Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. Um Tonight's um program has been slightly changed uh due to some last minute issues, but we are still going to have a fantastic cracking session. So the plan is the session tonight is on cable virus foot. I will start the session by sharing a couple of cases uh which have CAVO virus element and hopefully by the time I finish those case based discussions, um our, our, our guest speaker tonight, Karan Malura from Stanmore, um who has a wealth of experience will, will join us and then he'll uh give his perspect perspective on vis foot and time permitting. We'll get one of our fellows to share a cracking case on Cavo virus. Ok. So hopefully it will all work out well. So let me start with my case number one. Can you see me and uh everything clear? Yes. Yeah, clear. Excellent. So, ok, this one, this one is a 52 year old male uh who has no medical issues uh and presented to me uh with these radiographs. Now, can I ask one of you to tell me or show me what are the radiological parameters which are important? What, what do we see are the x-rays normal. If not, then what can we see what is abnormal, any one of you? Well, if you want? Well, I see. Uh yes. Uh Well, first of all, in the AP view, you can uh see that. Um, well, you have to, to see the, the line with the, the tibiofibular joint, you have to see that I, if it's parallel, the joint is parallel, also you have to check how it's rotated or not rotated the fibula in respect to the talus and the tibia. And the gentle line there, I can see some kind of rotation but well, the the joint is parallel also, then I see the, the foot, it is a bit displaced but the talus is fine and then it, and I can see also that it's uh well, no, it can be, you know, it's OK. And then in the, in the lateral view, I see you have to see if you see the syta, see, you see uh the c the fifth, the right that in this case, we are, we are we you can watch it. Also, the fibrillar is a bit posterior kind of posterior. And well, if you if you from a lateral size from a lateral view, sorry, you, you can see the, the fifth, the fourth metatarsal uh probably that, that, that uh foot is in, in virus. No is super, so absolutely supinated. So yeah, so lateral view uh II agree Um we, we, we have issues on both s both ap and lateral but lateral is quite typical of uh chemo virus foot. And the radiological parameters are we see these toes, we can see the clawing of the toes. Yeah. Yeah. Then we see the Mary's angle, the talar first metatarsal angle that's altered, that's not in a straight line. Uh um Then we see some hypertrophy of the fifth metatarsal and in cava virus foot that you know, it's a subtle finding because they are putting a lot of pressure on the outer border of the foot uh due to supination. And one thing which I always find which you see is if you see nice opening of the uh secular joint, then it's indicative of virus whereas valgus you see overlap. OK. Uh The other thing which has also been described is the talar calcaneal angle in both the AP and the lateral views. So, in, in a virus case, because of the uh talar declination, uh the Halo Calcaneal angle is lowered is less. Um This patient also has uh narrowing of the anti ankle joint space, which means there is some arthritis and osteophyte. Ok. So, these are the radiological changes which we see on the x-rays. Um This is the MRI scan and the MRI scan again demonstrates to what I was alluding to earlier that he has some arthritis of the ankle. You see here, you see there, that is what is happening with this guy. So 52 years old, he does not have any spinal problem. No neurological problem. Uh no sensory deficit, not diabetic presents to us with a chemo virus for deformity with some arthritis of the ankle joint. How should we treat him? And they can be lots of options. Not one is the right answer. There can be, you know, whatever, I'll show you what I did, but I want to prick your brain as to how you would like to treat and each of you might have an individual strategy. So we start, you have to be quick because we don't have much time. We have to share two cases. So you have to be quick to the point. How would you treat it? Mohammed? Well, here when the first uh management is conservatory, conservatory with orthotics is uh fails, then it will be surgi surgical. And in, in this case, is it flexible? I mean, you have to check if it's flexible or not, you can go through osteotomies if it's flexible. I don't know, was it flexible? So I asked you, Pilar, I put the question back to you. So what do you think in a 52 year old man if you or, or woman, if you see these deformities with some established arthritis, what are the chances of it being flexible or fixed? What do you think it will likely to be? Well, it can be a bit rigid. II think the chances are it was rigid. So, at, at that age, with some degree of arthritis with such a long history. So I should have told you it's been there for some time. Yeah. It's a rigid deformity. Not, not completely correctable. Yeah. So then when I was saying in the ap view, if the, uh, joint was, uh, parallel, uh, it was parallel, so I will start, um, uh, operating in the foot and, I mean, I wouldn't do anything uh above. No. So I will operate on the foot. And then uh I don't know here in the, when basically I will start in the heme foot. Uh I don't know if you perform a, a Subtalar arthrodesis versus a doer osteotomy if you are saying that it was rigid and the subtalar was a bit as probably you choose for uh for an uh arthrodesis. And then uh probably I saw that um those II didn't see one in the Sagittal plane. This one was, was a bit um uh Plantar flex. So probably if you want to, to correct more, see there, maybe you can do um osteotomy to elevate the, the, the M one, the, the, the, the first metatarsal. Brilliant. OK. In, in sake of time. Yes. Anything else? No. And it depends, I mean, about what you were saying of the disc, close to, close to toes and all that. II, II don't see very exactly what that maybe, I don't know if you want to perform some soft tissues uh release. Uh but basically the om would be that the subtalar arthrodesis in la bit vuls and elevating the first metatarsal and soft tissues releasing. Oh Pilar, can I just ask a question? You know, when we look at the MRI scan, he does have some ankle arthritis as well. So if you have somebody with a rigid deformity in the hind foot and ankle arthritis, would your approach be slightly different or will you have the same approach? Uh Well, the the thing is that this arthritis, I see that it's only medial. No. So, so for the moment, medial, medial and central. Yeah. Yeah, medial and central. So for the moment, I will try to preserve that. II don't know if you want to perform an arthroscope and check. But for the moment, uh uh there is still uh some parts of the tt that still are fine. So I II will preserve that joint. Ok, fine. So pillar, I did something I listened to you in some sense, but I didn't listen to you in other sense because I saw the patient. I had a detailed discussion. Let me see what I've said in my next slide. So yes, I have written the options of treatment which I think are possible in this case. Uh So you can do joint sparing surgery like uh classical Paca virus correction. And we'll hear more in our uh you know, hopefully our guest speaker will talk more about all those. I don't want to repeat that. Uh So yeah, th th this is how I do it. And I'm sure you know, these are the ectomy, lateral displacement calos t tibial is supposed to transfer peroneal repair or tibial is supposed to transfer to peroneal tendon, lateral ligament reconstruction, first, dorsiflexion, osteotomy, uh or you can do joint fusion surgery as you said, pillar. So what I uh uh joint fusion surgery you can consider and any of these could be right, you can consider triple fusion, you can consider hindfoot fusion. And this is what I did. OK. And it worked. So what I did was I did achilles slender. Uh I II like at least 10 II think its tension is too much. I did a hand foot fusion because of the arthritis of the ankle and the deformity, significant deformity. And I did a first metatarsal elevation ostectomy. And that was enough. And as you can see, as you were saying, quite rightly, you said the toes actually came down just by doing the first metatarsal ostectomy. So that is a nice case to demonstrate, you know, that, that there's nothing right or wrong. And this patient uh I remember his name. I had done him before COVID, I think 2000, I didn't and he's still happy with it. So this is what I did and this is one way you can deal with this issue. OK. Good. We will now move to my second case. Everybody happy here. Yeah. Yes. So second case is more interesting in the sense he's got bilateral issues. So he is a personal trainer and he was referred to me for bilateral issues. And on the left foot, he had some arthritis of the first TMT joint uh as shown on the MRI scan and he had already had injection with good pain relief followed by recurrence. So this was relatively easy. We said we can do first TMT joint fusion. Uh And I did this and solid recovery, very happy with the left foot. No problem. The problem was with the or the problem is with the right side. So this is the case. So this guy as you see in these clinical pictures, that's his right side. Yeah. So he has the Peekaboo sign. He has quite significant uh virus hind foot deformity, maybe some element of KVAS as well. And you can see from the scar in 2007, he had lateral ligament reconstruction. So he had lateral ligament reconstruction using peroneal tendon. And unfortunately, this has not worked for him and he has developed progressive hind foot virus deformity. OK. So he had actually bilateral lateral ligament reconstruction, right side has progressively become worse, sorry about that. Uh And we check with the clinical testing. So we want to see how is our uh hind foot predictable or is it driven by the forefoot? So that's the um Coleman block test. We, we call it the uh uh you know, you can put a book which we do, we have a, a text book and you can see that by offloading the first tray and putting the heel on the uh on the, on the, on the block. Uh his deformity is I mean to neutral, not going to all this but improving from here to there. So there is an element of correct of the deformity. So, in order of work up, what else? Well, first, let's see how he walks. So that's his gait. So just see his right side. So you can see he has got quite significant varus deformity and these are his weight bearing radiographs. OK. So you, he's got a marked t so remember he had a lateral ligament reconstruction, but he's got a mark tilt of the talus. He has large osteophytes uh of AAA around the tar tar neck. Um and he had a scan and that scan shows the tilt, the cyst, uh some arthritis and all the telltale features. Uh And then that's again another example of his um ct scan. You can see the osteophyte build up there. Um quite significant virus deformity, long leg views. And you can see the Saltzman or the axial view that there is the component is more infra maar in his case, rather supramacular. So with these I present to you the treatment options. Actually, let me ask uh Pilar had already had a go who wants to have a go to say about the treatment options for his right ankle. What can we do? Nobody wants to raise a hand. Uh man. Sorry, man. Because of I think there is arthritis. It's clear and there is subchondral cyst, I think effusion is good option. But the age, I think even with the age, absolutely. I would say that's a very valid option. So he's 38 years old guy and with that degree of deformity and with some degree of arthritis fusion is a very valid option. And he's a personal trainer, you know, so I dis I've already discussed that with him. So what's your opinion? Manage, what's your opinion of total ankle arthro blast in his case? 38 with that degree of virus and 38 year old I will not do and not a lot of maybe there might be some brave people who do it uh ankle arthroplasty with this degree of deformity in such a young person, it's not going to last for more than 10 years at the most. And I, so I agree with him. I don't think it will be a good option in my opinion. Yes, but a brilliant surgeon um can do it. And I if it does that then that could be an option but not, not for me. So as you said, an ankle fusion is an option. So let's see what I have written here. Here we go, ankle joint fusion discussed with the patient, patient doesn't want it. He's a personal trainer and he thinks if he has a fusion of the ankle joint, then he will lose a lot of mobility and put stress on the other joint very valid. So you have to respect the patient's views. There is an option of smart or medial open v osteotomy. Uh and Norman Espinosa will cover beautifully when he gives his talk on distal bu ostectomy. That's an option. But again, the patient has already done his own research. He does not want it. So my plan is and I I've done for so I my my plan is to do this lateral displacement cal nosy including a wedge. So Dwyer gives you better correction. I think both shift and and and a wedge. Uh first meal dorsiflexion ostectomy. We have already seen an example of that revision, lateral ligament reconstruction. I would actually, I don't think internal brace would be a good idea, but you can consider revision lateral ligament reconstruction and I'll tell you why. Uh so he had got big osteophytes. So you need to remove those osteophytes to give freedom colectomy. II li I like I told you, I like percutaneous cyclic to me. So hoax, so these would give a reasonable option. And the patient understand if these don't work out, then you know, we have to go to ankle joint fusion. So I've already done, I've, I've actually done in stages. So I've done the first stage already on him. And in the first stage, I did an open colectomy. He had actually a loose body um as an osteophyte. So I removed that and I've cleared out out all the osteophytes and it looks nice and I've done the uh at least, you know, to me and I've done the revision, lateral ligament reconstruction. I didn't use an internal brace. Why? Because remember we have to do a Calcaneal Ostectomy and internal brace will be in the way. So he had previously uh his Peroneal tendon sacrifice. So I've done a Brostrom and the first stage after the first stage, it looks good in the second stage. I am going to do the Cal osteectomy and revisional presented if you guys are there. So it's an interesting case. OK. I don't know K is there or not? If is there? Oh Karen, brilliant. So Karen, welcome. And thank you very much. So, let me stop sharing my presentation here and let me welcome KK. Thank you so much for filling in such a short notice. K is uh a young dynamic dashing surgeon. He's our media and communication director of FA, he works at Stanmore Hospital and he has an immense interest in vo vs deformity. Uh And, and, and he gave a talk recently uh in a meeting I was there and I was really impressed. So uh I II, I'm, I'm glad Karan is going to share his wealth of experience on feet. So I am going to hand over to uh k now so that he can speak on the cable. Thank you, Karin. Great. Thank you. Thanks for asking me. Um And um thank you all for being here. Can you see, can you all see my screen share? Yes. Ok. Ok. So um I'm not gonna reintroduce myself because um said it all and I'm a consultant for medical surgeon and um, honorary associate professor. Um, and this is my take on how I correct the neurological Cavovarus foot. Um, uh, a disclaimer about all of this. Um There's very little evidence which is better than level five, most of the evidence, which is better than level five is on your screen right now, which consists of two consensus statements which are a collection of level five evidences which I'm sure is still level five or 4.5 or whatever. Um But I just wanna start off with, um, when you look at a foot and when you start to try and imagine what you're going to do to the foot, it's very good and nice to envision a dream situation where you're gonna make this person perfect and they're never, you know, they're gonna be absolutely amazed. Um, and you're gonna reconstruct everything and you're gonna think that's perfect. I've done a great job and success. Uh But what you have to understand is that these patients were never normal and if you try and make them normal, um sometimes the skin, soft tissues won't take it and it'll all end in tears and always bear in mind what you're trying to achieve with patients. Because if you start in a situation where you don't really have much to go on, you barely have a roof over your head to begin with. And if your baseline is that poor, then sometimes all you need to be happy is stable structure which allows you and protects your foot from the elements. And then it lets you get on with life. So you don't have to go for gold in these patients with that in mind. The next thing to think about is when to intervene surgically before we talk about what to do surgically. And you have to understand the natural history of the disease and you have to understand that patients um have a choice in the matter because especially with neurological feet and CMT is the classic patients are gonna have this problem for about, you know, the rest most of their lives since adolescence, they have noticed it and they have school, they have university, they have jobs, they get married, they have Children and there's no good time to intervene. But at the same time, deformities progress with time and what's once flexible does become rigid and when it is rigid, then it robs you of options, it increases the complexity of the reconstruction. So if you take this patient, for example, this patient's come and went away and came back about five years later because she thought it's my choice and, and this really makes it for a difficult situation. And so what you need to know in your mind is what is the tipping point whereby you need to be advising the patients that you really need to think about surgery regardless of what else is going on in your life. Um, and you can sort of think about it like a traffic light system. So over here on the, on the left most side, you see, I call, I call this green and, and this is a situation where the weight bearing axis of the person or the patient is falls within their heel and this is a, you know, relatively stable deformity and there's no rush for surgery here unless they're very symptomatic. Let's look at this situation where you can call them meta stable if you want to. Um, or if you wanna use fancy words, but basically over here, the weight bearing axis still falls within the heel, but it's very close to the end. Now, the reason this is important as you all know is of course, the foot is always a tripod and you, you balance on your, um, big toe, your little toe or, or base of your foot, metatarsal and your heel. And if your heel and everything is over and the weight bearing axis falls outside of your heel, then you're gonna end up in a situation where you're a little bit like the leaning tower of pizza and you're gonna just keep tipping over. So this person is almost at risk because they've certainly progressed from the green. But if an insole corrects them, then they're probably, ok, we're making up atrophic like color here because this is a bit like the yellow except that this person is in equinus And that means when they stand because they don't have a fulcrum on their heel or they don't have a point to where, where on the heel, their ankle turns into a fulcrum point. And therefore this person, although they look like they're weight bearing a access to their heel, they're actually gonna be unstable. So this is, although it looks like yellow, it's actually worse than that and here's red. So this person has progressed and basically the weight of the body is not passing through the foot at all. And this person is only ever gonna get worse. This person really needs to be getting into surgery, um, regardless of what else is going on in their life really. And this, this, I've labeled it white because II give up with this really, they should never have got to this situation. So with that basic bit out, out of the way, I'm gonna jump right into s to surgical strategies and I just want you to think about what we're trying to achieve So this is both the same patient before and after surgery and what we're trying to achieve here. And it's illustrated well, with these pictures is you just need to put the hind foot under the body so that you get that little arrow, that line back to central. You wanna get the foot flat to the floor so that you restore the tripod and then you wanna balance the muscles so that it doesn't happen again. It is actually that simple and that's all you need to do. You just need to create a little stable base, a stable triangle and to get on with life. The how of what you achieve? This is where it gets interesting because you need to assess and address each aspect of the deformity and plan to treat it according to what that patient has. And because every patient is different, you have to sort of almost have a bespoken tailored operation. You can't just go by one formula. So you need to think about the soft tissues and you need to think what's tight, what means releasing what's overactive or relatively overactive and what might need transferring to balance it. You got to ask yourself, do I need to Lenten the achilles? Because sometimes they may look like they're in equinus. But if you look at the top right x-ray, you'll see that all of this patient might look to have an equinus foot and you can see that in the bottom picture. They're actually got a deformity at the midfoot, not at the achilles. So if you over lengthen the achilles, the Calcaneal pitch will go up, they'll be less stable and it's actually correcting the deformity at the wrong place. You 10 need to decide what bones need shifting and then you need to decide what ligaments need repair. And I only caught the last five seconds of what Manish was saying, but it looked like he was talking about repairing some ligaments. Um So those are all the things you need to assess and then you need to decide, are you gonna fuse them or are you gonna try and preserve the joints? And there's some surgeons who will say I fuse everything. But in my book, it's flexible when possible because these are patients who are gonna have to live with this for the rest of their life. There are patients who often don't have arthritis when they come to see you. And there's some evidence to suggest that actually patients with fusions are less satisfied, however, you mustn't try and preserve joints at the expense of the goals we discussed above. So if you can't restore the tripod without fusing it, then you're better off to fuse them. And if they're rigid or severe or arthritic, you're better off using them. I think either way in my experience, most of them need tendon transfers of some description. So the order in which you do things and we're gonna go over this a few times, you prepare all tendon transfers and relief, all soft tissues which are tight. You're then gonna correct the bone anatomy and you're gonna go from hind foot to midfoot to forefoot. And then finally, at the end, when you've got the bones all aligned where you want them to cause, remember the foot is a bag of bones and it's held together by soft tissues. If you release the soft tissues and correct the bones, then you've got the bag of bones where you want it and then you fix the tension transfers to keep that bag of bones in the correct position. And what that translates to mostly for me for a cables, foot is if they're flexible, they either have an achilles tendon lengthening or a stra if needed. And a lateralis calcaneal osteotomy. And then I correct the forefoot if they're fixed, I do a hindfoot fusion, which may be a triple fusion, an ankle fusion or a TTC fusion. And then I correct the forefoot and the forefoot's gonna be balancing osteotomies depending on what's left. And then I address the toes. If I need to, often I'll do the hallux IP joint at the same time, but I won't always do the toes, lesser toes at the same time because at the end of the day, there's only so much surgery your foot can take. And then I transfer the tendons. And in my book, most of the time, that's a tip post tendon transfer. And you can either put it into bone and if I put it into bone, I put it into lateral kidney form or you can put it into tendon. And if I put it into tendon, I usually do a split into tib and, and peroneous brevis or you can do it into and tertius, but we'll talk about all of that. So step one, as we said, prepare all tendon transfers and release all soft tissues. So what are the soft tissue releases that we have available? So that's the achilles. And most of the time people will just need a percutaneous release because percutaneous release is good for up to 10 degrees. And I do a hook which is three incisions, 53 to 5 centimeters apart. I do two on the medial side and one on the lateral side, more medial because it's safer for the nerve and the achilles is a bit of an inverter and it catches the bundles as the achilles spins around. But more and more, especially if they're not very rigid, I end up doing a stra because often they have more differential gastrocnemius tightness and actually with a stra if you do a good stra you can cheat a little bit and get a little bit of achilles if they have got fixed equinus, which is true equinus such as in this picture over here. And this is not CMT, but this is um someone who's got HSP um Then I do need to do an open release and the formula is what if you do an open Z release. The formula is one centimeter of Z lengthening, corrects about five degrees of equinus and you want to sit some achilles together and you want about three centimeters of overlap. So if you wanna correct a 35 degree equinus deformity, that means you need um 35. So divided by five, that's seven, so seven centimeters plus three, which is 10 centimeters of az So my tips for this is make first and foremost, I so I tend to do it through a little paramedial incision. So I don't do it directly over the midline. I do it on the medial side. Um because the skin is better there, you must make sure that the end is straight because if you curve the end because that looks natural to you. Once you get the foot out of equinus, that curve which looked innocuous will end up vertical. Right. Right. So it vertical will be up horizontal and then it will gape and you won't be able to close it. So make sure your end isn't curved, but it's straight because then when you bring the foot up, it'll 10, it'll get the wound closed again. I tend to leave about a three centimeter gap from the insertion of the achilles. And I tend to make my um distal incision lateral away from the neurovascular bundle and my proximal incision has to be then medial, which is away from the su nerve, um stretch it out and suture it. Sometimes at the same time, you need to um you all, well, you always need to cut plantaris and sometimes with the posterior capsule is tight, you can take a little knife and pepper pot. It um do that carefully, of course, um to release it a bit further. The other essential release, which I think you need to do and which I always do is um spring ligament and the tip post. So the tip post, I often often harvest for the tendon transfer and you don't need to do a big incision for that. You can do it to a tiny incision like this. So that's the tip post. You'll see that I've harvested and right underneath the tip post is the spring ligament and the spring ligament, of course, we go on and on about for flat feet. Um Over here it's our enemy. So I just cut it and sometimes for good measure, I take a wedge out of it. So it never forms back. They're not gonna get a flat foot um because their bone anatomy is different and their angle of their um calcaneal pitch and their cal subtalar joint is just abnormal. So they're never gonna get a flat foot. So just cut that spring ligament and that allows you to then reduce the talar navicular joint which is absolutely key because these patients have an overcovered talar navicular joint and you cant produce it unless you release these two soft tissues. The Americans talk about a plantar fascia release. I very, very, very rarely do that. It's not part of my practice. I don't think it adds to the stability. And if you correct the clots, it defunct, it, it brings, um, releases the attention of the plantar fascia. The rationale behind doing the plantar fascia release is that um it may be relatively tight although I don't believe that. Um and it can um help the arch of the foot relax a bit. I think that runs the risk of um reducing the um um effect of the plantar fascia on the toes personally. And I think if you are gonna do something like a veg tarsectomy for these tight ones, you just take it with a truncated bed at the level of the plantar fascia and that actually detentions the plantar fascia instead. Um But if you do want to do a plantar fascia, you can do that to a plantar approach. Um And, and that's, that's an accepted thing. Again, for me, it's a bit like are you going for a cosmetically perfect foot or are you going for a functional foot? And for me, I go for the functional one every time. Um Again, going back to this example, this is when you don't want to do an achilles release. Remember to assess and look for the core, which is the center of rotation of angulation of the deformity. So over here, in this case, if I release the achilles to get rid of the plantaris effect, um you will actually overdose flex the ankle and then get anterior ankle impingement. Um So this doesn't, this person doesn't need any kidneys release. They ideally need a correction at the navicular kidney form joint, which would be a vagectomy. But again, do you go for gold or do you go for functional and often in these cases doing a dorsiflexion osteotomy, even though it creates a zigzag foot and is not at the coa is still better than doing a big achilles lengthening or doing a veg doomy. Um And, and this patient was actually fine without either. So that's what you're doing to preparing a tendon transfer and releasing the soft tissue. So now we move on to correcting the bony anatomy and we're gonna start off with the hindfoot. We're gonna talk about the Calcaneal osteotomy, which which almost every patient gets and is a sort of workhorse procedure. 2022. Um Glen Fifer's group um wrote a paper which um defined that using 3D modeling. Um There are differences in the way the bones are shaped in patients with neuromuscular cavovarus feet and that's because they've had an abnormality, whether they've recognized it or not since childhood. And therefore, the forces on their bones have been abnormal and their bones are not normally shaped and you must recognize it because essentially the calcaneus is banana shaped. So you need to address this when you do a cal and loss. The Auto me personal, I do them to an extended lateral approach. Um And I go straight down to bone. Um I don't create any, the the flaps are full thickness just like if you were doing an open calcaneal. Um or if um you then osteotomized it, you can use a lamina spreader to spread them out. And then I take a wedge out of every case, um like a dwire type, take a vedge. So I take a wedge and I shift and I'll show you why in a second you can do it minimally invasively, but it is harder. Why do I take a wedge out? Um The reason is because the bone is banana shaped and if I simply did an osteotomy and shifted it, if you look at the overall alignment of the bone of the axis, the heel, which is the tip of the banana is still not in line. However, if I take a wedge out a veg plus a shift gives me a normal shaped bone with a corrected um area. So I actually do a wedge every time and a shift and I fix them, I actually use headless screws. Um This was, this is an old one when I still use headed, but I don't use headed anymore. So that's why you do Calcaneal osteotomy, you often have to take very carefully, put a sort of curved osteotome down the medial side and sweep the soft tissues off and away so that you can actually get a shift. So if you have done all this, you have achieved a heel which is under the body, a hind foot which is flat to the floor, a reduced telo navicular joint. I that's what you've done. And we've done that by correcting up to the hind foot. So now we need to address the midfoot and forefoot. So how do you do that? Well, the aims here are again to correct any residual deformity which can be pronation, supination, adduction, plantaris, or cavus or whatever you wanna call it. The goal here is to put the foot where you think it's gonna be on the once the tendon transfers are done and then see what you think still needs doing. I know that sounds simple, but it's not. And we'll talk about that in a second. But most often what you end up doing is the first metatarsal dorsiflexion osteotomy. But you may need multiple osteotomies and you may need a Vagit toomy. But how do you know which one? And if the foot looks like this, you may be struggling to try and work out in advance what it's gonna look like. So we asked ourselves the question of how do you predict what the forefoot is gonna look like? And we did a series of four papers which culminated in this one, which was published just last month where we took s foot built. It found out where the deformity is, took a computer model and then fed that in and basically did a virtual correction of the tar navicular joint and hind foot such as we would do during surgery and then saw what deformity would be left in the forefoot virtually. And we actually managed to classify this and we found what 60% of patients have what we call a type 1 ft. And that's what you most commonly expect to see. So once you reduce the hind foot and tailor navicular joint to do all your releases, the first metatarsal is relatively blunt effect and that's what we commonly see, but there's also 20% of what we call type two where not only is the first metatarsal planned, the second and the third are Ponti fex as well. And then 10% have what we call type three where the foot is genuinely still adducted. Remember, most adduction that you see is not true adduction, but it's actually a combination of plantar flexion of the first tray and rotation of the tail and navicular joint. But there are a group of patients who actually have true adduction, which looks like this. And then 10% of patients actually had no deformity at the end, which is easy. So how do you manage it? Type one? So 60% they've got first grade planta flexion only and, and that can be seen clinically when you could reduce the tear joint. They are easily treated with a dors defection osteotomy. I do my dorsal flexion osteotomies vertically because it's a smaller incision and it's a powerful correction. And I tend to put a medial plate, you can put a dorsal plate and we can talk about this in the Q and A if you want to. But I prefer a medial plate for a type two osteotomy. When you correct the tailor navicular joint, you see that multiple rays are plantar flex. And in these cases, they actually, if you just raise up the first ray to the level of the second, they will both be plantarflexed. And if you raise the first ray to the level of the lateral side of the foot, then the second ray is gonna be relatively plantar flex. So they may need multiple metatarsal osteotomies and you can just do a first metatarsal dorsiflexion osteotomy and you can do a BRT osteotomy of the 2nd and 3rd. But in practice, I end up doing multiple TMT joint fusions because it's a bit easier to do co it's easier to fine tune um and balance them out sequentially. And um to be honest, they're always stiff there anyway. Um but you can do either it's the principle which is most important or type three. These are the ones with true adduction and if you're not aware of this, it can be quite difficult because they are often multiplanar and you need a proximal correction which or does some sort of derotation. And for this, you need a Vars toy or a soar fusion or triple fusion. But in the interest of trying to save the hindfoot joints when you don't need to sacrifice them. A vegectomy may be preferred and there are multiple techniques described for this and you can just eyeball them. If they're in one plane, you can put two wires and saw everything off in between and just close the gap. But if you wanna preserve joints in a young patient, if you've got multiple options, then you have an option of using patient specific instrumentation. And the time I use a guide is when I have deformity in more than one plane. If I've got any Coronal plane deformity, because that's very difficult to get your head around if you're trying to save joints or if you were just starting out or it's a complex deformity. So here's an example, I had a patient who had 37 degrees of cavus or plantaris, deformity of the midfoot, 49 degrees of adduction and three degrees of rotation. This patient was gonna get a bad shaky. So I planned this, I planned where the resection margins would be and what it would look like afterwards. And I knew that at the end of the day, I'm gonna correct all of the adduction, not all of the sagittal deformity, but we accepted that, that we don't have to get a perfect looking foot, just a balanced foot and some of the rotation. And we accepted that there's gonna be a bit of play in the lateral column over here, which is gonna make up for it. So that's what we planned. How do we do it? We get a 3D printed jig, we make a lateral cut over here um secured with K wires and just saw all the way across the foot and take a wedge out. And this is what happens if you look at this video here, it just snaps back in one big surface which heals really well and you fix that with some plates or screws or whatever you want. If you've got no deformity, then you don't need to do anything. It's easy. But what if we need to go down the fusion route? Well, if you need to go down the fusion route, you have the option of doing a triple fusion or a lamb. And for those of you are not aware, a Lamber N is a type of procedure which you do when you have a plantaris deformity, which occurs not at the ankle but within the talus or the talar navicular joint itself. And to correct the plantaris here, you don't need to do an achilles release. What you need to do is actually bring the t navicular joint up and you can do that by resecting the head of the talus or on the surface of the talus. And you essentially do that by when you prep the talus, take a big wedge out, you can do it with a saw and you almost just go parallel to the floor. Um, and you bring the foot up and this is what you're left with. This is the same patient before and after, and I haven't done an achilles release here. I've just brought um the, I've just taken off a lot of the bottom of the talus and this fuses pretty well. Um And the patients tend to do fine. Um You can do hind foot fusions again. So this is an example of a TTC fusion where the patient had deformity in the ankle and in the subtalar joint. And I did a um TTC fusion dorsiflexion, osteotomy P uh A IP joint fusion and um tendon transfer. So this, this kind of case takes you four or five hours. My tips for fusions is that remember which is gonna be stiff before you even start and the bone shape is abnormal. So just take out veges don't be shy. You can take a saw and take out veges. They're not gonna miss the bone. I think you should prioritize reduction at the talar navicular joint and that's gonna shape the um the rest of the forefoot. And once you've got the tailor navicular joint where you want it, you can close down the subtalar joint. And often what I do is I put the talar navicular joint where I want it. And then I sometimes close the subtalar joint as best I can take a saw and just saw out the bits in the middle and it gets rid of any asperities and just lets the subtalar joint then close down, um, into where I want it to be. Once you've done that, you then wanna finish the forefoot. And that can be things like Hallux IP joint fusion or a Jones and lesser to, to not of P IP joint fusion. But you all know that bit because that's, that's basic 4 ft stuff. So the last stage in the algorithm is to fix and tension the tendon transverse. So for that, my advice is transfer the stronger tendon and often that's the tibialis posterior tendon, but it may sometimes be Peroneus Longus. So for a Peroneus Longus to Brevis transfer, which is done, that's useful when dorsiflexion is preserved and all you're trying to do is get a bit of aversion um and, and lose a pronator. So you can do that through the Calcaneal osteo or you can do that through a separate incision above or below the mali, it doesn't really matter, but you basically grab the Brevis and pull it up as hard as you can grab the longest, pull it down, tie them together. That defunction the longest and it puts all the tension on the brevis, the tip post transfer is what I do more often. However, and I pass the tip post through the intraosseous membrane because that turns it into a dorsiflexor. And that's useful when the end dos flexion is lost, you can go circum tibial. But the evidence suggests you get a bit more power through the intraosseous membrane and you can insert it into tendon or bone. So I do it through a little small incision. Now, if you're gonna go to, if you want to do tendon to bone, you need a longer incision um to get more length. I um take the tendon off over here. Um I cut the spring ligament as I said, I then take the tendon out about uh 5 to 10 centimeters above the uh medial malleolus. Um I, if I'm doing a split transfer, I'll split it at this stage and whip stage, both of them and then I'll take it out behind the tibia and front of the fibula, the process membrane through another small incision where I then put it depends on what I'm trying to do. Um And we can go into that later if you want, but you can either put it into bone or you can put it into tendon. If you're putting it into tendon, you can put it into a single tendon which is often not balanced or multiple. If you're putting it into multiple tendons, you can either split it, which is easier or you can take it and weave it through multiple tendons and a single tendon weave, which I sometimes do. How do you decide? Well, it depends what you want. If you want more dorsiflexion going into bone and the intermediate form is good. If you want more aversion, you can put it into the perineal or the cuboid. The reality is you often want a bit of both. And so your good bony target is the lateral kidney form or a good split target is a tib and Perron Brevis. I tend to go over the retinaculum, but you can go under and sometimes I do under the retinaculum to the tib and over the retinaculum for the Pyrones Brevis. If you want more forefoot control, then you can go into Edl and Tertius, but don't be fooled because if you look at this, this looks like this patient is, is in a good balanced position, right? But the reality is that over here, the ankle is over dorsiflexed. And if you actually get the ankle in the right position or the hind foot in the right position, you see the deformities coming from the front and this is a patient who would probably benefit from Vars. But if you wanted to do it with the tendon transfer and you put this into the tib and, and the Perron Brevis, it's not gonna control the forefoot. So if you want to control the forefoot with your tendon transfer, you need to either span the area where you have the deformity by going into the lateral knee form or going into Edl and Peyronies, Tertius. Um, that's quite technical, I appreciate, but it's just some of the things that I just want you to say that, you know, you have to think about. So how do you fix it? Um If you're going into bone Biot, tenodesis screws are the best way. Um You can do suture anchors and stitch it to the periosteum as well, but that's less effective than biotin screws. If you're going into the tendon, you can do a side to side or a pulver Toft or weave it through the strands of the edl. What does this mean for patients? Well, postoperatively, they are six weeks in a cast and six weeks in a boot. If you're fusing them, they're about three months in a cast and non weight bearing for 4 to 6 weeks. It takes them a year to adapt and they often still need orthotics. They're not normal, but they're a lot better in terms of having a stable foot improved balance and they can fit into a shoe. There are complications and we find that in our patients up, up to 40% will have at least one wound which doesn't heal within two weeks. Some may take up to six, you can have wound breakdown tendon, pull out nonunion, malunion under overcorrection. Um Symptomatic metalwork recurrence etc. But using this algorithm, we looked at 25 patients who had a variety of bespoke procedures and found that at one year they had improved and had maintained for four years and they had improvement in the foot shape, pain, quality of life and calluses. It didn't always help falls and balance because that's multifactorial. So in summary, um history and examination is key to treating patients because every patient is different and needs a bespoke treatment. But you need to have a systematic approach to follow and you need to understand the basic principles to deviate from the above approach when you need to. Thank you very much. Brilliant kin. Thank you very much for an excellent, very thoughtful well consisted uh key, take home messages. Uh So I will open it for discussion. Uh So follows. Do you have any questions? The first thing I would like to kick off the discussion with currently, you type three, you know the classification we talked about is type three Metatarsus additives plus other things like, yeah, we we are having, we are in the early stages and we it's it's actually more difficult to quantify than you would think. It looks easy on the examples I've chosen. Of course, I've shown you the best examples haven't I? Um the I think it is a combination of metatarsus seductus, but that metatarsus seductus may be occurring at the navicular knee form joints. And often when you look at it it's, it's so it's not the metatarsus ductus. You think of like you would have, for example, a pure adductus or a skew foot. I think it happens at the, at the navicular knee form joints in some cases. Um And a lot of the counter deformities that we've observed when we see the, the deformities happen at the navicular knee form joints, your foot twists at the tail or navicular joint and then tries to untwist all the way down the path. But most of that seems to happen at the navicular joint. But I might tell you something different in two years. Once we study it in more detail, I know. Uh So before you came, we talked about two cases and both my cases, one of them was uh a rigid uh hi foot kill virus. No, no, um uh no known abnormality. So my question, what other question which I want to ask you is wha what uh you know, we, we always been taught in medical school and even as as orthopedic training, that virus, I think neurological 50% are neurological, but I see quite a lot of them idiopathic. What's your experience about? You know, even uh so obviously, I'm, I'm biased because of my practice having a very large cmd referral group and HSP referral group. But um I would say I've noticed the following, there is a very high incidence of subtle CS which can progress. And if you look at Indian populations. The population series suggests that up to 20% of Indian populations can have a degree of cts. The pure idiopathic cavs is a lot of them undergo genetic testing and come back normal. But that doesn't mean they don't have a neurological problem. In my experience, I think about 30% or so will have idiopathic avis, but they actually tend to last longer before surgery because they're balanced for longer and they tend to come because of endstage callosities later in life. The one thing I noticed, which is interesting is when I was in a registrar and I learned it from my exams, I always learned or and jo I learned that Davis foot equals high calcaneal pitch and flat foot is low calcaneal pitch, right? And as anyone who do know that's rubbish, most of the CMT don't have high calcaneal pitch. But I think the idiopathic cavs do have more of a posterior cavus with a higher Calcaneal pitch. And I think therefore, that's the two big things to notice when you're treating the idiopathic Cavs is one is they don't need the same tendon transferase. You might not need any tendon transfer and two, they actually have a higher talking out pitch. So your your operative strategy needs to take that into account. And if you lengthen their achilles, they talking out pitch then can go up to like 80 degrees or something ridiculous. Um So for some reason, II seem to think that their bony anatomy is different, particularly their, the angle of their subtalar joint versus the alis and versus the inferior aspect of the heel is different. Again, II, at some point, I want to try and quantify that better. One of our fellows who's now consulted in Italy, um unless you looked at that in some detail, but I think there's still more work to be done on that. Great. Thank you. You know, II II presented a case earlier to the fellows who was 52 year old, quite significant c virus deformity. But idiopathic, there was no known neurological cause and he had some arthritis, fixed deformity. So I did, I put fusion for him and he actually did quite well along with first. So we were talking about different spectrum and and yeah, I mean, II knew you'll come and talk about the extreme spectrum. But on that note, one of our fellows Mohammed Mohammed. Do you want to present your case? Yes, you can share. You can share, man. You can share you. If you try sharing, I will allow you just try sharing, please. Uh You can, you can show I sent for you money. Oh You, you have sent me, I sent for this. You've sent to me on linkedin? No. Yeah. Yeah. And I won't be able to share. So you have just one, just one. I will, I will just share by my doctor. Yes. So, so Hammad actually discussed with me one case. She's quite, and I thought if he brings it I II think it would need, II didn't know much details, but it's quite an extreme deformity would need wedged ar. So, whilst my mother is trying to uh put his case on the screen. Yeah, um any of the other fellows, do you have any other questions from uh for current? Yes, thank you Karin. Uh And congratulations for your uh presentation. This is Pilar from Spain. Uh I would like to ask you uh this type three virus that you, you showed to us. Uh that is still to me that you performed. You were saying that the Ka is uh between the navicular uh CNI for uh and kind of also T MT? No. Uh Where, where do you uh that, that, that video that you show us? Uh where did you perform the um the CS uh in the T MT and you closed or you? Oh no. So we went across the navicular kina form joint and the cuboid. OK. We take out a wedge from the Cuboid. Yes, wedge from the Cuboid and small wedge from the navicular from joints going across it like triangular. Yeah, like, like it, but it's, it's, it's like a, it's like a, it's like a um trapezium but in, in two planes, you know, it's truncated in both planes though. It, it's very, the reason we use PS I is, it's very difficult to, to work it out in your head, you can, but you got to be really smart and, and if you don't plan this beforehand and you get your first cut wrong, it's a bad day. But the way we, the way we, the, the way you want to sort of do it is you first say, look, I'm gonna, um, decide where my first cut is right. And often that will be something which takes away the navicular cuneiform joints and goes through the cuboid. And then you almost need to, the way they do it in it, in, in the planning is they take the foot, move it to where it should be, see what the overlap is and then minus that overlap, that makes sense. So you, you're sort of creating a shadow of a correction. A foot looks like this. You make one cut, get it to the position, it needs to be work out what that overlap was. Return it to normal and subtract it. But to do that in your head is very difficult. So if you were gonna do this without patient specific instrumentation, the best way I would say is you need to make two cuts, one perpendicular to the hind foot and one perpendicular to the forefoot. But in multiple planes. Ok. Well, and you just cut and Yeah. Yeah. Yeah, exactly. You know, so it's, it's difficult because you never got to think right. I'm to do the hind foot here in the coronal plane, sagittal plane and axial plane. And now I'm perpendicular here in multiple planes. And somehow the cuts that I do can't take too much joint and I must be left with enough bone. OK. And you fuse the uh navicular with the CIFS and then you close the wedge of the colon and that's it. Yeah. And I often put a um um just some short plates around the navicular uniform joints. If you have to bridge the TMT joints, you bridge the TMT joints, I can always take it out later. There's no problem with that. Ok, thank you. But you what you can't bridge is the cuboid unless you have to then because then you have to bridge the shower joint because you can't bridge onto the 4th and 5th. So the, the, the amount of cuboid you have left is the rate limiting step. And if you can't do it by that, then you have to do it through the choper joints because you have more bone there. Thank you. Uh Can I ask you about uh the tendon achilles lengthening and uh and cava foot? Yes. Uh At which time you decide to do like or, or go to the open and what is the decision about this? And usually it is, it is safe because of and some, yeah, the picture is difficult to decide how much lengthening of that. So, so, um I have, I have an advantage probably over most of you in that I have weight bearing CT scans as my standard imaging in my hospital. Yeah, but if I'm honest, um most of the decision is made on clinical basis and, and the more experience I get, the less and less I rely on imaging. My way of assessment is this ok? II grab the ankle under the heel, uh hang on, I'm gonna vanish for a second. So um II basically, um, grab the foot underneath like this. Yes. Yeah. Oh God, it's upside down, whatever. And then I see how much I can move. I'm gonna have to do this. I'm gonna pretend this is the patient. Yeah. Backwards. Ok. So, yeah, I'm gonna grab, grab the foot like this. Yeah. And um, I basically put the foot against my forearm and holding the heel. I don't let the midfoot move and then I kind of see how much dorsiflexion I can get at just the ankle because that isolates the ankle, right? The patient's foot is gonna be like that. I grab it like this. I hold them underneath the leg. I'll do it the other way around. I hold them underneath the knee and then I literally just move my elbow back and forth and see how much I can move them up and down from the ankle. Yes. That gives me an idea of what my equinus is at the ankle, right? Ok. After that. And I then do that with the knee extended and the knee bent. Yes, that's the silver score. If the difference is at the ankle. But with the knee bent they actually get up to 90. Then I do a stra, yes. If it's truly at the ankle and it's locked either way and it's less than 10 degrees, which it usually is, then I do a ho, if it is truly more than 10 degrees, then I do an open lengthening. If it's more than 10 degree. Yeah, you'll go for opening. Yeah, because I don't think a hole can do effectively more than 10 degrees, but it has to be at the ankle and then I separately assess the plantaris and then I look at the imaging and I see what is the angle when they're weight bearing between the, the talar angle of declination and the tibia. And that should normally be around um, the tibial angle and the talar angle of declination that should normally be about 20 degrees. Yes. And if it's, if it's about 20 degrees or sometimes 10 degrees, then an achilles lengthening is not the right thing. But if it is actually genuinely the talus is pointing down, then I do a achilles lengthening. So those are my two ways that I assess it. Yeah, I do like you. But in case of myopathy, we fear from et and usually make like uh gastroc and sometimes I do two things. First, I do gastroin give me like 10 or 15 degree. And after that I do little uh a uh percutaneous and give me like more 10. Is this is working? Uh you tried this or not before? Um I II have to say I've never done that. Yeah. Um So I think that's a double whammy on the achilles and, and the stra I see, I see where you're coming from but actually if you do an open achilles lengthening in that setting, you don't lose much power. Mm um You're probably talking about not CMT you're probably talking about patients with cerebral palsy. Yeah, talking about myopathy. Yeah, myopathy. But you're worried about getting a crouch gait because they've got a Yeah, this is the problem. So in that case, a stra is is still fine, still fine as, as you know, in in those cases the pus acts as a knee extensor. Yeah, but the gastroc does not. So doing a stra is still fine if you want to do a good powerful stra doing the stra a little bit lower. Yeah, is probably preferential to doing a hook and if you're really worried about couch gate, it's probably doing a lower, more powerful stair is probably more interesting. OK. This is the case. Uh Yeah, this is the case. So yeah, II managed to open mom. Do you want to describe your case? I'll try to open. This is, this is my 30 years hemiplegic uh and come with severe uh equinus and cas. Yeah. So you can look at the X ray and the video of the patient also. Yeah. Yeah. And this is the video. At least dad, dad, dad, dad, dad. Yeah, I didn't know again. Yeah. At least I think and also for knee flexion contracture also. Yeah. What, what do you want to achieve for this guy? We need to plan grade food citrate lower limb and the bells. Uh oh so he's got, he's got total lower limb weakness, hasn't he? Is he a spinal cord, spinal cord injury or is he he, he? Yeah, ok. He see. From what? From cerebral die? He so, so, so in cerebral palsy tendon transfers don't tend to work very well. Uh because either spastic if they have anything. Um and um you know, you can make a crouch get worse. I think the most important thing with him is expectation management because I have a few patients like that. Yeah. And you've got to tell him that we can make your foot straighter. Yes, but you're going to need to wear an AFO and possibly a ground reaction force orthosis afterwards. And um fusion works better in patients with CP without much weakness. So with, with someone like him, I would probably be doing an open lengthening an FDL and tip post and FHL and posterior capsule release and then a triple fusion and say that you're gonna be in an air four afterwards because I don't think there'll be a transfer option available and, and if you don't go in an air four with a gra for your, your crouch, it's not gonna help your crouch gait. And the advantages to him is he's gonna have a foot which looks better in getting a shoe and will not be as painful to load, but it's still gonna be a flail foot. So kind of first we do at and booster capsular release. So in the way, the way I do these, I tend to do a medial approach. A poster medial approach, do a open achilles release. Yes, I tend to do um P crossing of the posterior capsule, of course, just cut the plantaris. Yes. Um Depends on how brave you are. If you are, if you're comfortable with the anatomy, you can do an el release through the posterial approach. Um Yes, because by the time you get him up, his toes are going to curl like crazy close. Equal, right? So you can either release the FHL there or you can release the FHL at the north of Henry. Yes. Sorry. What about um for the FDL? You can often just do a percutaneous release under the toes. Yeah. What about the posterior? Because of you? You need to make a little incision and, and, and to be honest, you, I just cut it, I just cut it and just do, yeah. A recession. You mean recession. Yeah. Yeah. And um and then I'll do a triple fusion for the, for the hind foot to get the hind foot corrected and then his ankle will be flail, but he needs an A four. The other option is to fuse everything. But I don't think that the patients with CP do that well, with everything fused and it's quite a lot to do and his bone is gonna be really thin and it's gonna, so it starts to do a soft tissue and look and see. I think it started to do a soft tissue better. And if it's, he's got, he's got fixed equinus and he's got a lot of his deformity seem to be at the um triple joints rather than the midfoot of what I could see. OK. So when a is it the fusion? I think. So, what do you, what do you think? Winnie? I II um currently, you know, uh I work with uh Benjamin Joseph who had a bit practice of cerebral palsy and simply lengthening the tendons and you don't want to do tendon transverse in cerebral palsy, simply lending the tendons tib poster Len. I still remember root and frost procedure and, and at least Len and then doing the fusion procedure is I think the best uh uh way forward. It's, it's, it's a very difficult case but keep it simple, just land on the two tendons and do your uh fusion. OK. OK. Thank you so much. Thank you. There was a question in the chart, uh, current and I'll just read it to you. Thank you k for your condition and good afternoon everyone. I'd like to know. All right. Just, just one second. Ok. Yeah. Sorry need to go. Yeah, it, it won't be long now. No, no, no, it's ok. It's just, it's, it's uh, Karen. Uh many, can I ask Karen one question before we go? Can I finish this question? Finish the chat question? Yeah. Yeah. OK. They just, sorry, go ahead presentation and good af uh good afternoon everyone. I would like to know if you only needed a cutting guide to plan the osteectomy. And in that case, it's not clear to me why there are two approaches you on the foot and all. Yeah. Um OK. That's a good question. So, um well, there's two reasons. One is I'm a coward and the second is I need to fix it. Um So basically I'm gonna be sawing across the entire foot. And what I do is II, prepare the um the lateral side. I open the dorsal immediately and then I take a retractor and put it across the neurovascular bundle on the top so that I make sure my saw doesn't cut the neurovascular bundle as I'm sawing the whole foot. And the only way I can be sure that I'm going where I am is if I can get some sort of visualization on the other side. And then of course, I need to put a plate on the top, on the medial side as well. So I have an incision there. Anyway, when I first started, I actually was crazy and I did three incisions. I did one on the medial one on the left, one on the top. Um And that patient, I tell you, he had a bit of, he needed some pregabalin for, for um a few weeks after that. But, but he was fine in the end. But as I've got a bit more experienced, I do it with two incisions. Thank you. Thank you. Can I ask you? Can I now? Yeah. Uh Just one question about the case of uh CMT Charco disease every day. I see two or three patient with the same picture like weak uh dorflex uh T booster is working and foot. What is the best option for these cases? Really till now? I not touch anyone. So what is the best for him to take t posterior transfer? Make osteotomy first to what's your opinion? We are interested in that? Yeah. Um sa without, without mean. So I think, I think when the algorithm that I put up is is what you have to say. I mean the thing is there are nuances to every case. So again, it's, it's II always follow the same thing where I go by the same principles as what I said. I always think how am I gonna get the foot underneath? How am I gonna get the foot flat. How am I gonna balance the tendons so often the bony bit is the is similar. But II do exactly what I showed the pictures of. So I will say right, the heel is too far in. So I need to get the heel out as just the achilles. I then in clinic put my hand on the, on the t navicular joint. So II put my fingers on either side of the talus. Um I then reduce the talar joint. Um And until I can feel it's reduced and then I see what the foot looks like. And I see is it just the big toe which is down or is it multiple big toes which is down or are they still down or and, and still in? And you get a good idea clinically. If you have bog standard CMT where when you do that, just the big toe is down, then my procedure is o release if needed. Calcaneal osteotomy. Um tip post transfer, first metatarsal dorsiflexion, osteotomy and whatever the toes need. So if, if the hallux is like this, then the IP joint fusion and the toes are clawed, the IP joint fusions. Um Although I don't usually do the lesser toes at the same time because it's too much swelling. Um And the tip post transfer is as you, as you feel the easiest and simplest, if you don't wanna think about it is put it into the lateral knee form, but you need bigger length and it's not always possible and you need good physios who are not gonna overdo it and pull the and pull the tendon out in the first few weeks, which is the risk. Um And that is what I do for, for, I think about 60% of my patients. So the best 40% I do different things depending on what I feel like. So uh current about transfer and CMT this does not lead to foot collapse. Become never, never, ever, ever, never. So um so there's only one patient who I've had, who had CMT type two. Yes. CMT type two is different than CMT type one. A right there. They are profound weakness and she did not have that much of a deformity. And I decided for some random reason that I was gonna put the tip a post into the cuboid and I put it into the cuboid and I thought, wow, she's too everted because she had very low muscle mass. So on the table, I recognized that took it off the cuboid and put it onto the um lateral kidney form. And um she was well balanced. Again, it goes back to this. Remember they are not, they don't have normal foot anatomy. There, there, if you look at the a normal person, a flat foot and a cavus foot and you look at the angle of the angle of GSE, you look at the angle that the subtalar joint makes it's different. Flat feet are a bit flatter. You know, when you make your tal osteotomy for a flat foot, if you do your cut in one direction and you do the cut in the same direction for a cavus foot, your, your screws will be coming out the plantar aspect of their foot. And you know, so the, the whole calcaneous shape is different because of the shape of the articulations. Because remember, stability of your foot is a combination of bony articulations and anatomy. Um The static structures such as your spring ligament and your dynamic structures such as your tip post. So if the bony anatomy is abnormal, no amount of tip post pulling is gonna be able to overcome that. So you're never gonna get a flat foot by releasing the tip post because their natural anatomy is such that their um talus, the place their talus sits on the, remember, the lateral talus is hypoplastic, the medial talus is hypoplastic. Their talus is gonna be sitting on top of their calcaneus. No matter what you do with the tip post, it's not reliant on the spring ligament to do that. Hm I agree with current, current. Um In fact, not only the post transfer, I know, I mean, I'm II don't do plantar fish release very often, but in severe virus deformity, I have done um plantar release and t uh t is supposed to transfer and I haven't had any issues with that. Um 22 final questions. II know it's late and we need to let uh Karin go. So two final questions, Karin, one of them is uh or a comment or an observation. The reason I do achilles tendon lending in severe um chemo vs foot where I'm transferring my tibialis post here is that if I do not do my hoax procedure, it's very difficult to transfer the tip post to the midfoot until, unless you have dorsiflex, the ankle, which is by releasing the achilles. So that's one of the reasons I do hoax procedure when I'm doing because of the length. Would you agree or disagree? You are going into bone, you are going in the board. Yeah, that's why, yeah, it is difficult. It is. It is. Absolutely. And, and, and, and I don't, I don't disagree with you at all and I sometimes do it for the same reason because I do, I do think, and sometimes like you, I do hope but for a slightly different reason in that, if I can't achieve a certain amount of dorsiflexion on table, which is, I know they're going to not achieve what I can on table in real life because they're going to weaken a bit, it's going to stretch out a bit. So I try and get a bit more on table accepting that they will at least then get up to neutral. Um, but I, but for that reason, I don't do tendon to bone that often because I find that I am over dorsiflex more than I would otherwise want to because I'm trying to get it into bone when actually I don't need to because if I put it into tendon, um, but I ii don't think there's a right or wrong answer. You know, I think this patient group is so forgiving, they are so grateful for what you're doing for them and, and I think because that you get away with so much, we don't know what the perfect answer is because they're happy. Absolutely. And you go on your experiences and your training and everything else. Um I switched away from bone because a my incisions were quite big, but that's not really the reason, but also I had a few pull outs and I initially when I started. So I took it for Han used to do it all the time, but it's interesting even he had an evolution in the way he did it and he used to go to navicular. Um, and what I found is I had a few patients where the, um, uniform almost exploded. Um, I had a few patients where I had pull outs on table, particularly not necessarily the cmt's but HSPS and the myopathies. Yeah. Um, and I had a few patients who, when they had physio, it pulled out because one of the risks of, um, tendon to bone is early failure. Oh, absolutely. Um, and and I have so I then started experimenting with tendon to tendon. I have to say ob not objectively, but subjectively when I do a tendon to bone, I am happier with my absolute range of dorsiflexion because when it sticks, it sticks better preten tendon stretches out a bit. But, but, but that being said, none of my 10 tendons are unhappy or any less happy or their problems are any worse because I think what they have is still enough for them. No. And, and as you say, I mean, there is a, there are two patient, two groups of patients where you do Tilis Tenon transfer. One is the chemo virus, deformity, neurological or opic or whatever. And the second is the foot drop and the foot drop, you have to do tendon to bone. I don't think you can do tendon to tendon in foot drop. I disa I disagree. You disagree. So all, all my, all my pure foot drops, all my pure foot drops. I've done tendon to tendon. Have you. Um And a lot of the literature supports 10 to tendon. Um II think the original literature was described for leprosy patients um mainly and they, they described going a split transfer to EHL and Edl Tertius and I actually do um split to EHL one and split to Edl Tertius the other and I've been very happy with it. Um The, the, the reason being is because the foot drop patients more than the CMT don't have a plantar deformity. They are pure Equis and their bony anatomy is normal. So their tendon pull is normal and if you can reattach it to the tendons which were weak, they then become physiological is my, is my opinion. And, and II, and, and sort of my review of the literature and that's matched my experience. I don't have a problem doing it into bone but it's, but it's, it's certainly easier to do it into bone because it's not, it's not tight. Yeah, I mean, II just feel that it gives you that, um, you know, the liver arm that, that bow string effect, that you would be able to do more dorsiflexion. That's my anecdotal um, feeling. Anyway, that's how I classify. You can do it. These are the two ways and you can do it and my head, but I can consider doing next time when I'm doing a neurological foot drop. I can consider doing it to tendon tendon. Uh, the second comment or, um, question I was going to ask you was about the psi, now you describe current that, you know, when you do psi because you don't take into account the soft tissue procedures. By the end, you've done the soft tissue procedures and you come to the bony procedures, things might change. So it's not practical. But wouldn't it be better to do a two stage procedure where you've done first, the soft tissue release and then done your CT scan and then the PSA that for PSA point of view, that would be more accurate. Possibly. But yeah, for it's, it's rubbish. Basically. You need two questions. You, you, you are right. And um, ok, so the first one I did with PSI, I took 10 hours to plan it. Ok. On my own time at night with engineers sitting multiple iterations. The second one I did with PSI but, but remember we, we were sort of co developing the technology with the company at the time and they had, they hadn't done it for the foot and we hadn't done it. And, and I think I did the first one in the UK and, and we, I spent 10 hours planning it. Right. That patient, I spared his joints and he went from pretty much two crutches to 20,000 steps a day in four months. Um No, the reason it took me. So now it doesn't. Now, now, now we both sides have the experience to do it within, within half an hour or whatever, what I had to estimate in my mind. And I brought this guy back many times to see him. How much can I do with my soft tissue correction? Can I imagine what my soft tissue correction is gonna be like? And then I get the engineers to replicate the Calcaneal Osteotomy, the correction, the soft tissues. Exactly as I feel I can achieve interop based on my clinical examination and assessment of his stiffness. And what I say to myself is I know that I can balance his tendons to the point where navicular joint is reduced. Yes. Ok. Then I'm going to reduce the telo navicular joint and plan the vagectomy based on that. But that's very difficult. It's actually easier to do a stiff foot where I know I have no correcting by the soft tissue and, and then just do mastectomy. Not but, but the other way around is a lot harder. There is also, I have in that situation designed three versions of PSI printed. And I've said I have a version printed for zero or, or 10 degrees correction, five degrees correction and complete correction or whatever. And then I can choose which PS I guide I use based on what I've got. And there is a fudge factor because ultimately, it goes back to what I said, what I really use psi for is my starting point and a rough ending point. And then what I do is I just literally take the bits of bones, put them where I think they roughly need to be. Um If the, if the bones are ending up a bit this way, I then move it to where I want to leave a gap, take my saw and just saw it through. But I've got my starting point and then I know I'm not gonna sacrifice the wrong joint. So I fudge it and I've had to fudge every single case a bit, but that's ok. That's just life. Right. Uh No. Absolute. Yeah. Yeah. We, we know that PSA is not accurate and especially in these complicated procedures where there's a bit of, and, and there's another thing about psi, which you need to think about. So the company initially told me, don't do psi on standing ct because the body anatomy is not gonna be replicated interop. Mm. And I said I have to do standing ct otherwise, I don't know how much to correct. So we do it on standing CT and we have to mess around with the bone anatomy a bit, especially for spanning joints because I've then got to pretend I'm putting the full patient weight and I've got really work out my triceps to push their foot up and then put this psi on. So it's not, it's not perfect. It's absolutely not perfect. But I think the results are better than guessing. Absolutely. And after I been there, I think psi is to be acknowledged and to be used. So after coming back, I've had seen two or three horrendous cases. Yeah. And I'm going to get psi and I'm going to try doing that. But look, Karin, thank you so much for coming up and, you know, giving such a nice talk at such a short notice. II think it's been very, very useful to our young fellows who uh you know, we are going to some uh quite a lot of fellows do not attend because of time difference, but they watch it on uh med all um uh catch up content. So we'll, we'll, I'll post it tonight and uh I don't want to take any more of your time. And I thank you once again, thank you for being with us. Thank you for inviting me and thank you all for listening and asking me such a good question. And 11 last thing, those who are still there and want to hear more about Cavo virus. Uh bofa's Master Techniques would be on 18th of June where Karin will be talking again as well as we have one more speaker. So if you want to come and get more information, more discussion, then do join us on the Master Techniques of Bos on 18th of June at eight PMU K time. That's why my advertisement for BOFA. Thank you very much and have a great evening wherever you are. All right. Take night. Bye bye. Thank you. Thank you, Kim. You're welcome. Good night.