canvas and more various position. You are going to have to address all three parts of the triple and you're going to have to bone grafts. The medial side may slightly and take slightly more off the lateral side to get that correction. You may also need to do a fairly substantial midfoot osteotomy or a rotational osteotomy or fusions, depending on what that foot needs.
So to put it all together, one of the easiest ways to do that is to look at a sharp konmari tooth, which is probably one of the more common aspects of a cave over its position foot. So sharp motif is a hereditary motor sensory neuropathy, and if you can remember that name, then you can talk. You can say everything you need to say about shark tooth to pass the exam, and that is that this is an inherited condition and hereditary.
It affects the peripheral motor and sensory nerves, motor and sensory loss. And then if you want extra bonus points, you can say the main two types are the cause a demyelination of the nerves or Lariam type degeneration is progressive. It can affect the arms. It affects the longer peripheral nerves first, and it affects the nerves at different rates and by different amounts, so it causes an imbalanced weakness.
So this is very important to specify. It does not cause spasticity of certain muscles. It does not cause certain muscles to be overactive or tight. It causes all muscles to become weak, but at different rates, so some will be stronger than others. When you examine the foot. So this is a shellcode married tooth type foot, and you might get something like this in the exam and be asked to describe the deformity if you are looking at the foot on the left to the patient's left foot.
You might say looking from the front, there's a peekaboo heel. I can see sense of recruitment and I can see drawing of the toes. Looking from behind the foot, I can see a various position of the hind foot. Midfoot abduction and an increased arch. I can see that the first ray is planned to flex and I can also see from this side the coring makes sense. Recruitment sort of discussed.
It appears as an acquaintance position and mix, and then you can go on to examine it. Remember that this is muscles that are weakened by differing amounts. So any shark tooth typekit Rivera, you will find it peronist brevis will be more weak, so they will have loss for very weak, active evasion of the foot. What they will have is retention of the Pyrenees longer.
So remember that this is not strong or overactive. This is just last week, so you will get that classic plantar flexed first metatarsal. So this will be a four foot driven cave, various type foot that plan to flexed first ray caused by apparently its longest. We'll give you that arch shape, and it will also tip you into various when you stand on that front of flexed first ray.
They will also have a weakened Taliban, so they'll have a foot drop. They'll have that high stepping foot slap and gate, and they will also start to use their extensor tendons of the forefoot to lift the front of the foot off the floor when they try and clear the floating foot in the swing stance of gait. This claw of the toes actually causes several problems to do with the cave of their sport and shock.
The first thing is it will extend the CPGs. When you hyper send the MTB gs, the flexor tendons are being pulled around a further distance, which causes that flexed position of the PIP Jays and Jays. Because the toe is now sitting on top of the metatarsal. Whenever you stand, you wait there through the flexes and that drives the toe vertically down on the metatarsal head. And this is called the plunger effect.
If you have a toe, that's cord and the base of the proximal flexes on top of the metatarsal head. It will be driving that metatarsal into the floor when that patient walks. It will also exacerbate that windless mechanism by pulling the plantar fascia, which is inserted into the base of the planter aspect to the proximal phalanx around the metatarsal head, which will tighten your plans flush and more, stiffening the foot and raising the arch even higher.
As the hill sets off center, it's in a shortened position, so a Solis securities complex will be sitting slightly immediately and not completely open positions that will be contracted over time. If it becomes too long, it came a very sorry, if he's been left there for too long, you will start to get stiff or arthritic joints in that position, and it stops being correctable through soft tissues or osteotomy, and then you're looking at fusing joints.
So starting at the top and working down for a Charcot Murray tooth typekit covariance, you would say something like, I would first assess the serious Achilles complex doing a silver scale test if it's positive. I'd do a gastric slide. If it's negative, I do an Achilles lengthening. Then look at the hill position, the hill is in a medial various position, so I would do a lateral closing wedge, Kilkenny or osteotomy.
This lateral eases the weight bearing position of the heel, which applies a corrective force through the hind foot. If it's fixed for a subtitled subtitle is arthritic, you do a tame effusion. Working forwards, you can assess the perennial tensions and most likely, you'll need to transfer longest to brevis, so you're going to need to actually release the longest off that first metatarsal, which is going to allow correction on the one, which is to allow your plan to flex first metatarsal to come away from the floor mat will help through the tripod theory.
You're then going to transfer up to the Revit so you have an active inversion force on the lateral ball of the foot. Releasing the tape post again will take away some of that adoption plantar flexion of the medial column force, taking it through the intereses membrane and plumbing it in the top lateral aspect of the foot will give you some active dorsiflexion and inversion. And then you can consider the force looking at whether you're still going to need to do a Dorset flexing first, ray osteotomy, if releasing peronist long off the first rate hasn't done enough.
Are you going to have to lift that first rate up in the air? Are you going to do a generous procedure? And are you going to need to balance your lesser toes? And you'll only really know that once we corrected your hind foot and that's why we start at the top and work down. So we're going to lengthen the serious Achilles complex, either through gastric or Achilles that will allow your heel to come back in its correct position.
Then you're going to lateralize your heel, then you're going to remove the deforming forces and use those deforming forces to correct the foot, such as tip post transfer to the dorsolateral foot. And apparently as longest of reverse transfer, then we can correct the forefoot in the fourth. That's probably the most complex part of all this in balancing those toes and getting them to sit where they want to.
The easiest thing you could possibly say is I'll do a dorsal flexing first metatarsal osteotomy, and I'll probably need to do an extensive tenotomy and MTPA releases in most toes that will allow the toes to come down, but you might need to do things like flaps to extend the transfer. If we look at that foot, we just looked at a few seconds ago. We'll actually see on the right foot.
There are already some scars from correction, so this isn't a case of mine. This is just one I got off the internet for descriptive purposes, but you can see here this is a perfect case that you will get in the past. Yes, you say here is a patient with bilateral deformities. They've got a cable, various position with the left foot and you describe all those things.
We talked about peekaboo heel high arch with recruitment of expenses, pulling toes, various hand foot position and Achilles tightness and on the right foot. They've had previous surgical correction. You can see three stab incisions from a percutaneous triple release of Achilles. You can see a lateral based scar from the peronist longest transfer to brevis. There may also be that calculi osteotomy has been performed through this incision.
And there's also some formidable scars, potentially from the dorsal flexing, first rate osteotomy or a journalist procedure. And then there's some small scars over the lesser toes, suggesting there's been soft tissue balancing of the lesser toes. So I hope I've given you a bit of a whistle stop tour as to all the aspects that are involved in a cave various assessment, and you will see that to understand the 3D deformity of foot, you have to know very well the anatomy.
You have to understand the biomechanics of the foot and you're looking at three or four different models in the foot to talk about the various and how you get it. Correct it and then you've got a multitude of surgical options available to you, and you're going to have to design this operation around this patient. Now we talk about an Carte operation, and it really does mean a La Carte. So if you went to a menu, you would order exactly what you felt like on that day.
And that's exactly what you do for a foot like this is not an algorithm based assessment. You're going to look at the hind foot and say, how various is the hind foot? How it is the hind foot, how calcaneus is the hand foot? How high is the arch? Is this just a vertical elevation of the arch? Or is there some rotation? Is there a corrective rotation of the forefoot?
Is the first rate blunt to flex is the tail. It's more covered by the navicula, and you're going to have to use all those X-rays and all these assessments to figure out what you're going to do for this spot. It's not a straightforward thing, but it is a beautiful thing once you start to understand it. I hope I've given you a little bit of an overview, and I'm happy to take any questions that you might have.
Thank you very much, Mr G. That was really nice. Although I've done that before I there are certain aspects that I've learned, especially this stepwise management plan, which I really, really liked. I have some questions that has been put by the audience. The first one is about the silver skilled test and whether there is any difference, whether when, when, whether it is done with the patient sitting or lying.
And that probably is, but the only difference, really, that crosses all those joints would be sciatic nerve. So if you're going to do it with a patient sitting, you're going to have some tension on the sciatic nerve. So I always you've seen me in the clinic, Abdullah, I always sit-in my chair down at its lowest point. And if the patient can get their foot onto my knee, then I know already that the sciatic nerve is OK.
On the odd occasion, when I Dorset flex and ankle of a patient, they might say, oh, it's a bit tight down the back of which case I can do it with the foot in a lower position so I can take the foot off my knee onto the floor and do it again. So if you want to get the patient on the bed, then yes, that can be beneficial in some patients who have sciatica.
But I don't see it as a problem. I usually do it with the patient sitting. I can do my whole examination with the patient standing and sitting. Excellent fine. The questions they have is about the investigation whenever you get the first case of kivus. Would you always do a neurological assessment and a neurological investigation in the form of MRI of the spine or the brain or any such or not?
You assume that it's been done already as a foot and ankle orthopedic consultant. It's rare that I would get a referral of a patient that doesn't have a diagnosis, so most patients that would come to me with a caving various foot will have a history of CTV type treatment as a child, or they will have shark tooth running in the family and they will have been assessed at childhood because their mom has it.
Or this will be something that's been known about or there will be a known cerebral palsy. In the odd case that I do get where this is a first presentation of a case where there is a foot, then absolutely you would do a full assessment from top to toe. You would be asking neurological type questions. Has your gait worsened? Have you become more clumsy?
How is your walking pattern changed? How? how are your other senses? Do you have any pain radiating down your leg and you're going to have to think, is this brain? Is this peripheral nerve? Is this spine? Is this a neurological, muscular type problem? So I've seen patients with NewCo polysaccharide oasis with various type position and mcquinn okigbo various type position.
And there are so many different things that present as a cave to various foot, and they're all totally different and must be managed completely independently. But in answer to your question, yes, if there is no diagnosis and this is the first presentation, you're going to have to do a holistic top to toe approach. And that may require several months of I'm going to get an MRI scan of the spine of the whole spine, plus or minus the head are going to send you to see a neurologist.
We're going to get nerve conduction studies. You might need to speak to multiple people before you go anywhere near this foot with an eye because it will affect how the foot behaves accordingly. So, for instance, with a polysaccharide oasis, the muscles don't become spastic, they become stiff. So the muscles still have some activity, but the muscles can't stretch. They become stiff with the laying down of the gag proteins in the muscle so they don't stretch.
So your muscles can't stretch out for that Stallings curve to contract back down. So you're going to treat that very differently to something like a chakra motif. And if this is a progressive problem, you're going to treat it differently. If you think you can rely on muscle power to stay there, then you can use the muscles that are working for transfers. If you think that all muscles are going to become weak over time, then you're going to be looking for more definitive bony options, such as osteotomy or fusions.
The next question is mid is first metatarsal driven. Should you always do a dorsal metatarsal osteotomy, or will you as a new plan for it beforehand? Or will you go with an open mind and assess how it is in the operatively because you've mentioned this proximal to distal approach? Absolutely that's absolutely correct. So there is no always and there is no never. You're going to do each aspect of this operation and you're going to see how the foot responds to what you've done.
If you release the peronist longest off that base of that first metatarsal and attach it to your peronist crevice, that may be enough that the foot will correct how to phrase what you've said in the exam. So in the exam you've got in the clinical situation, a patient with us. And how would you say that I will go with an open mind? How would you phrase it in the exam in a way that conveys that what you're talking about, but at the same time, you know, you appreciate how complex the issue is.
So if my screen is still up? Yes so if we take the patient's left foot, that's in a reverse position here. What I would say is so before we have got a patient with bilateral foot problems, this patient has a preoperative left foot and a post-operative right foot on the left foot from a anterior position. I can see a peekaboo heel, a high arch and flooring of the toes of extensive recruitment.
Looking behind the foot, I can see that there is both straining of the Achilles tendon with a vigorous heel position and to correct this foot. First of all, I've discussed with the patient what they've tried previously, what their main complaints are, and if they're willing to consider surgical correction, surgical correction would be in the form of a 3D deformity correction starting proximally and distally. I will do a silver scale test to assess whether this needs.
The gas rock lengthening or Achilles, if it's positive gas dropping its negative Achilles. I will then laterals the position of the heel using a lateral closing wedge that will give me a Lateral position of the posterior aspect of the tripod, giving the foot. Some correction. As part of my assessment, I would do a Coleman block test. If that's positive.
That tells me two things. One, that it is a four foot driven deformity caused by blunt flexion of my first metatarsal two that the hind foot is supple. If I have a positive common block test, I would then do peronist longest to Revit transfer. I would see the position of the first metatarsal if it correct after this all well and good, if it does not. My next option would be to do a flexing closing wedge osteotomy the first metatarsal or if the X-rays showed arthritis of the TJ or do a dorsal closing wedge fusion of the first TNT to elevate the first metatarsal, then I would balance the soft tissues of the forefoot.
Other options for the first metatarsal would be a joans procedure. So it's a very difficult thing to put succinctly because there are so many options, but it's just having these things available, but you'd have to assess the whole thing and then talk about it from top to bottom. But it's able to use appropriate surgical options for a foot like this is very important.
So the key ones you really need to know are you going to do something for salis Achilles complex? Definitely that's an absolute. You will. If the heel is virus, you're going to want to put that into Vegas. If your first rate is down, your options are long to brabus transfer, if longest works. And your next option is Jones, if you want to do something dynamic.
Don't forget, if you're doing a Jones, you've got to fuse the IPA. You may need to Dorset reflects the first metatarsal through a non fuse and also flexing, closing and closing wedge on the dorsal aspect or fuse the TTMT. If you think that's painful and arthritic, then you're going to balance your forefoot and they're really the ones that you should definitely know for a cave that's supple.
If it's not supple and it doesn't correct on a Coleman block, you want to see X-rays to probably got home for arthritis, in which case, you're probably going to do a triple. That's the easiest I can make it. Absolutely as you mentioned, it's a three dimensional deformity, and unless you understand the anatomy and the biomechanics, it's very difficult to give answers something.
Another question I have here, which is related to the post-op protocol for these patients. Now I'm assuming that again, it depends on what you did exactly, because that with the aim of the management. Have you done first, ray as well, fusion or not? But in general, what is your routine post-op for the cases? So I try and make things as simple as I can. And for most 3D corrections, so something like a virus or a flat foot, I will usually do six weeks non weight bearing in a cast, followed by 6 weeks weight bearing in a boot.
That's just a general run of the mill thing when I've got osteotomy to heel and tendon transfers to heel. Mm-hmm And there are other things I might look at, so there are certain things I can do in a flat foot to speed things up if I'm going to do synthetic ligament reconstructions. But on the whole, six weeks non weight bearing, followed by 6 weeks weight bearing and a boot. Excellent and for the physiotherapy, when do you start that and what is the aim of it?
It just depends. So it really depends. If I've done, if I've gone for effusion, then I'm going to go minimally on my physiotherapy and I'm just going to be doing a little bit of sagittal range once I'm at the cast so the patient can remove it. So if I've done a triple, I would say six weeks non weight bearing, followed by 6 weeks without burying a boot and.
I might get the patient out after the first six weeks and starting doing a range of the motion of the ankle. With something like a more complicated correction, random transfers, I might want to get those patients going a little bit quicker, so I might actually put them in a boot at around four weeks and just start some gentle range of motion exercises. But it's patient by patient basis. It depends on the patient factors, operative factors, surgical factors, load loads and loads of aspects would really come into that compliance and tissue situation and exactly what you did and how the field was during the operation.
Excellent OK, so again, next question is, how would you correct the forefoot adduction? Abduction is usually driven by tip post, though post is what adopts the forefoot. Unless you've got unless you've got one of these very skewed feet like a TV where the ankles are facing off laterally and the forefoot is facing very immediately, the usual case is that it's a post type adoption and you'd see this on the door.
So planet of you as Taylor covering. So if I just skip back to that view, you will actually see over covering of the four foot, so you'll actually see that the picture is being pulled around the tail ahead. So in that one, if they've got a foot drop as well, you've got the perfect option of releasing the tip post from the navicular. And because you actually need to pull it through the intereses membrane to the anterior aspect and insert it.
You are actually going to have to take that as long as possible. So it's worth taking off to post with a sliver of curiosity and running down to the cuneiform to give you a little bit of extra length. The worst thing you ever want to see in the world is when you take it off and you can't quite get it to the bone where you want to insert it. So keeping as much length as you can there with a sliver of curiosity and then pulling it through intereses membrane onto the lateral dorsal surface of the foot.
So the lateral cuneiform or the voyage that will release that, that deforming force of the post and by plumbing it in on the top and lateral aspect, it will give you that active Dorset collection and the version of the foot. So you actually get a removal of a reformer and an addition of a character. And there the beautiful options where you get buy one, get one free.
Yep yep, beautiful. Fine I have another question here. But shall we do these surgeries just for because Mrs. No, no, that's what plastic surgery is for. So I do these. These are big surgeries. They do not, give someone a normal foot. They give someone improved biomechanics. So for any foot surgery, what you're looking for is a stable, weight bearing platform and something that's pain free and chewable.
Are the things you're looking for stable, weight bearing platform, pain free, chewable. So if they walk in and they're wearing the boot hands and they just don't like the look of a certain bump on their foot, then they're not going to want major reconstructive surgery of osti, optimizing the bones and releasing tendons and transferring them elsewhere. You're not going to get this back to a normal foot, but you can improve things.
And so surgery is really for when there's weight bearing issues or when there's pain. And that pain might be due to the weight going through the aspect of the foot overloading the soft tissues or arthritis. So it could be related to fractures and things that are associated instability. The people that aren't appropriate for surgery, usually the simple task of explaining what the surgery entails will make them realize that this is quite a substantial task for them as well as you.
And they will usually self-select and say, actually, you know, don't worry about it, it's fine. I'm quite who remain solid. Excellent there is a question that I didn't fully understand from Cynthia Kumar. Now I will say it. If you if you understand it, then fine. If not, then will invite Mr synthy Kumar to say it. So in case a fixed Guevara's painless foot can we follow non operative?
I think he means, can we go with this conservative treatment? Of course, of course. So non-offensive is always a viable option in surgery, in my mind is a last resort option. So doing nothing has very few risks, but doing something does put the patient through a substantial risk in the post-operative period. And I only do that if there are clear gains to be made. So there's only there's only reason to put the patient through the risk of surgery.
You think that there are substantial gains that are likely to be made. So if you have a patient who has a K Rivera's position of the foot and they can see you and say, oh, it's deformed doctor, I don't I don't like the look of it. Does it hurt? No, it doesn't hurt. It just annoys me.
Then you can say, well, let's get you some good, good going insoles and some shoes that fit your thought rather than making your foot fit the shoes. And let's see where we get to. And a good thing to say to these patients is that surgery is always there. My favorite thing that I like telling the patients is I'm going to be working there for 30 or 40 years, so I'm not going to go anywhere.
And they can come back whenever they like and have the surgery. But you can't then do the surgery, so you exhaust all of their aspects for an operation like this before you, before you jump for the NIPE. Excellent well, thank you very much for your time and your presentation, and I'm sure everyone has learned a lot. I certainly have.
Thank you again for giving us the time and putting it so succinctly and nice. Make it towards the exam.
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