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Good evening. All. I hope you can see me and you can hear me. Uh I welcome you to the 13th episode of the bofa's Master Technique series. Uh And tonight's topic is on Cavo virus, uh deformity and the surgical management, which in my opinion is very interesting but challenging subject. And we are privileged to my, you've just muted yourself. Can you hear me? We can now? Yes. Yeah. So the first speaker, he tell, he's going to take us through his uh surgical decision making algorithm uh et cetera. Uh and as per the s uh how to proceed with the surgical treatment. And then our second speaker, Karin Matra, he's going to talk about the surgical principles and operations and surgical techniques in detail. And then we'll have about 15 minutes, 20 minutes discussion time where you can post the questions on the uh chat or message and then we'll pick up the appropriate questions and present it to the speakers. So without further delay, um I would like to invite our first speaker, Heath Tailor who is a consultant orthopedic foot and ankle surgeon in Bournemouth and Pool since 2004, uh is very much interested in teaching and has been awarded trainer of the year award by, by Sex Dry. Uh He has been a member of the Bos Council for seven years and he was our president uh Bos in 2019. So I am looking forward to listen to Heath about his take on virus deformity assessment and his algorithm over to Heath. Thanks Manish. So I'll just get everything going. So hopefully you're hearing me and seeing my slides, if not feel free to uh interrupt. So I'm gonna go through um the decision making process which I think for Cavers foot and neurological foot and the terms are used interchangeably, I think is the bit that I found hardest to get my head round. I think actually learning how to do the operations, we can all learn how to do an osteotomy or a fusion. It's knowing which ones to do and when to do it, I think is very difficult. And um Naughton Dunn is one of the founding fathers of orthopedic foot and ankle surgery in the UK and paper in 1922. And there's a really good quote says in no other branch of surgery is the patient is in a better position to judge of the practical success or failure resulting from any operative procedure. And that applies to everything that we do. But it applies particularly, I think to Cavers foot and neurological foot surgery. Um This is er, Vitruvian man, Leonardo da Vinci and there's a sort of, you know, is this art or is this science? And of course, everything we do is supposed to be very science and evidence based. And you'll hear much more science from Karen than, than I think you'll hear from me. And I think definitely in my practice, I think the decision making in complex deformity, surgery and neurological foot deformity surgery particularly I think is, is as much an art as it is a science. So I think it meets both criteria. And of course, when we, we're deciding what procedures to do, we want a classification like this. This is a um sort of a simplified, I guess Johnson and Strom simplified version of post dysfunction. I know there's a new flat foot correction, but this is just relevant to demonstrate the point and this is really nice. Cos if you have stage one, you use orthotics or debridement and stage two, you do a F DL and a Calcaneal osteotomy and a three, you do a triple and a four, you do a Pantalar fusion or a triple with an ankle replacement and you know, variations of that. But the classification really guide you as to what procedures you're going to decide to do. And so you have a sort of set menu. It's really easy. You have a starter and a main course and a dessert and there's not much choice as to what to do. And the problem with Cavers foot deformity and neurological foot deformity is that you are much more a la carte and I don't claim the credit for thinking of this, but I think it's a really nice way of, of thinking about it and we have all these different options of starters and pasta and pizza and main courses and bread and side dishes. And do you want a steak as well with it? And then some signature dishes, which are the kind of the main things. And so how on earth do you decide when you're faced with this, uh, with one of these sort of complex CVAs neurological feet, what you're going to do? And so what I'm gonna try and do is give you some sort of logical way of trying to break it down to make it more reproducible. And, and all of these are neurological feet. The top left, one is clearly a very flat foot, but it's still a neurological foot. And the others are all cavers foot and II don't know how you make a useful classification. Certainly ignore the top left one, the flat foot, but the other five are all cavers, cavers feet or Cava Vera's feet. How you make a classification that all of these fit into that tells you what procedures you should do. And so I'm gonna try and put some logic to that. And here's two of my patients, you'll get used to seeing this corridors outside my clinic and these are two patients, both with neurological feet. One with clearly very neurological, the younger lady on the left in the top and pajamas and the older lady with a very flat foot, but again, a very neurological foot. And so how do we decide what to do? And we'll, we'll come back to both of these patients in a while. So what to do. So I'm fairly sort of simplistic in a way I think about things. So as with a lot of things in orthopedics, start proximately and work distally and I'm gonna start at the hindfoot, but I doesn't exclude starting at the back and the hip and the knee. And I, you know, I make no excuses for, for saying that, you know, don't miss more proximal deformity. So I'm gonna go through the sort of a la carte, what's my menu of choices that I have? And this is probably most of the things that I would consider useful when doing hindfoot. When I'm thinking of what hindfoot procedures will I will, I use whether it's things around the achilles, calf release, osteotomies, fusions, double, triple fusions or, you know, er, perineal tendon surgery. So that's all the hind foot stuff. I'm being slightly, um, sort of using AIC license to differentiate between hind and midfoot. I'm not saying there's a strict border, but then in the mid foot. So what are we gonna do with the midfoot? So, t post trans and split tant transfers again, osteotomies, infusions and soft tissue releases and tendon transfers. These are all options for you and then in the forefoot. So, toe deformity, we can correct toes, amputate toes. Jones procedures do osteotomies in the forefoot, soft tissue balancing. So, we've got all these options. I have no doubt you can all think of more things that could be on that list and, and that's absolutely fine. So, what investigations do I do? Do investigations help us? I think by far the most useful, um, tools for deciding what procedures to do in neurological foot. Deformity is a detailed history and clinical examination. I think the investigations are a long way in third place when deciding what you're gonna do. However, we do do them clearly. We do plain x-rays. This is a, this is a really nice x-ray of, um, somebody with a cavovarus foot and I've got a really good imaging department when I ask them for a lateral weight bearing of the foot, this is what they do and this is their lateral weight bearing of the foot and look at the, at the ankle is an ap and yet their foot is a lateral and it shows how much of a rotational deformity these cavovarus feet can have. You can see there's, there's a few little bits of wire from many years ago, some sort of tendon fiddling procedure was done. Um, I'll use CT scan and MRI scan as well, particularly if we want to know if things are degenerate, if there's, if you want to know if joints are degenerate or think about coalitions or abnormal anatomy. I think it's really useful to have a CT particularly, but sometimes MRI scan as well. Um So let's go through a few cases. So this is that lady with a very neurological looking, very flat foot and she came and her symptom, she's walked around on this for years. She's got polio and has lived with her polio perfectly well. But her symptom is midfoot pain. That's what she came in with. She didn't come in saying I've got a funny shaped foot. She struggled to get shoes on and all the things you can imagine. And this is her walking up and down in my corridor and you can see her left foot's normal and her right foot, she's got this very plain. Valgus abducted Valgus heel. You can see a scar from previous surgery many years ago. And so how on earth do you sort of unpick a foot like this and try and decide what procedures are you going to do to try and give her the function that, that she wants and, and needs. So, here's her x-rays, here's a way of brain x-ray. So you can see why she's got midfoot pain. She's got midfoot arthritis and that's pretty obvious she's got quite a severe ha valgus as well. That wasn't symptomatic for her, but it was her midfoot arthritis. Was a problem and you can see her walking despite this crazy deformity, she's a really fit active lady lives on her own, does all her own shopping and that's her weight bearing lateral X ray. You can see there's stuff been done around the ankle before. Probably some sort of ankle. Subtalar effusion. I'm not entirely sure what very, very flat foot. Um, so what to do? Well, she had a valgus hind foot, I think straightening her heel is pretty straightforward with a cocaine osteotomy is gonna give her a much better, um, position to walk from. And then what about her midfoot? We'll come back and look at the X ray. So she's got this severe midfoot osteoarthritis where we can with that by fusing her tarsometatarsal joints. But at the same time, if we do a corrected midfoot fusion, we can correct that. So I did a corrected midfoot fusion with a medial closing wedge and I just did an en bloc resection, being careful to protect all the soft tissues. And then what about in the forefoot? Well, she's got that sort of severe fixed hallux valgus. I don't think any of us are gonna try and fix that with a scarf or a Chevron or a Mica or whatever your preferred Helix Valgus option. And I think for me, a fusion is a good option. So you look at her Alex Valgus, I think fusing that is gonna give her a really nice correction And, um, so that's what I opted for and that's what I did. Don't worry about the form of fixation. I use different things now, but it doesn't matter. Plates, staples, screws. As long as you get the deformity right, and get the bone surfaces together. So nice bony correction. The midfoot fused really well, big bony surface area. She came back to have a left Hallux val. But so this was her about a year down the line. Remember it was the right foot. She's got a nice straight heel. She's still got a short leg. It's clearly not perfect gait, but much, much better. She can get her shoes on and she's really happy. So that's how that sort of a la carte approach can allow you to put together a set of operations for this lady that will, that will help her. Here's the other, the younger lady that we saw. So she's at university. So she's got shark and Marie Tooth disease and her main problem was pivoting on her right foot. She was very, very unstable as she turned. She was trying hard not to use a walker. She was still trying to use sticks because she's young and she had a, there was a sort of psychological element to her using a walking frame, which she really struggled to get her head round, but she was stumbling over, particularly when she was turning around, even furniture walking and she felt very unstable. So you look at her feet. She's a bit CAVO virus. It's not the worst in the world for a CMT. We see them much more severe than that. Her deformity was really correctable. So this is me, you can see pushing her heel out into valgus. Valgus corrected easily and look how much residual forefoot pronation she's got or first ray plant flexion if you want to call it that. Um And so we've got to deal with all of these deformities and she was had this very unstable, very mobile hind foot, which is unusual in a cava foot. Of course, they're usually quite a stiff foot. But you can see how I was able to bring the heel from valgus right round into varus. And we screened this. It's all happening almost all at the subtalar joint. So there was with that heel right there in almost extreme varus, the ankle joint was almost perfectly congruent. So this is a severe subtalar instability. I'm sure compounded by absent perineal tendon function. So, what to do. So we got to think about what to do. Well, she was in a little bit of a equinus. We know that patients with neurological deformity don't like a quins and it's very difficult to walk in a Quins. I'll come back to that. But a single fusion, a subtalar fusion is gonna solve her problem with that subtalar instability that allows you to put the heel into a little bit of valgus and will solve that problem of Subtalar instability. And at the same time, she was a little bit unstable in her ankle. So I did a Brostrom as well. I'm not even convinced it was necessary, but we were there and I just wanted her to be stable. Then in the mid foot, she had a foot drop. It's very um energy inefficient to walk with a foot drop when you're weak anyway. So at post transfer will help that. I did a plantar fascia release. I don't always do that. It just felt tight and cos she was young. And if we believe that the o relative overactivity of Perones longest causes this progressive deformity. So I did a Peroneal tenodesis in her lateral hind foot. Um And in the forefoot, I do flexed her first ray. I put that in 4 ft. So a, a dors flexed an osteotomy at the base of the first metatarsal. So this is her about six months. POSTOP. She's still really unsteady, but you look at her right foot now, she's much more stable. Her hind foot's not collapsing into varus and she's able to pivot and stand. She's really happy with it. It's interesting. Her left foot hasn't gone as much. I suspect she'll be back at some point. She's determined to stay on her feet to at least to finish university. Um So she, she was really happy with that result. Another good example of a cavovarus foot. Um That's such an obviously tight achilles. If you look at the, the view from the back, you can see it um how tight the achilles is with the healing varus and the heel doesn't even touch the floor. This is him trying to put his heel down on the floor. Um This is that x-ray you saw earlier on, so you can see how much rotation there is. As I say, this is my really good de radiology department, taking an ap of the ankle and a lateral of the foot and there's extraordinary, a couple of X rays. So what to do our easy decision here, we're gonna lengthen the achilles. Um And we're gonna do a triple fusion. This is a very stiff foot with a significant rotational component at the triple complex. So triple the decision making is easy. This is quite a difficult triple to do if you haven't done many. But er er for him worked very well and then he had quite a significant residual um first rate plantar flexion. So I opted to do a plantar flexion laparus rather than just a dorsiflexion osteotomy. It brings the apex of correction a little bit more proximately and I think it just gives a nicer looking foot and this is a really nice POSTOP X ray, partly because of the crazy metalwork. Um But also the, this is that same patient, you can see the bits of wire everywhere. So we've now got an ap of the ankle and an ap of the foot and a lateral of the ankle and a lateral of the foot. Um, and, er, it was a really big rotational erection through the triple complex and this is him POSTOP foot's now flat on the floor. He's still a little bit of swelling to settle down the wounds healed nicely. This is him walking stiff foot, but it was stiff before he's really happy. His foot progression is much better. Um And he, he's, he's got a really nice correction. Another example again, shock and my tooth, very little Cavo virus. She's all foot drop. Well, she's foot drop and equinus look how much aquis she's got and she's back kneeing and tilting her pelvis as a result of her aequus and she finds this, she's tripping over all the time, keeps falling over and of course, she's weak approximately as well because of her neuropathy. So, what to do again, I think easy decision, achilles release to get that ankle dorsiflexion beyond neutral. And at post transfer, I didn't think she needed any bony correction at all. Um So, you know, CMT but with no bony correction, um I quite like a split t post transfer. I think Karen's gonna talk a little bit about tendon transfers more than I will. Um But you can see the classic, I do a classic harvest distally pull it up approximately, make a big hole in the intraosseous membrane and then pull it through. Um, you see the tendon comes through, you can do it. There's a single strand and just pull it through and stick it into the top of the navicular or one of the KA forms. Like a, like a split transfer pulls through nicely through a really big hole in the, this guy's brilliant. So he came into my clinic. Um, so it was like my sort of RC SA exam. This guy's 71 fit and healthy, worked all his life never had a diagnosis. Other members of his family have been told they've got funny feet, but he still plays golf. Um This is his feet. I mean, it looks like a picture from Happy orthopedics, champagne bottle legs, severe cava varus and clawed toes. Um Hi for varus. You can see those classic x-rays that we've talked about and this is him walking around, look at his hands as well. He's got that classic CMT posturing. Um And he's walking unsteady with his cape of various feet and just starting to struggle now as he's getting a little bit older and getting a little bit weaker but never had a diagnosis. So with these sort of patients balance is really important. Don't just do bony corrections, always think about soft tissues as well. So I think again, decision for him, easy achilles release. You could see how tight his achilles were triple fusion. I think again is an easy decision to correct him. But we've got to correct him. So this was his weight bearing X ray. Look how much his medial structures, the tip post and the spring ligament and those medial soft tissues at the tail, navicular joints are gonna be really tight. So you're gonna release them anyway. Well, if you're gonna release them, why not use the release and do at post transfer. So I did a tip post transfer as well as part of my medial release. It'll help his foot drop. Um And he's II II haven't got his. Um I didn't, I don't think I got a video of him walking afterwards. I must get that. I must get him to do that. So before I finish a few pills, things, I've learned down the way things, I've learned the hard way. Don't leave patients in equinus. Um for a number of reasons. If you leave the hindfoot in equinus, your deformity will recur because the patients will, will try to push the heel back over into varus or val there, Varus in this for this purpose of this talk because the achilles is tight. You must release the achilles. If they're in a Quins, it's also exhausting to walk in a Quins. Um because you, you have to climb over your foot. If you think about trying to walk in a equinus, it's really hard. I mean, you've already got neuropathy. Um So don't leave them in equinus and don't treat, don't forget to treat foot drop. So that guy with the CMT, the golfer. So he didn't come in complaining of a foot drop at all. But I think, you know, you're there anyway to do a tip post transfer takes an extra 10 or 15 minutes. They don't even know why they like it, but they like it because they don't have to lift the foot up so high to walk. Um And it goes with the achilles release. So you can't do a tip post transfer if they're still in the corner. So the two go together very nicely. The other thing that comes up a lot and Karen's gonna talk about this a bit more, I think is when to fuse and when to do an osteotomy. And I think there's definite art not signs to this. I've definitely regretted doing only an osteotomy. I think if you've got heel virus and you do a dwire or a modified dwire, Calcaneal osteotomy, even if you take a big wedge and you shift it a long way. Um There's only so much correction you can get and I think if you've got someone with a stiff hind foot and a significant virus, I think they're probably better to have a fusion because you can take bone out, you can release, you can get that heel out of virus. Um But an osteotomy is a good option, but II don't think I've ever regretted opting for a corrective fusion. I've definitely regretted not doing doing an osteotomy and then come back to clinic and you look and you think, oh, it's still a bit varus. Um, so what are we looking for? This is the basic principle. So we're looking for a painless balanced plant grade, not infected. To think about your incisions. They need to be able to feel it. They wanna get a shoe on and it's not cosmetic surgery, but it kind of is if it looks nice and it looks like a foot, the chances are they'll get a good result. And I come back to what uh Norton Dunn said. So I think this is really functional surgery and I think the patients will tell you um, how successful you are. Thank you very much. Sure, there will be questions which we'll discuss in the Q and A session. Um So our next speaker, now I would like to invite uh Karan Matra. So Karan is a very dynamic young surgeon consultant, orthopedy surgeon at Stanmore. I'm sure most of you know him. Uh, he's also an honorary associate professor at college London. He is a member of the council and chair and he's a director of the com media and Communication committee at BOFA. He's very active in research and education and has a number of publications. And Cavovarus forte is actually one of his forte. He, he, he loves this topic and uh he's going to uh share his experience with us Kin, right? No, thank you. Very much for injection ish. And thank you heat for, um, a good talk. I think you've covered a lot of stuff that, um, I was going to, um, say, but it's, it's worth reinforcing. Um, so, um, I'm gonna talk about how I correct a Neurological Kar's foot and most of that or most of what you'll see is going to be things like CMT. Um, he said that I'm gonna talk a lot about literature, but I just need to warn you that there isn't that much literature out there. So I'm not gonna have slides full of literature, um because most of it is based on consensus statements and, and personal opinion, just as he gave his opinion, I'm gonna give you my opinion based on my experience and literature. That's there. I wanna start by something. What you might think when you start addressing AC vs foot, sometimes you see a patient and you think, you know what, I'm a great surgeon, I can make this perfect. I'm gonna absolutely sort this patient out. They're gonna have a perfect looking foot, that's it. And you may even achieve that and you'll be on cloud nine, you'll be celebrating, but the foot can't take it because it's never been normal and it all ends in tears. And so what you need to remember is that when your baseline is really poor and you're starting from a really um poor expectation, actually, all you really need to be happy is to have something stable which protects you and let you get on with your life. And you have to remember that when you intervene surgically, it's just as important as what you do surgically because especially with neurological feet, patients live their entire lives with this problem and they have lives, they, you know, things progress, they have to go to university, then they get married and they have Children and lots of things happen. So you have to be able to guide them. You also have to consider that deformities progress with time and what's flexible now may become rigid and develop arthritis later. And if it's rigid and it's arthritic, then the complexity of your reconstruction increases. But really, when patients come to me, I sometimes say, what is the tipping point? I like to think of it like a traffic light system. Uh You start on the left green light. So over here, the weight bearing portion. So the weight bearing of the, the body weight goes through the center of the ankle. And if that then comes out through the heel or close to it, and that patient is relatively stable and they've got time. They don't really need an operation right now. Most likely if you look here yellow over here, they started to tilt and the weight bearing axis is starting to go to the lateral side of the calcaneus. If they're correctable with insoles, then they're not. And, and they can look like green foot um with insoles and they're probably fine. If not, then you want to think about doing something. The next one, which I labeled blue looks like the yellow one. But the difference here is that they are in equinus and so they have less stability and when they walk, they're more likely to tip over. So that's actually a more urgent situation over here. You can see in red, this is probably a bit too late already. And that's when the weight bearing is already past the heel. And this is a bit like a leading tower of pizza. Once it's gone this far, it's gonna just keep going on rapidly. So you want to intervene soon, otherwise you'll get to this stage. The white one where you really should never get to in the start. So, with that in mind, what are my surgical strategies for CVAs foot? Well, it echoes what he said. I think the first thing we want to know is what are we trying to achieve? What we're trying to do is to put the hind foot underneath the body, get the foot flat to the floor, restore their biomechanical tripod and then balance the muscles. And if you do that, you achieve what I've got here in the left to here in the right six months later, it's all about getting a basic structure that will keep the patients happy, not a cosmetically perfect foot. So how do you achieve this. Well, you have to assess each aspect and plan to treat it accordingly. You need to work out which soft tissues need, releasing which ones need transferring. And although he's talked a lot about lengthening the achilles and treating the Equus. Not all patients have problems of equina at the ankle and you need to be careful not to over lengthen the achilles. You need to work out which bones need shifting and which ligaments you need to repair. If any, a lot of this, like he said is actually done through clinical examination with imaging as a supplement. I'm gonna come back to these images here, but just to highlight it if you see here, this looks like the patient's in equinus. But actually the equinus is happening at the midfoot rather than the ankle fuse are preserved. Again, he touched on this and the proponents of both I tend to do a flexible one when possible and reserve my rigid um fusions for rigid ones or who have arthritis, either way they need tendon transfers. And there's some evidence to suggest that if you can do a flexible correction, then they do better with it clearly the younger patient. But it does depend. The next important thing is the order in which you do things and part one and two sort of come together. But you need to prepare all tendon transfers, release all soft tissues and then correct the bone anatomy in a step wise fashion. Exactly like he'd said 9 ft, then the midfoot, then the forefoot and then at the end you fix intention to him and brother. The key thing here is that this is not just a linear thing because in order to correct the bony anatomy, especially of the midfoot and forefoot, you have to imagine what your tendon transfer tension is going to be like and what the foot's gonna look like and then correct that. So you do need a bit of experience to do this. But what I mostly do for a cable bars, foot, if it's flexible, I mostly do an achilles lengthening or stra if it's needed, it's not always needed. Lateralizing calcaneal osteotomy again, if it's needed. And if it's a fixed deformity, I do fusions, as he'd said, either a triple fusion or an ankle fusion or a DDC fusion. I then go on to the midfoot and forefoot with balancing osteotomies, use the halo like B joint. I don't often do the plateaus at the same time because there's only so much surgery your foot will take. And finally, I do the tendon transfer, which is often a tibialis posterior tendon transfer and it can be either to bone or to tendons and I'll talk about those later. So let's run through all of that quickly. So the soft tissue releases the kidneys release with a percutaneous release such as a hope you can get up to 10 degrees and often that's more than enough what you need. Because as he said, feel just a bit tilted, the achilles is just a little bit short and you just need that hope to unlock the achilles a bit. I do three incisions, 3 to 5 centimeters, a part two on the medial side. Sometimes you actually just need a stra especially in the younger patients who have come early. I reserve an open release for someone who's got true ankle equinus and something like this. So this patient is actually not CMD, they're HSP but over here they've got about 35 degrees of equinus. And the formula that you can use is one centimeter of lengthening of the achilles gives you roughly about five degrees of equinus correction. And then you want to overlap by about three centimeters at least. So to correct the 35 degree equinus, you need about a 10 centimeter Z my tips for this are that if you go on the medial side or paramedial, that's a little bit nicer for wounds. And you need to keep the end straight because if you keep the end curved, which is tempting once you get, you get that equinus up and the foot comes up, that little curve, which is just a harmless little curve becomes horizontal and then gaps. Whereas if you end it straight, it then actually closes together nicely. Again, I do my medial um incision superiorly to go away from the sural nerve. And I do my um step of the z distally laterally to avoid the neurovascular bundle. I leave about three centimeters. Other essential releases. I mean, sometimes you need to do a posterior capsule release. But I think the tibialis posterior and the spring ligament are key parts of my um releases the tip post. I'm gonna harvest anyway. Nowadays, I tend to do it through a small um incision and you can see the tibialis posterior on the left and I've resected it and then you can see right under the tip post is a spring ligament which you can see my forceps pointing to um the spring ligament in cavovarus foot is your enemy. I always cut it. If they've got severe cavovarus, I take a wedge out of it. They're never gonna get a flat foot. Their bone anatomy is just different. Um So that's absolutely not a problem. Plantar fascia releases. Um That's not a usual part of my practice. I only very rarely do it. I don't think it necessarily adds to the stability. And when I do the clots, um it reduces the tension anyway. Um Often if I'm going to do, I'm faced with someone who needs a plantar fascia release, I'm often gonna do a vegectomy or something with them anyway. And I detention the plantar fascia through there. So I don't defunction the plantar fascia in different philosophies, however, and it goes back to what you're trying to achieve a cosmetically perfect foot or a functional stable foot. Um But II would occasionally do a plantar fascia release but not usually um when not to do an achilles release. So, again, this comes back to this situation over here. Um So you have to look for the center of rotation of angulation of the core of the deformity and make sure that if you're doing a release, you're not over dose, flexing the ankle to make up for mid ver equinus over here. If you see that there is actually not in equinus deformity and the Calcaneal pitch is fine. Um And what this patient really needs to get a perfect foot is a vegectomy, but that's a bit much. And actually, I've created a slightly zigzag foot with a dorsiflexion osteotomy, which is balanced and fine. On that note, we'll go on to the osteotomies. So if you're gonna correct the bone anatomy, what do I do in the hind foot? Um Well, it's a lateralizing Calcaneal osteotomy because that helps to get the bone under the body. Um You can do this through a multitude of approaches, you can even do it at a s although it's harder, I tend to use an extended lateral approach cause it's versatile and you can do a Perine as long as the Brevis transfer to the same thing if you need to um you need to release the soft tissues from the medial side. So I often put a laminar spreader in after completing the osteotomy, open the gap up, take a little osteotome, go out to the medial side and really separate the soft tissues on the far side to allow a good shift. They always take a edge. Um because there has been a recent paper which suggests that the abnormal, there's abnormalities in the bony shape itself and the radius of curvature is actually abnormal. So, in essence, in the neurological foot, the shape of the calcaneus is like a banana. And if you do an osteotomy on a banana, as we all know, it gives a good shift, but it doesn't make it straight. But if you do a wedge and a shift, then it creates a straight structure which is better biomechanically for these patients. Um So this is what I do, I do um like, like I can osteotomy, I tend to fix it with headless screws um cause I spend too much time taking out headed screws. Um But it really doesn't matter how you fix these. So what have we achieved so far? Well, we've got a heel which is underneath the body, a hind foot which is flat to the floor and by releasing the hip post and the um ligament, we have hopefully reduced the tear joint, which is absolutely key, which I'll come to in a bit. So we prepared the 10 counts to really soft tissues corrected the hindfoot. Now, we need to go on to the midfoot and the forefoot. So this is about balancing the residual forefoot deformities. The aims here are to correct any residual plantaris or cavus, any pronation or supination and any adduction. You do that as I alluded to you before you need to put the foot where you think it's gonna be once you've tensioned all your tendon transverse and then see what you think still needs doing. Most often. You end up doing the first metatarsal dorsiflexion, osteotomy, but some patients will need multiple osteotomies and some patients will need a be shaky. How do you know which one? As he said, there's no good Johnson and Strong classification system for this? We've looked, I do a lot of these and if I'm faced with a foot like this, I'll struggle to know, especially if they're not flexible enough for me to decide preoperatively. So we also cells a few years ago. Can you predict what the forefoot deformity is gonna look like? And we've done four papers on this now. And in essence, what the four papers show is that most of the deformity is actually a rotational deformity about 23 degrees at the tail navicular joint. And what we did is put this into a computer and simulated correction of vara feet around the tar joint to what we would achieve intraoperatively, then saw what deformities were left and classified them. This paper has just been published last month or two months ago now. So we found that 60% of cases are what we term type 1 ft. And that's what you commonly see where only the first ray is relatively plantarflex after you've reduced the rest of the foot. But that means that 40% of patients actually have something else rather than what your standard technique might be. And 20% of what we call a type two where not only is the first ray relatively plant effect, but so is the second, possibly the third and 10% have a type three where they actually have true adduction. Most adduction is actually plantar flexion and rotation in disguise. But some patients have true adduction and about 10% have type zero where actually they're balanced and they don't actually have a 4 ft deformity at all. So instead of just going with the flow and doing the dorsiflexion osteotomy, each time we think about how we manage each individually. So type one, just the first ray is blunt effect. These are easily treated with a dors osteotomies, which is what we do as standard. And I tend to do a vertical osteotomy because it's more powerful and you can do it to a smaller incision. And I tend to use a medial plate, you can use a dorsal plate. But if you go to type two and you can see here, this is an example of a type two. And when you correct the foot of the tail and navicular joint, you see all the toes are slow and you can see over here that multiple toes are slow. Over here, they need multiple dorsiflexion osteotomies. Cause if you bring the first up to the second, they're still too low. And if you bring the first up to the rest of the foot, the second is too low, you can do a first meal dorsiflexion, osteotomy and B RT osteotomies. But I often end up doing multiple T MT joint fusions because I think they have a more powerful deformity and I need to fine tune things. Often it's a bit closer to the cora but it doesn't matter. Um But these patients often have a few um stiff d empty joints. Anyway, the type three is a challenging type, particularly if you're unprepared because they're often multi planner with adduction, rotation and um plant ale. And these need a more proximal correction which derotate and this is done by a vegt sector or you can do a chop fusion or a triple fusion. But if you're trying to preserve joints, a beds starts Omy is the way forward. But the problem is even if you do a lot of these, if you're unprepared and you come across it and you suddenly realize you have to do beds starts, that's a bad day. The ectomy is difficult and you got to use K wires to guide you. You need to really work out how to do it in multiple planes. But fortunately, there is the option if you're prepared of using patient specific instrumentation or a guide. And I tend to use a guide if the deformity is in more than one plane or it includes rotation. I also use a guide if I'm trying to save joints and if you're starting off, it's something which is I would encourage. Here's an example of using a guide. I have a patient who's got a um equine or a cavus deformity of 37 degrees induction of 49 degrees and a bit of rotation. That's obviously quite difficult to address. But a guide can tell us how much bone we can take while still leaving enough to fix and then simulate correction where you don't correct all the cavs, but you've got 20 degrees, which is still better, but you do correct all the adduction and you correct most of the rotation. What does that look like in real life? Well, we put a guide on the side. We, so we your bone and then literally, we just close it in one fell swoop and fix it and it actually works really, really well. What about a type zero? Well, a type zero has no deformities. So you don't really have to do anything. You can finish the operation there, talk briefly about fusions. Um He'd mentioned triple fusions. There is a type of triple fusion modification called labra N. So if they have, but the equinus is not just at the ankle and actually occurs within the talus itself or the talar navicular joint, you can then take as your saw blade and saw the bottom of the talus off, including the inferior head parallel to the floor, bring the rest of the foot up and fuse it. And that is uh this is the same patient before and after it brings the quis up nicely without you actually having to do much to the achilles. So if they've got deformity at the ankle and the um subtalar joint, then I often do a TTC fusion and it gave us foot correction and this deformity, although it looks severe, actually had a simple forefoot deformity. It just needed a hind foot fusion. My tips for fusion is that remember, the foot is going to be stiff and the bone shape is abnormal. You have to take out wedges, don't be shy. I prioritize reduction of the tailor navicular joint first because that is what you're gonna build the forefoot around. After you reduce the tailor navicular joint, you can try and close down the subtalar joint. And if it doesn't close down, you can just run your so blade through to take out any asperities and just allow it to close because you need to sort of disconnect the talar navicular joint and the shower joints from the subtalar joint to correct these because the shape is abnormal. And often that means taking out the anterior facet, taking out the i inferior aspect of the talus and even a bit of the, um, Calcaneocuboid navicular complex and I saw it is really good to do that. And then I finish up the fourth foot, um, for the hallux that's usually an IP joint fusion. A Jones and a younger patient. But often the adults are a bit stiff and the Jones doesn't do much. Um, and lesser toes. I often do F DL tenotomies and the IP joint fusions only if it's a young patient with good skin. Otherwise I do that. So we've done all of that. Now, we finally need to get the fixed intension, the tendon transfers, which tendon you transfer well, the stronger one. And in practice, that's often the tibialis posterior. Although you can do a per as long as the Brevis transfer, as long as Brevis transfers is useful when dorsiflexion is preserved and you just want to get a bit of eer because it takes away a pronator and adds an eter. Um I often do this through the Calcaneal osteotomy. Um just lift the extended lateral approach flap a bit higher and the tendons are right there, but you can do it infra or rec or supramalleolar. Um But basically the idea is you pull the Brevis up, put the foot in e you pull the longus down and tie them together, which defunction the bit of Longus at the bottom. The tip post transfer is a workhorse. Um It, you pass it through the intra membrane, you can go circum tibial, but the intraosseous membrane has more power in various studies. It's useful when dorsiflexion is lost, you can insert it into bone or tendon. How do I start? Um I take a, a small incision, I take the tendon out there. If you want to go to bone, you need a little bit of a longer incision or you're starting out and, and don't do lots of these, then you, you wanna make a bigger incision. That's absolutely fine eye of the incision doesn't matter. Um I release the spring ligament as mentioned before and then I take the tendon out higher up um behind the tibia again, like heat. I often do a split. Um And then I pass it through the intraosseous membrane. I didn't have a video of that like heat does, but um his video is fantastic. Um Options for insertion. You can insert it into bone or tendon. If you're sending, inserting it into tendon, you can do a single tendon, which I rarely do because I think that's often not as balanced as multiple tendons. If you're putting it into multiple tendons, you can either split it or take one tendon and weave it through multiple. Um And II usually split it unless the tendon looks a bit weedy. In which case, I'll do a single tendon weave. How do you decide? Well, it depends on what you want. If you want more dorsiflexion, go to the intermediate cuneiform. If you want more aversion, go to the cuboid or perineals. You want a bit of both, which is usually go to the lateral cuneiform or tant and peroneous brevis. Um, which is what I often do. Um, you can go under, over the retinaculum. It doesn't really matter. Um, if you want more forefoot control, then you can go to Edl and Tertius. Just think about what your tendon is controlling. If you look at this foot, it looks great, doesn't it? But the reality this is over dorsiflex at the ankle. Um And actually when you have the ankle at neutral, um you find that the deformities of the uh uh midfoot. But um you can use your tendon transfer to control this if you want to over dose, flex the ankle. It's just that it's gonna be a tendon which spans those joints. So this tendon transfer has got to be to IDL Arius or to the um uniforms to control the equinus. If that's what you want to do, how do you fix it? You can use all sorts of techniques, suture, anchors, staples, et cetera, but biotin desis screws are the best for bone. Um If you're putting it to tendon side to side with some one B is fine or you can pulver off it, you use doing to the Edl, you can weave it through and create a pulver off um through the strands of the Edl. So just winding up. Now, what does this all mean for patients. Well, if you've had a flexible correction at six weeks in a cast and six weeks in a boot, you've had a fusion. It's three months in a cast and non weight bearing. For the 1st 4 to 6 weeks, it takes them about a year to adapt and rehabilitate and they need to be aware of that. They often still need orthotics. It doesn't give them a normal foot, but it's still a lot better with a stable foot, slightly improved balance and they get into a shoe. But there are complications in our series. Up to 40% of people have some wound or the other which doesn't heal within two weeks. Um, wounds can break down, tendons do pull out. You can have non unions, malunion under overcorrection. Sometimes the metal work needs to come out and you always need to warn them that it can reoccur or progress over time and it's slightly less um common with fusions. And what are the results? So Bishan Singh published this 25 patients using a variety of procedures bespoke but according to similar algorithms and noted by, by one year and maintained for 4 to 5 years, um the foot shape improved pain, improved, improved quality of life, improved. But interestingly, it didn't help default and overall balance because that seemed to be multifactorial. So my final thoughts, history and examination, as he'd mentioned is key to treating patients. Every patient is different and needs a bespoke treatment. But hopefully I've laid out and he's laid out a systematic approach that you can follow. But I think it's most important to understand the basic principles because that will help you understand when to deviate from all that we have said. Thank you very much. Thank you Karin. That was excellent. You have laid out really nice, um, you know, principles out there, uh try to simplify this complicated, um you know, neurological problem. So, what I'll do is I'm going to uh kick start the discussion and I'm going to use two questions from audience and I've got a few questions of my own. So, first of all, there is um a question from Benedict who is asked and both of you can chip in um if you do a prostate transfer, uh is it not important to stabilize the chop joint as well? Should I go? I mean, it's a great question and it's a question I've asked and it's a question that um often gets asked by trainees or by people who um you know, you would think we spend so long, you know, anyone who has a tip post, dysfunction ends up with a plane of s foot. So how can we just harvest tip post? The honest answer is it, it doesn't seem to matter. II can't think I've hardly ever seen. I think I've hardly ever seen somebody develop a flat foot from harvesting to post, you know, do you need to stabilize the tail in the V joint. I don't think you do. These feet are already quite stiff. Um, and they're CVA anyway. And so I think the spring ligament and the plantar capsule is, and the tail in the joint itself is so s generally quite stiff and stable if you're doing this, uh, you know, a tip post transfer in isolation. So I've, I don't stabilize, uh, the shape of joints with a medial column. Um And it doesn't seem to be a problem. I can't think I've had a foot that's collapsed after I've just taken to post. And I think it's for those reasons. Um II, would I, I'd agree with that. II think the, the, the science behind it is there was a paper in 2022 which looked at weight bearing CT and analyzed the morphology of the, of the feet. Um II, wish we did that paper but we didn't. Um And um what it actually shows is that the bony structure is abnormal and you have a hypoplastic inframedial um talar head. Um And you have a hyperplastic bits of the navicular hyperplastic bits of the Calcaneus and the Bolar angle and angle are all different in the CS foot. The angle of the subtalar joint, the angle of the medial facet to the posterior facet are all so different that the bony configuration prevents you from getting a flat foot and you never ever ever will get a flat foot, no matter how, almost, no matter how hard you try. The one exception that's only happened to me once is I had a patient who was CMT type two. And remember the CMT type two patients don't present in their adolescence, they present in their twenties. And therefore she had a milder version. And although she presented with profound weakness, it was later in life after her bones had already formed. And so in that situation, I did actually put her TPO into duvoid and say, wow, that's pulled her over, but she's the only patient that's ever happened. And on table, I recognized it, took it out and put it more medial and she's been fine. So in the C MP type twos, you could possibly have it but most CM T type one, A C MTX and CMT type four of which they are only about 16 in the world or something. Um They, they, they will not get a CV foot for those reasons, sorry, not get a flat foot foot. Thank you. So, whilst we are on the subject of posterior transfer, can I ask you um both heath and current? Um do you always do a split transfer or do you uh where do how and, and, and if you do a single versus split transfer, uh when do, how do you decide and when to do it, do you, do you wanna go first with that one? Um I think it depends on the phase of the moon. It depends on what happened to my last patient. Um It, it, it is art II have to say I sometimes don't decide the long table and I OK. Uh, to be completely honest, the, the reality is that, um, I don't think there is a perfect tendon transfer and, um, sometimes you see something which you think is not perfect and the patient is delighted. Sometimes you do a tendon transfer, which you think is per perfect and the patient hates it. Um I prefer going tendon to tendon because I think tending to bone have an early failure rate, pull out. I have to make bigger incisions and I always struggle to get it in. Sometimes the bone is soft and I think the cute bo is gonna explode when I drill the hole. If the tendon is big enough, which it is mostly I will do a split transfer because I think that's more balanced and I think I can attach it to the inside and outside of the foot and it almost becomes like a bridle. A and the reason is if I do a single tendon transfer, then I have to put it into um, somewhere in the middle of the foot which ends up being Edl. And if you go into Edl, I find sometimes that makes the toes claw up more. I went through a phase where I hated that. So I actually started putting it into Edl, touching Edl of the toes and reinserting Edl like a Jones procedure into the lesser metatarsal heads. Um, but it, it was a total fact. It did work very well. But then I thought the split count work better. So my default nowadays is a split for those reasons and people have different experience. I mean, I think a similar answer, II agree with you about the bone fixation and, you know, I've broken a navicular and a form and I think if the bone is soft, hold up, you know, post menopausal women, um I think trying to use an interference screw because often you want to put it in really tight and you're really asking a lot of the tendon, the fixation to hold. So tendon to tendon is a better fixation. I think if I'm just doing it for foot drop in isolation, then I tend to just do a single you into the top of the midfoot somewhere. But for a neurological foot where I'm trying to get balance, then I'll split it. That's, that's sort of how I think about it, which I think. Thank you. Yeah. Yeah. No, I II agree. Thank you. Thank you very much for that clarification. Um The other two questions which I had put in of uh heat you, I mean, both of you have covered achilles tendon lending in detail uh and, and heath looking at your talk and I II agree. I like it. I like to release ach, least tendon more often than not. But, uh, I mean, I do majority of my neurological by the hoax procedure. Uh, do you, do you do the same or do you do open procedure for, uh, at least tendon lengthening? Yeah. So I really liked, um, Karen's way of, uh, trying to be slightly more scientific about it. So, I just have two types of achilles titers, which is the heath tailor type one where you can just do little 33 little cuts and kind of push until it goes with a pop. And then the heath tailor type two where it's just so tight that you just think it needs more. And then I do an opening, I do a Coronal split. So I get a 10 blade and II split it coronally so that they slide over each other. I just find it's a less bulky repair and it doesn't seem to press on the wound as much. So II II think I like Karen's. Karen's the more scientific way of saying what I've said. But I think if you need a bit of correction through little cuts is fine. But if it's a really big tight, you know, if the heels off the floor completely and then I'll do it open and do I do a Coronal split Coronal Z basically. Wonderful whilst you're there. Um He, you did mention about Plantar face share release as well in one of your patients and we in UK do not do a lot of Plantar F share release. Um And II just want to have your take with your experience. What, what, what, what do you think? Yeah, we don't, you're, you're absolutely right. And whenever I, you know, we have a sort of local complex foot clinic and you go off to, you know, we all go to because of the case conferences and people show cases and I, again, I have no signs to it. II watched, um I went to watch a chap called Wolfram Bent in Heidelberg do a lot of severe CVAs deformity and he was doing quite a lot of plant fascia releases. And so I started doing it and again, I've rarely regretted doing it. I haven't given anybody a flat foot. I think it just allows that, that arch to come down nicely. Um So I will often just decide on table if I just think it feels, you know, when you push the first ray up and it just sometimes feels so tight, I'll just make a small, a small incision and release it. Um If I think it feels tight. Um again, I'm afraid it's the Heath Taylor type one and the type two I've, I can't give you any more than that. Um But II II do it more um than I think some people do. Um Yeah, it, it's a bit, it's a bit out of fashion in the UK. Yeah. Thank you. What about current currents? Type one? And currents type two uh or achilles? No, for plantar facia? Oh So II think it's, as I said, II mean, I think when you release the spring ligament and the, the navicular joint comes around it often um by just virtue of being in the right plane all of a sudden it, it releases and remember II take a wedge with a shift. And what I do is I detention the plantar fascia through my osteotomy. So what I didn't mention is my Calcaneal osteotomy. I don't just go flat across, I do a shortening osteotomy. So when you're looking at it, if you're bringing the heel towards you, if you tilt your hand so that your hand goes more um distally and you do the osteotomy, then what you do is you bring the insertion of the plantar fascia inwards a little bit as well and you detention the plantar fascia that way a little bit. Um And I II think the ones which are really tight, like he said, I tend to end up doing age tarsectomy on them anyway. And then I base my fat on the fulcrum, not on the bone but on the plantar fascia. So I detention it, I II think I've done one or two. BP is not, not very many. OK. Fair enough. No, that, that's absolutely. Um He, you did uh I mean, um you did touch base upon Subtalar joint fusion and, and, and, and II agree with you. It's um you know, difficult with Calcaneal chip. So I've got to ask two questions. First of all, I've always found that the medial displacement is easier in Calcaneal osteotomy as compared to lateral displacement. Are there any tips as to how you get, you know, more correction, uh resecting more bone using bur or obviously releasing a Gleason anything like that. And second question was regarding your subtle joint fusion, if you're doing subtle joint fusion for a varus deformity and you're releasing the medial structures, do you use a medial approach to do subtle joint fusion or you do the lateral approach? OK. So question one is tips for doing a calcaneal osteotomy. So II almost never do just a wedge because I think II, II really like the Karen's animation on the banana. I and II, haven't I sort of heard that and I'd seen that paper, I think that demonstrated it really nicely, but I do a wedge and a shift as well. So II do a wedge and I go put the lamina spreader in, I go all the way through the medial side, you know, being careful obviously, and then I release all the medial soft tissues and so I close the wedge and then I slide the heel fragments as well and I'll often slide it by a centimeter or so. So you've got the wedge and the slide. So it's a sort of modified wire II, I've made that name up. I don't even know if it's called that. But do you know what I mean? And I think that gives more correction, I think just taking a wedge. Um, I, I've done that a few times and they, you think, oh, I've taken a big wedge 1012 millimeters and, and they come to clinic and they stand up and it's still in a bit of varus and just think, oh sure. I had this better than this. And so I now will always slide it as well. So that's, I don't know, I can get it really released and I really release the middle soft tissues. Your second question was regarding the approach, I do almost all of my subtalar fusions from the lateral side, certainly for um for hi for virus because that, that's the sort of friendly side for the wound anyway, for this deformity. Um And II do it all from the left side and I'm just, you know, with experience, you get used to getting the lamina spreader in and I get right through to the medial side. I see the medial soft tissues um and you see F HL running in the back corner and I just release it all and make sure and I'll take bone away if necessary um to allow that correction to, to come. II agree with Karen. It's interesting. I think the more severe the deformity, whatever you're doing taking bone away is your friend so shortening and um you know, just don't be scared to take bone away. It's not like doing an inside you Subtalar fusion for a bit of arthritis. Um So take bone and it just relaxes everything. Thank you. Um I just echo everything he said my my tip as I said um for the Calcaneal osteotomy, um lamina spread uh take a curve os tome, uh poke it around the side and just try and lift the soft tissues off the Calcaneus on the medial side and you got to sort of hold it um like that and, and take it down and be really gentle and sneak it around and do it. But if you do that, then it allows you to get a better shift. If you don't, if you skip that step, then I think you struggle and you fight. Um The other thing is as a hoax some, if you really can't do it, a hope really helps. But, you know, I usually do the h before the lost. So it's not a problem. Yeah, me too. Yeah. No, thank you. So, few more questions have appeared from our uh audience. First one. Are we, can we do a staged correction or we uh have to do all the corrections in one setting and foot 4 ft midfoot. Um I'll go first. So II don't usually do toes when I'm doing a CVAs foot correction. I think Karen, I heard you said that as well. And I agree, I think for a couple of, for a few reasons, one I can't stand doing toes. Um, another reason is, um, I worry about infection so you're gonna put wires in toes or however you fix your toes and I worry about that if you're just gonna be hi foot. And also, I think, I think you don't know what's gonna happen to the toes because there's often a bit of flexibility and I've had quite a few CVA foot corrections where they've got quite significant claw toes. And if you get the hind foot and the mid foot right and leave it for 6 to 12 months, they don't complain about the toes and actually, I think the toes sometimes just kind of settle down a bit and they relax down a bit. And so I don't usually do the toes, which that, that fits with the sort of, how long does it take? Question. So, um, do I do, I do it all in one go? Yeah, I do. Do it all in one go. I don't do the, the hind foot and then come back and do something else. Um, it's just about being, doing it regularly and being efficient and make sure the procedure keeps advancing and, you know, if you've got a tendon transfer and effusion to do and you're doing the fusion and then you ask for the screws. And I had, I had this this morning Um II was um I was doing a Subtalar Fusion and an F DL transfer and I would do the Subtalar Fusion and for whatever reason, they hadn't opened all of the drills that go for the screws that go across the Subtalar joint. So you can either sit there for 10 minutes and wait for the screws to come. Well, I just got on and started harvesting FDR. By the time the screws arrived, I've done most of the tendon transfer. So it's just about being efficient and using your time efficiently and progressing through the procedure. So I painted it all in one go. Um I don't know, Karen. How long do you let your tourniquet stay up for? When do you get nervous? Um I II don't mind really. I mean, I do, I usually write it down between two and 2.5. But to be honest, II, II never get that far with the, gave his foot um Anymore. Anyway, I II echo what he said exactly the same thing. I think the toes swell more. I don't like the wire sticking out, I think for the want of the toes. It sacrifices the blood, it confuses the blood supply to the rest of the foot which may compromise another wound. I tell all my patients, you got four operations with me. You got your big operation on your right, your big operation on your left about nine months to a year later. And then you'll come back a year later after that to have 1 ft done and then the other. So we'll know each other for three years or so. Um, yeah. And, you know, it, it, it takes a lot of time in the beginning, especially if you're not used to it. And you have to think and when I started, I think it was, you know, it would take me 2.5 hours and I'd be letting the tourniquet down and thinking, oh my God, I'm running out of time and um now it takes me an hour, hour and 15 minutes or something to do. Ok, with foot. Um It's just as you understand the flow and as you do lots of them, um it becomes easier. Thank you. Yeah. No, I mean, II, II have a, you know, I was reviewing one of my patients who had a CVA foot and eye with arthritis and I did a hind foot nail first metatarsal ster to me at least and lending and they had a lot of deformities of their toes, but I was the Xs and the toe deformities when I was doing flattened. So it looked, looked pretty good. So, yes, II agree that you don't have to do the toes. Uh Is that because you kept the plantar fascia intact by any chance? Yes. Yes, I did. Is that your point? Thank you. Um So the next question is about the testing, um neurology genetics. And then one question I am going to ask you both. What's your experience of idiopathic cavovarus deformity? Is that, is that or? Yeah. Yeah. So, so genetics, we, we're lucky, we're based, we are partnered with Queen Square. Um So we, we know a neurologist. We, we often get a lot of referrals from them. But equally if I have someone without a diagnosis, I will often send them or a diagnosis because a they often need a lot of support in other things, particularly if hands are affected, et cetera. And they often want to know what the risks are to the rest of the family, particularly if they're young. Um Even if I suspect idiopathic avis, I will often send them for a review because I mean, at the end of the day, what do I know orthopedic surgeon? Um The Idiopathic cavs is different. Um So um Alessio Bernasconi, um when, when he was with us, he's now a consultant in um um Naples did um some work on this comparing um CMT versus idiopathic and there are differences for one. They don't have as much rotation, they don't have the same. So they have deformity, but it's mostly in the Sagittal pain. They don't really have as much Coronal pain deformity and he didn't quite manage to find this. But I think that's because of the methods they use. But my personal experience is that if I see someone with a very high Calcaneal pitch. I think they're much more likely to be idiopathic avis than CMT. Most of my CMT patients don't have a high Calcaneal pitch, but most of my idiopathic Gavis do have a higher TCA pitch and they actually have more pronounced Gavis, which is actually harder to treat. So, um it's just about, again, it's pattern recognition, but it's about recognizing the differences in the pathology that you're treating and treating the right thing for that patient. The other, the other big thing is I'm less likely to need tendon transfers in my idiopathic cavus because they don't have a foot drop and they don't have an unbalanced foot this way, they just need a little pain correction to an extent I calculated osteotomy. So, um just, yeah, bear that in mind. Really. Thank you. Do you want to add anything? No, I agree completely. They, I think that's exactly right. Um I agree about that. The idiopathic ones don't usually have, they don't have weakness. So it's just getting the, they usually just come with either colo or loading on the lateral border of the foot or perineal tendinopathy. And it's just a case of, II agree. So the selection of osteotomies in a bit of peroneal tendon surgery um often is what they want. Wonderful. One question which I think was very interesting, um and was directed and that's the last question I'm going to take was from my pediatric orthopedic colleague at Leicester ANA P. So this question was directed to you current and she complimented you on your traffic light analogy. Uh And she has asked that, is there a role in adolescents to do a tendon transfer to prevent progression? So, for example, if somebody is asymptomatic, uh, and they have a correctable or, you know, minimum deformity is a role of doing tendon transfer to prevent the progression. Yeah, that, that's, uh, that's a, that's a question, isn't it? I mean, that is the question. Um, ok, so, uh, let me put it, let me put it to you this way. If someone is presenting to you. Yeah, as an adolescent, it's probably because they've got severe deformity, right? So you're unlikely to see a mild deformity presenting to you at adolescence and, and if it's not correctable, then ab absolutely. I would, I mean, on some of the hardest cases, um, I have 1718 year olds who just had really onset, you know, their, their grandparents have had it and it, whatever anticipation or whatever their phenotype is quite severe. Um, it's actually sometimes harder to convince them that they need it and the traffic light system is one way. But the other thing I do, which I picked up from Nick Geary, um, is I get them to stand on a paper and I haven't shown this slide. You've seen the slide before, but I haven't shown the slide in, in this dog because it's fine. I get them to stand on a paper and I trace around their foot and then I put a mark on their, where their heel is a mark where their big toe is a mark where their fifth toe is. And then I draw the marks with the malleola and in between the malleola is the center of their big bearing access. And you can draw this triangle between the tripod of their foot and say, look, if your preparing axis misses that triangle of tripod, you're just always gonna be unstable and they definitely need something. Um, II don't, II try and wait until this greatly mature because just because that's my practice and I normally don't see that many Children. But, um, you know, I wouldn't, if you can see someone is progressing and they're not controlled by insoles and a lot of adolescents will not wear their insoles. I absolutely think there's a role for that. I've, I've never done a Calcaneal osteotomy myself in someone who's gleet immature. Um, but, um, II suppose it's done, um, you know, and if, if they're presenting, you know, they're more likely to present when they're 15 rather than they're when they're 12. So, you know, they'll probably have finished their growth anyway in their heel. So, um, yeah, II wouldn't really worry if they are actually progressing. I don't know what you guys need finishing. No, I agree. II think there's no, you know, when young people heal well, the risk of complications is low, the recovery is good. And I think sometimes this, it's often fitting into their life as well. So, you know, G CSE SA levels, university, all this sort of thing. There's the timing of this thing cos, you know, we all know the recovery takes ages and so it's fitting it into when, when they've got a gap in their life to have something pretty major done. And it's often bilateral, you know, 4 to 6 months apart. But I think it's II, I've, I don't do young, I would say my practice is all kids is all, you know, sort of late teens onwards. I don't do younger kids. But, you know, see 1718 year old, if they've obviously got a progressive deformity with a planta flex first ray, you know, I think to balance them and do a longest to Brevis transfer and a, you know, once they're completely mature I II have no problem doing that. Um, and I agree that they don't come asymptomatic. I don't think that I don't think I've ever seen that. They always come, they've got something. Thank you. Thank you both. Thank you both so much. Um I think it's time now. We have gone past nine and it has been a very, very educational evening with a wealth of experience and practical tips about this difficult topic and I'm sure all of us would have learned something today. Um Thank you, everyone for joining us. Uh The next master techniques would be sometime in October, either the first or second week. And if there's any burning topic, you would like to be uh presented, then please please let us know I'll be more than happy to facilitate that. Um So thank you very much, very much. Hope you all have a good evening. Um And, and you can I can I ask that man? Um They can let us know on medal if you're following us on medal on the medal page. There's a threads comments section which you can leave comments there, which is um easy way to get it to us. Excellent. So you, yeah, you heard that you can, you can, you can just let us know and obviously you are, I'm sure you'll be filling your feedback and you'll be receiving the certificates. Uh So yeah, thanks once again for joining us on the BOFA Master Techniques. Have a good evening. Thank you.