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So uh flat foot uh is called West Planus. Essentially means uh low medial uh longitudinal arch as compared to higher medial longitudinal arch uh in the uh cava foot, uh it's not only the forefoot, it's the whole foot. So you see uh the picture, you know how the normal foot is like uh and how the flat foot behaves. So the reason for pain is that the joints which are not meant to take the weight starts getting wet. Yeah. So, so your one of you guys were asking about the windless mechanism. So windless mechanism is essentially maintaining the arch kind shape of the foot and that helps in weight distribution. So, plantar fascia runs from the calcaneum to the toes and it maintains the dome or arch of the foot and that helps in weight distribution. So foot is essentially a tripod. Yeah, the weight transfers to heal fifth metatarsal and first metatarsal. So that windless mechanism is ex exaggerated in cava and it's less working or it collapses in flat foot. So what's responsible for maintaining the media large? Uh There are static stabilizers and there are dynamic stabilizers. Static stabilizers include the long plantar ligament and it's called calcaneum vilo halo calcaneonavicular ligament. So this long ligament uh so essentially halo calcaneal navicular ligament. That's the spring ligament. And there is another one called long plantar ligament, which is on the plantar side of the heel and it runs uh from cuboid bone in inserts into the metatarsal. So that is probably not shown here. So it's the spring ligament which is the main stabilizer of the medial arch and uh that sorry, this is long plantal ligament and this is part of the spring ligament. So, talar calcaneonavicular ligament. So you can see in the normal foot, this spring ligament is intact in flat foot. This is stretches out and that's how the talus head it becomes not supported and the whole foot, the forefoot abducts or it moves out because the talus head, it invasions in and kind of breaks the foot in the middle. So other static stabilizers are plantar aosis. Um plantar sis is a big structure. There are three distinct parts. One is the medial part, one is the central part and one is the lateral part. Other static stabilizers are the plantar plate. Plantar plate is present in all the MTP joints and the plantar plate along with the long flexors, it supports the MP joints. So plantar epineural uh it goes from the calcaneum and it inserts into the plantar plate and it's this action which maintains the medial arch and is responsible for windless mechanism. Now, as the foot flattens, this becomes less dynamic stabilizers are the tendons. So this is the tibialis posterior tendon F DLF HL and triceps soon. And other damage, dynamic stabilizers are peroneal and tibialis anterior. All the long muscles actually. So the main dynamic stabilizer is tibialis posterior, which is responsible for maintaining the arch. And that's what we test in acquired flat foot deformity. So we do single heel raise, test to see if that hip post is working or not. So it inserts into the navicular but actually it has a long insertion which goes right up to the bases of the metatarsal. So that's what the function of the TPO is. It causes plantar flexion in in inversion of the foot. Other dynamic stabilizers are a muscle and it uh inserts into the calcaneal tipsy and it plan and inverts the heel in flat foot. It actually causes valgus of the heel. Uh how it does the valgus of the heel is a little bit complicated, but just remember that a tendon can be tired in both varus heel and valgus heel. So in Kuss foot, it is wear healed, but still the tendon is tight in flat foot, it's vuls heeled, but still the tendon is tight. So as a part of treatment, you release dili tender, so flat foot is also called as posterior tibial tendon dysfunction. We don't exactly know the exact cause of posterior female tendon problem. We there are various theories we think because of uh uh various reasons, you know, increase in weight or lack of exercise. Uh posterior tibial tendon is not in good health and because of constant microtrauma, it eventually gives way. So 20 years ago, when we start diagnosing this problem, we used to send samples of the tendon to see if there is any infection, you know, which causes the tendon to give way. But we haven't found anything. We all we know is that the tendon degenerates and gives way and it start functioning. It is a progressive problem. So once you identify a posterior tibial tendon dysfunction, it is likely to get worse over a period of time. So, posterior tibial tendon is first to go once it becomes weak, then slowly, the static stabilizers also stretch out and give way and the arch thesis. So, because the starting point is the posterior tibial tendon, the pain is mainly on the medial side first. And when the spring ligament gives way the heel goes into valgus and that gives rise to lateral pain, which is because of irritation of the subtalar joint or you can say early osteoarthritis of the subtalar joint. So, depression diagnosis for flat foot or tibialis, posterior dysfunction is inflammatory arthritis, degenerative arthritis of the hind foot, uh lir malalignment or tt joint osteoarthritis leading to deformity, tarsal coalition and traumatic injury to plantar facia. Now, the foot as a whole, uh there are various other stabilizers like the big toe. So when the hex vs develops or when there is bunion deformity, the forefoot stabilizing effect of the big toe goes away. So it kind of is it doesn't directly contribute to the flat foot. But if you have severe bunnia, then there are more chances of developing the posterior dysfunction of flat foot diabetic opathy. You know, it leads to malalignment of strength ligaments and causes a flat foot deformity. So, uh helix valgus, you see, because the toe is out of alignment, it doesn't uh support because the forefoot donates gradually, the hind foot also pronate. So as in cava foot, the big toe causes supination. Opposite of that is, and because the this becomes flat and this goes into pronation, the hind foot also pronate secondary to forefoot. So, clinical presentation depends upon what stage patients are coming to you. If they are coming to you, uh in the early stage, they will have the pain on the medial side. Uh If they are coming to you in late stage, they will have pain on medial and lateral side and there will be associated deformity uh of the foot and ankle depending upon what stage they are coming to. Usually flat foot is more common in patients who are overweight who are slightly uh you know, more than age of 40. Uh so that uh you know that uh acronym you use for gallstones, uh that also applies to flat foot. So there may be medial pain. Uh me, me medial block, uh pain on the foot, there will be lateral pain. There may be history of trauma. Uh Usually they give uh gradual onset pain which has worsened, started on the medial side and then over a period of a year or two, it has gone on to the lateral side. And patients say that uh they get easily fatigued and not, not able to uh go for long walks. Some of them have noticed that the foot shape has also changed and the arch has collapsed or you know, the heel has twisted out. So all these uh can be presenting symptoms. Uh We discussed this most common age 30 to fif 50 female commonly overweight. Uh inflammatory arthritis could be the underlying factor uh often. Uh although it's not mentioned here, often it is associated with accessory nabila. So if you see a patient of flat foot, then uh think about smoking diabetes, steroid use, these are all the deciding factors when you are deciding about surgical intervention. No. So in examination, on a flat foot patient and exam, you do the usual look, feel move, look for the range of movement in the ankle and subtalar joint and both foot. And also the big toe. Look whether the foot is flexible, I mean the hind foot is flexible or rigid. So I'll come to that, uh look for gastrocnemius tightness, look for alignment of hind foot to forefoot and look for posterior tibial tendon, the stent by doing the single heel raise test also do the neurovascular examination. So in this picture, uh you can see uh that from behind, left side is worse than the right. Although uh you know, left side, uh you can see the valgus deformity of the heel and uh on the right side, uh it's not that bad, but still the forefoot is pronated and you can see to too many toe side. So these are what you will see in flat foot, valgus position of the heel collapse of medial arch. And you may see swelling on the medial side or swelling in the sinus tar side. So single, he was test is to assess the strength of posterior tibial tendon. So you ask the patient to go on both tiptoes, they are more or less, you know, always able to go on both tiptoes. Then you ask them to go lift 1 ft in the air and ask them to go on one tiptoes. And if their tip post is working, then they will be able to lift themselves up or lift their weight up into air. If the tip post is not working, then they usually collapses or complain of pain. Uh you know, on the medial side. Now, if the heel valgus corrects when the patient goes on tiptoes, that means that the subtalar joint is still mobile. If the heel remains in deform position, as it is in this picture then they probably have subtalar joint, arthritis already and the subtalar joint has become fixed. So again, uh this is the same angle uh we measured in the foot, it's called Mary's angle. And normally the long axis of talus goes to the long axis of p metarsal when there is break in Mary's line. So here the toe is not quadriplex, but dorsiflex. So you see the Mary's line is coming here and the toe is dorsiflex. So and here again, the Calcaneal pitch angle will be less than 20 degree, no, sorry, less than 15 degree. I think this is again an important measure which is called a talus head uncoverage. So more severe the deformity, the talus head becomes uncovered and the forefoot goes into abduction and this is the angular measurement to assess the talar head uncoverage. You don't need to remember this angle just as you can pick up on the radiograph that the nevi kind of covers the talar head all the way along when there is flat foot due to forefoot abduction, the talar head can become uncovered. So, II in general, uh you know, uh we need weight bearing x rays and you can confirm that tibellus, posterior dysfunction uh with ultrasound or an MRI scan. A CT scan uh is only if MRI is not possible. Otherwise, MRI and weight bearing x-ray gives most of the information we need. Now, there is grading of tibialis posterior tendon dysfunction. Uh Usually you see patients when they have reached a stage two. So stage one is, there is no, there is only pain but no deformity. And this will be the patient who comes to you with pain on the medial side of the foot. In a stage two, there is deformity and pain also starts developing on the lateral side in the sinus side where the subtalar joint is uh stage two, is usually divided into uh few further stages. So two A is where there is heel valgus, but the deformity is flexible. So here if you correct the heel and you deal with the tibialis, posterior tendon, then you will get good result. Stage two B is there is heel valgus plus the forefoot is also involved. So talar head is uncovered. So here you have to, you know, uh along with the above which is the post and the heel vuls, you have to deal with the talar head uncoverage. And stage two is where there is hypermobility of the first ray. And for that, you deal with uh the first ray as well. Uh Stage three is uh where you have developed arthritis. And uh because of the arthritis, the treatment uh involves fusion. Stage four is when there is ankle involvement. So along with the subtalar joint, the ankle is also involved and then you involve the ankle in the treatment as well. So, did we understand these stages? You know, uh uh do I should I repeat it or hello. Yeah, I think it's quite important. So you essentially, uh, stage one is no deformity. Stage two, deformity is there, but it's flexible. If it is only in the heel, it is two A, if it is in the heel and forefoot, two B and if it is heel, 4 ft along with, uh, hypermobile prate. Stage two C, we see two A and two B more commonly. Stage three is the one with arthritis of subtalar joint and stage four is ankle involvement. I've got a follow up question for your two CS. Um If you got a a hyper mobile, um first ray would a would a liped not also be a an option so you can do lapidus but as you do that, you know, heal. Yeah, the forefoot usually in flat foot, the forefoot is stupid more as compared to high foot. Yeah. So when you correct the high foot it lifts up. Yeah. So to drop it down, it usually lifts up along the talar joint. Well, so you drop it down at the medial uniform, you can drop it down more there as compared to lapis, right? Ok. You can do lapidus. Yeah, but you need to be more accurate in doing lapis, you know, say you need to, you need to sort of, yeah, you need to get, you need to take a wedge out to do the lapis, right? Technically a little bit more difficult. Ok. Yeah. Fine. So it's easier to do cotton. You have the wedges on table, you put one wedge in. If it's not enough, you put slightly bigger wedge in and whatever makes the big toe touch the ground, you stop there. Yeah, fine. Yeah. Yeah, cool, thanks. So, oh sorry. My thing is stuck. Uh My lights are not moving. Mhm My slides are not moving. Let me start again. So flat foot, uh the deformities are exactly opposed to cas foot. You know, uh there is hill virus there. So there is hill uh valgus here. Uh The medial arch is lifted up there. Medial arch is collapsed down here. Uh in flat foot, the pain starts from the medial side and it goes onto the later side when the subtalar joint uh starts uh getting involved. Essentially, 90% of the patients we see in clinic are stage two. So if you get an exam, you know, more than likely, it will be stage two. If it goes to stage three, then it becomes painful. And you don't like to bring patients uh to exam who are in pain. So, uh signs of flat foot, uh you will see medial arch collapse, you will see too many toes sign. You will see uh medial swelling and lateral fullness. Uh and single he was test will be positive on X ray. You will see break in the Mary's angle and Cal Calcaneal pitch would be decreased. This is uh to see the Taylor head uncoverage, this was the classification. Now, management depends upon the stage uh of the, you know, presenting symptom and the stage of the patient. Uh So this is stage one. So what would be the treatment? You know, we discussed uh One of you can take it up, you know, uh it's, it's uncommon but it still one of one of you can read it and just discuss the treatment. So, uh for a stage one, tip post insufficiency is predominantly non operative. Uh So, analgesia activity modification, uh physiotherapy to strengthen up the tip post tendon. Uh and you might want to put a medial uh wedge supporting, well, a medial arch supporting um orthotic um to give that medial arch a bit more support. Um If those don't work, then you might go on to steroid injections down down uh to surrounding the tip post sheath. Uh and then follow on from that. You may then think about doing a debridement or sinusectomy of the uh tip post tendon sheath um and possibly a plication or a sort of a yeah, application type procedure if, if, if you're really stuck. OK. So there is slight change. Uh you know, in this uh treatment stage, one, uh don't say steroid, you know, uh some uh people, they don't like steroids and I have seen patients or, you know, you will also see these patients in your clinic where somebody has given a steroid injection and tendon has actually given way. Uh I know, uh you know, uh you know, a few of my colleagues involved in medical legal uh cases, you know, because they have injected a steroid and the tibialis posterior tendon has ruptured. So it is a strong tendon. Uh you know, two places where you should not say steroid. One is aqueous tendon, aqueous tendonitis and posterior tibial tendonitis. Yeah. So, avoid steroids, rest, rest is very good. Yeah. Uh Last thing it is almost, you know, uh it progresses invariably to stage two, especially in young patients. So you can consider tendon transfer surgery. Uh if it is not getting better with all the things that you have mentioned, you know, you have tried exercises, you have tried for two years, three years, patient keeps coming back to you and you are worried it's progressing. It will go on to later side young 25 year old patient. Uh It's always good to, you know, consider reconstructive surgery to stop the progression of the disease. Yeah, you see the picture, that's where the pain is. That's where they come with the pain and you put your finger on the tip post and they will confirm that that's where our pain is. So, no deformity. This is a air cast, stus posterior tendon brace, you can made made to measure in. So which are probably more commonly used than this. Uh this uh cast. This has got uh inflatable, you know, there is a little balloon which patients can inflate according to their, you know, if it is less flat, then they can inflate less. If it's more flat, they can inflate more. So according to their comfort, they can inflate it and deflate it. You talked about insulin stage two. A Yeah. So someone else was gone. Ok. Um, everything is there. So you just have to read that way you're able to remember. Yeah. So um you can initially do your soft tissue procedure. So we already talked about doing a FDL transfer. Um And then you can do a Calcaneal osteosis. So, in this case, um because you've got a lengthened medial column and a um short lateral column, you could do a medial closing wedge osteotomy. Um You could also do a silver skill test and if they had a particularly tight um tender achilles. So it was coming mainly from the uh the 10, the tender achilles itself, you could do a ta um uh lengthening or release. Um And then I think that's probably what you'd have to do for a stage two. I don't think you'd have to do a lot more for that. Yeah, good. So this is the most common uh you know uh case if you get in the exam. So uh this is the common uh presenting patient to your clinic. They come with heel vuls, they have lateral needle pain and usually the deformity is flexible. So you ask them to go on tiptoes and the heel vuls will correct. So, uh in KVAS foot, you do lateralizing ostomy and in flat foot, you do medial me, medial slide of your knee. So that you know the soft tissue structures in the heel, they are very less on the medial side. So the heel can slide up to a centimeter or maybe more on the middle side. But on the later side, it, even if you try hard, it translates only about it slides only about 23 millimeters. So it's wedge osteotomy on the left side, or you can say closing wedge osteotomy on the left side and slide osteotomy on the medial side. So stage two, conservative management includes uh UC BL or Arizona Support. Uh These are quite cumbersome in clinic. Nowadays, you know, when we started treating for foot, we, when we didn't have surgeries, we used to use these uh devices, but I haven't seen them. Uh when I was training for a uh rotation, you know, this is I'm talking 2002, 2003. We used to have an orthotic department which, which used to make these basis nowadays, uh if the patient is not fit for surgery, then it's different. Otherwise, uh we use me to measure insoles and then go for surgery. So this is the medial slight osteotomy. So you see it slides medially. So aim of the surgery is to put the heel underneath the chin So you do this view in theater and when you start the heel is on the outside underneath the fibula and you slide it to a level when it comes underneath the shin, usually from 8 to 12 millimeters. And you transfer the FDL nowadays uh instead of stitching it, uh you have a good, you know, screws like the bio screws you use for ACL and you fix and tension these with those screws. Uh And that is much better than when you used to stitch them and do uh and do things like that. So, difference between a stage two B and two C uh is midfoot and forefoot involvement. Uh If you identify all the deformities, then you'll be able to correct them. If there is tailor head uncoverage, then the options we have is either lateral column lengthening or if it is not really bad, then you can put a sinus DSA screw uh to derotate the talus and to cover the head. So uh if there is 4 ft pronation after correction, then you do that Plantar collection ostomy we talked about. OK. So now someone will take this up. This is a good case. Uh Yeah. So describe this picture, please. Uh This is in the ap view of um the foot um which shows um uh significant um 4 ft abduction and um uh possibly about 50% on coverage of the tailor head. Yeah, I would like to obviously see other see other, see other, see other, see other views as well. Yeah. So what more investigations you would like to, you know, plan your treatment? Um So, so could you repeat that, please? So what more investigations do you need? So what's going on in your mind? So it is a severe flat foot? Yeah. Yeah. Uh you will do medial reconstruction. Maybe you will require lateral reconstruction. Yeah, like let column lengthening or something else to cover the talar head. For that. You need to know how is the talar navicular joint? Is there a is there any arthritis in the talar navicular joint or subtalar joint? I mean, you can, I mean, I could uh I could assess it clinically to see if there's any pain when I, when I'm palpating and moving the tavi joint um going forward. I mean, you also get a CT scan to look at the joints in more detail. Um So MRI will give you better uh you know uh information A it will tell you that FDL tendon is in good health. You can use that for transfer. Yeah. Yeah. You can also, it will also tell you about if there are any uh changes of arthritis in the talar negro and subtalar joint. It will also give you an idea about how bad is the spring ligament, right? OK. Yeah. So MRI CT scan, uh if you are considering arthrodesis, you know, say uh you see an X ray and you already see, you know, significant arthritis and you want to see the bone stock, then you need CT scan. So, MRI usually is enough in flat foot. Ok. Yeah. So after weight bearing x rays, your next port is the MRI in flat foot deformities. Ok. Yeah. So here we have done Calcaneal Osteotomy. Uh We are trying to do a lateral column lengthening. So I don't know if you can see, but there's a graft in there and there's a plate over like the graft. And you s you check on the ap view that the tailor hasn't head is covered. So you start distracting it. You try eight millimeter, we then 10 millimeter until the T head is fully covered. Yeah. And that's lateral opening with osteotomy is called S osteotomy. And this is cottons in the medial uniform. You make a cut here and put a wedge there. Uh Again to check that when it touches the ground. Awesome. So stage three, OK. Uh someone else can take up stage three. Oh Yeah. Yeah. So, uh Alex has asked, you know, uh do lateral calcaneal closing, wedge, ostomy, lateral slide doesn't shift much. Evidently, that's correct. So laterally, even if you try harder, uh you know, uh do all kinds of release, you can't shift more than five millimeters. And there is a reason for that. What will happen if we, if we can shift the Calcaneum laterally, what is that? It doesn't, it doesn't sound very Mr Gava. I think you're still muted. Uh medial side, there is the main neurovascular bundle of the ankle. Ok? So if you slide the calcaneum laterally, you will pull all the nerves and the vessels. Yeah, you will put tension on the nerves and vessels. If you can slide the calcaneum laterally, that's why the structures on the medial side are very strong. They do not allow the calcaneum to slide laterally. However, you can push it medially and it will slide easily. OK. Let's, let's take the stage three. OK. I'll, I'll, I'll go for it. So, this is a clinical photograph um uh showing uh on the left side uh a uh uh heel valgus um and 4 ft uh supination uh and um a deformity on the medial side as well. A swelling on the medial side. Um I suspect this is a uh um flat foot deformity. Uh I would, I would uh um test this uh uh clinically uh uh ascertain whether this is uh a fixed or a supple deformity uh by performing a heel, um heel rise test. Um and uh and then um uh assassin uh uh radiologically good. OK. So, MRI shows significant subtalar joint, osteoarthritis, advanced tibialis, posterior tendonitis and minimal talar head, uncoverage, uh weight bearing X ray shows that the talar head uh is more or less covered with than so, 4 ft is not that bad. So, what would your treatment be? So, it's, it's predominantly, well, it's predominantly a hind foot problem. Then uh if the patient is symptomatic, uh and this is a fixed deformity, uh conservative, conservative measures would probably not be very helpful at this stage. Um I would uh uh aim to offer the patient a corrective osteotomy to realign uh the heel uh in line with the er anterior tibial border, uh by performing a um um a performing a medializing calcaneal osteotomy and uh to um and also a FDL tendon transfer to uh substitute the uh function of the uh um dysfunctional uh TPO tendon. We agree or uh does anyone that? Sorry? II disagree. Um I think he's got a rigid flat foot deformity with subtalar arthropathy. So you're looking into fusion territory at this point. Yeah. So your heart when the heel doesn't correct, that means that the Subtalar joint is fixed. Yeah. So even if you do the Calcaneal osteotomy, it will line up the heel. But if patient has arthritic changes in the joint, the pain will not go away. Yeah. So you need to do Subtalar fusion. Yeah. And at, at the same time you put the two surfaces in a way that the heel wall that correct. OK. So uh you take your uh you put the joints in a place when you have prepared the joint surfaces, you move the heel medial. Yeah, you translate it as much medial as possible and then fix the Subtalar joint and you're right that you will do FDL transfer to stop the 4 ft from getting worse. It will keep the nevi in place, stop the deformity progressing there. Ok. So we still have to balance the foot along with treating the arthritis. Ok. Yeah, thanks. That makes, yeah, that makes sense. Yeah, thank you. So, stage three is, uh, you know, more advanced where maybe the tip post has ruptured, the deformity is there and it has become fixed, there could be 4 ft deformity as well depending upon that, you either do cottons or uh you know, you do FDL transfer. So, uh stage three, the aim is correction of deformity, subtalar fusion or if there is arthritis in the talar navicular joint, then you do subtalar and talar navicular fusion. If there is arthritis in the TMT joint, you do TMT fusion depending upon the deformity, you plan your treatment. So uh that's uh again, the stage three, you used to do triple fusion in these, these are rare. Now, you know, usually we pick them quite early. So I don't think you will get stage four. it's very, very rare. So essentially because of, you know, progressive heel vs the deltoid ligament stretches and gives way and then these patients develop arthritis in the ankle and that's stage four, but it's, it's quite rare. Uh I must say in last five years, I may have seen one. So unlikely you will see it. So, remember what is more common if you do stage two, you know, that would be enough. So in conclusion, summary, complex problem management, guided by stage and patient factors. Uh every patient presents with different problems. So you need to have an individual plan. Uh especially elderly patients, always try conservative management. Uh they often can, you know, get good 7, 10 years with conservative management and that's enough. Try a reconstruction before fusion, especially in young patients, flat foot uh is, is a big spectrum. You know, you see all kinds of cases of your foot and the surgeon and often it takes a time when you start getting them right. You know, you get your own learning curve. OK? And any questions?