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Deep Dive Subspecialty Series: Foot & Ankle Surgery

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Summary

In this on-demand teaching session, a seasoned medical professional shares their extensive experience beginning from medical school up to their current position as a foot surgeon in Aberdeen. They offer insightful practical guidance for students aspiring to pursue a surgical career. You'll learn about the importance of mastering anatomy, ways to grab rewarding opportunities during your medical schooling like getting involved in surgical societies, taking up integral degrees, and seizing upon chances to attend workshops and research projects. You will hear the expert talk about the value of building a robust CV by completing audits, papers, and presentations during your studies. The session also includes lots of tips on earning relevant degrees and successfully passing medical examinations. This session is beneficial for anyone looking for practical advice on how to enhance and navigate their journey through medical school to a surgical career. The speaker shares unique insights from their journey, including the joy of being a foot surgeon and intriguing aspects of foot biomechanics.

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Description

THOR, EUTOS, and UOGTOSM proudly present our Deep Dive Subspecialty series, a teaching series where experts in the field guide us through common procedures in the various orthopaedic subspecialties.

For the fourth talk of our series, we're delighted to have Mr Senthil, who will discuss the concepts of foot and ankle: ligament repair and fixation.

Speaker's Biography:

Mr Sriskandarasa Senthilkumaran is an orthopaedic surgeon with a specialist interest in Foot and ankle Surgery in Aberdeen. He is also a general adult orthopaedic trauma surgeon. He performs all aspects of foot and ankle surgery, including ankle replacements, minimally invasive foot surgery, diabetic foot surgery, and deformity correction using circular frames.

He completed his Orthopaedic training in the North of Scotland Rotation across Aberdeen and Inverness. He undertook his fellowships in the art of foot and ankle surgery in Glasgow and Australia. He started his consultant career in 2021 in Aberdeen.

In this talk, Mr Senthilkumaran will talk about the intellectually challenging foot biomechanics and the breadth of foot and ankle surgery.

Learning objectives

  1. By the end of this teaching session, participants should be able to troubleshoot typical technical problems encountered during medical presentations, such as sharing screens or resizing presentation materials.
  2. Participants should be able to understand the importance of basic anatomy knowledge for aspiring surgeons, as emphasized by the presenter's personal experiences in medical school.
  3. Participants should learn about the benefits of gaining hands-on experience in clinical settings, such as scrubbing in on surgeries, to enhance their medical education and career prospects.
  4. Participants should be able to recognize the importance of continuing education and professional development throughout their medical careers, through the presenter's discussion of various postgraduate and career development opportunities.
  5. Participants should gain understanding of the different potential specializations within orthopedics, based on the presenter's personal journey in specializing in foot surgery.
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Computer generated transcript

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

Hi, my name is, I'm from the medical, uh, support team. I noticed you were having some trouble sharing your screen. Is there anything I can help with? Yeah. Just kind of get the presentation up on, um, the thing. Um, uh, can I check if you're on a Mac? Yeah, I've got a, um, PDF, so I'll see if I can choose to take the PDF. Maybe, if not, it might be a settings issue. So, so it worked when you start, when you tried at the start, it worked at that time. I think if it's too much trouble you can just present as it was and then maybe just increase the size. Yeah. And, uh, yeah, starting to look the side, a lot of pictures. I suspect it could be, um, give it, give it a couple of minutes and see if it'll start. Ok, that's good. Yes, perfect. I think it's supposed in the slide in the background, but I'll talk away while it's doing that. Um, yeah. Sorry, sorry about that. Uh. Right. Yeah. So, uh, yeah, I work in north of Scotland and, and Aberdeen. Um, and one, yeah. So talk about the journey in the medical school and what you could do to enhance your CV. And at the end, I'll touch a bit about the foot, foot biomechanics and things. You know, this is not an educational lecture, but I'll tell you what the fascinating thing about the feet and why I get excited as a foot surgeon. Uh so started back in 2003. It was like a long time ago now, 20 odd years ago now. And so the first year, obviously, you learned your basics and uh had a quite a keen interest in anatomy and think you're gonna be a but surgeon. That's what you need. You need to know your anatomy inside out. Because whenever you got a knife in your hand, you need to know what's under the skin that an M and you cut. So it's absolute vital that you know your anatomy. And then second year, uh actually any medical school have uh surgical societies. I got involved in the a society at the time and also the Royal College of Edinburgh, they used to do a fair bit of um uh workshops and stuff for the medical students. So I used to go to them and um quite quite a few things out of them. You, you speak to various people and you get, you know, make a bit of contact, especially when you come to the end of your medical school. You know, you may have to have to do an elective. It's good to have those contacts because you might need, you wanna go away somewhere exciting to do a project or something. We could have that contact. Then in Aberdeen, they offered to us to do abi an integral degree. So II an art and then decided to take up that offer. So I did a B ABC and uh I got interested in orthopedics through uh this guy here, Mr Sutherland. So I did a project with him. We were doing ACL reconstruction and looking at uh pain relief after that. And uh you know, I, as I worked with him for about a year, six months to a year, you know, on the project and I was scrubbing in theater with him. And as I, as I got through my kind of the early months I knew what he was doing. So he would let actually let me do the operation, not all the operations. So part of the operation by the end of the kind of six months or so as a medical, I was really excited about that, you know, someone actually takes uh takes um takes you under the vein and uh let you do stuff and, you know, keen to teach. So, and as part of my BSE, um obviously, they wrote my uh thesis and a couple of papers out of them all I was doing my project. He also had other projects on the go and, you know, you get to do those audit stuff or research stuff and then get some um, papers and presentation of your CV. And, but the, my ba was quite good. I enjoyed it. I managed to present it at a couple of places as well. So, you know, at the time the inter conference was being set up in Bristol. So we then presented that and then went to Morocco to present at the international orthopedic meeting. That was a good experience as a student, you know, to go to Morocco Marrakesh holiday and also do some presentation. So I got a lot out of my BSE. So I think it'd be worth considering if you think about surgical career. Definitely, I think it would be something to think about. And the fifth year in Aberdeen is uh is quite good because by fourth, you've done all your finals, um disc COLC today in fifth year. And so you got more time to kind of concentrate on doing other things to build up your CV. So in my fifth year, I had a placement in orthopedic trauma and I pretty much work as an F I one in the in the department. So you need kind of how the system worked and you got to know people and you kind of, you know, have a rough idea what orthopedics in involved because even as a medical school, even though you learn about various specialties, you don't know what it's like until you work in that specialty because 80% of any specialties, only the bread and butter stuff. So I know you need to enjoy that bread and butter stuff. So that's why you can learn on the job almost. And then during that time, um there are few things. Again, the Royal College had a few events for medical student, like the symposium, the basic surgical skills for the students as well. And it's discounted price for the medical students. So it's quite cheap and you got to go and do some suturing and learn how to stitch things, do laparoscopic techniques and stuff. So it's quite good. And nowadays it's kind of expanded now. So all the Subspecialty orthopedic Society like the Bo the British Fac Society bota itself, the trainee association, the POA, they all have various student and things you could do to, you know, like events even at their big conferences, they have a session for students as well. So you can register and go, go, go to them if you're interested and some have um bursaries for electives for research projects and essay prize as well. So it's quite good to get involved here thinking about um uh surgical specialty and things. Yeah, and also the associate surgeon in training and they also do stuff as well. Very good. So that's why I did in fifth year then did my foundation training in Aberdeen and um Elgan. And during that time, I did a few audits again, that's a good one thing to get in your CV and audit and then re audit, uh, whatever you, uh, changed. And that's a good way to get a, get some points for your application later on in your career. And again, you can do further courses, um, you know, there are some basic courses that aimed at I one level and again, do those things to get, uh, not just to get on your CV, also to pick up your skills as well. And I did my mcs during that time and as a good medical student, you'll pass mcs. It's not, it's not that hard to be honest, you just need to study and do the questions and uh practice. But for your part too and you'll pass that and one option I and I did the E SQ, the ESS Q was one of the online and post graduate thing the URGH College was coming out with at the time. I think the other universities nowadays do it slightly different or identical one now as well. So what it does is um it's a three year part time masters, online master's. So, uh if you do the first year, you get a certificate and if you do complete the second year, you get a diploma. And if you complete last third year, then you get a master's in surgical sciences. So it's an M se um end of the day and it's good to have a degree behind your name. And it's good in a way that the SQ prepared you for the mrcs. So you kind of studied along as you went along and you did, I did have to pay 3000 a year for it. But at least, um, you know, if the MRC was included as part of that um tuition fee at the time. And so you kind of did the exam and he also learned your surgical um anatomy and surgical pathology and everything as well. And then the final year he did a project again, you can pick up any project you like and then you write thesis on that. So it's quite, I find it quite useful. It was quite tiring to do it while you're working. But actually, I think it is um quite worthwhile doing it. Then once you do all this stuff and then it's up to yourself to get yourself an interview place, isn't it? So all this will get you points for your application. And when you apply, um you know, they'll, you'll get, you'll tick the boxes and the next stage can be the interview stage interview, then it's up to yourself to impress uh the on the day and, and things, um you know, quite competitive orthopedic general is competitive in Scotland. I still run through training. So you get in at ST one level and uh if you pass every year, you should be finishing your training at SD eight in um, four different regional training training centers here, uh, in England, you still have to do your core training, then you have to apply for your ST three number after that. All this and stuff, um, that I've talked about already and we'll get you all that points to get you that, um, interview place and stuff. Ok. And once you're in the training, um, it's hard work. Uh, uh, um, you know, you run from T one to HD eight or orthopedic trauma is a basic specialty in itself. I'm sure you have, you're seeing more, more frail patients, people are living a lot longer. So we are seeing a lot of uh elderly people if they have fractures quite unwell patients as well. And also we're seeing a lot of um people with arthritic changes as we are living longer, then more joints are gonna wear out. So, orthopedic is one of the busiest specialties across the medical and surgical fields. So I did my training in the north of Scotland and where we got to man and Abdin as part of our training up here. Then what do you do? You know it's more specialty, you have to pick what you want to do, um, what specialty you wanna do, uh, self specialty you wanna do. So, you know, in orthopedic, you can do it from hand, spine and hip, knee, whatever you like or combination of things. So II picked foot, tell you why I picked foot a bit later on, I wasn't scared of feet because I put stuff, put a lot of people off because they scared of feet as in like they don't want to touch anyone else's feet, which is fair enough. Some people have a bad phobia about that. I also didn't take it because I have, I have a foot fetish issue or anything either. I think the foot is a fascinating thing. And also it's about role models again. So Neil for is one of the consultant in Aberdeen, a foot surgeon. So he, I trained under him as T five and I quite enjoyed working with them and the pathology, we saw them again, the operative stuff we did. I'll show you a little bit more later on about the different type of operation we do. And that again, um excited me. All right, I really want to be a foot surgeon because again, he let me do a lot of stuff as a senior trainee. So again, I mean, that good role model kind of help me push, help me decide on the becoming a foot surgeon. So I thought, right, I need to go learn more about it. So I went to Glasgow did my fellowship there, learned how to do the ankle replacements and yeah, which are not common. It is getting more and more common. But so I went to learn how to do them in a, in Glasgow because we didn't do them in Aberdeen, we send all our patients down there if you have to, then I went to Australia because I wanted to travel and I went to see this guy, I need a lot of foot surgery, especially sports surgeries as well in, in Melbourne. So as you, as you know, Melbourne's a great place for sporty stuff and so work very close to the MCG. And we saw a lot of AFL players and learned all sort of techniques and in one year and it was a great, great time with the family. And this is probably one of the things I would recommend for senior trainees to think about um for your fellowship and stuff, go and go somewhere, um you know, outside your training region, uh far away if possible to go and pick up some skills and um sometimes you think, oh, actually I have it better than them, some, they have it better, but until you travel, you don't know. So that was a good, yeah. So, so I came back as a consultant about three years, 3.5 years ago now and, and set up my practice and that's kinda kind of a little bit training bit of, I'll answer some specific questions about training later on if you have any, I'll tell you about the foot and ankle pathology. Why that excite me. So, being a doctor, it's all about being like being a detective, isn't it? So a patient can come up with, come with symptoms, one or two and then you have to find what, what's wrong with them. So it really olu as your detective skills comes in, that's why your history, your examination comes in. So, you know, people laugh about orthopedic surgeons and you only have one thing. So it's broken, you have to fix the back to the right place, right. But that's true in most places when you come to foot stuff, it's quite tricky because the foot is quite a complex structure. And so when patient present with a problem in the foot, there's multitude of things that could be wrong. And then the the thing that you looks obvious that on X ray, that could be the problem, it's not the problem. So is poorly assessed um by, you know, orthopedic surgeons and a few years ago. So because it was kind of ignored at the end of the end of the uh list. And so all the generals orthopedic surgeon used to do a bit of feet at the end of the hip list or something. So it wasn't really properly looked at. And now it's a specialty in his own, right? As we understand more and more about it, we understand how complex it is as well. So I II I'm not going to bore you with anatomy, but as you can see the foot, you know, multiple bones, a lot of joints, a lot of muscle ligaments and it's amazing how this structure helps you, helps um a bipedal human propel you forward and last all this time. So it's, it goes through a lot of strain and over time. And gate gate is fascinating. If you're ever interested in um gate, go and watch people on down, down the road and just have so many different gates, how people walk just by watching people, you can pick up pathology as well. And now we know there's no one that gate, there's so much variation in gating and this traditional talk about heel, strike foot flat and then to is what we still look for. But as we understand more and more, not everybody do that because there's a recent paper came out from, uh from the States. I think they were looking at all the Olympic um runners or h or everyone has slightly different and first contact. So some contact with a heel, some contact with the midfoot, some contact with a full foot, but they all like Olympic level athletes. So there's no pathology in them. They just, that's what they do. So it's quite fascinating how humans walk the, you know, when, when you think about foot, foot stuff, you know, people get obsessed about feet, don't they? I mean, like, oh, they always compare other people can go, oh my God, my feet are not like that. And I want to be there like their feet, adult patient do not, do not look at other feet, uh, only normal is the other foot. Everything else is variation of normal. Yeah, there are really abnormal one but there's a big variation in normality. So, what's normal? Nobody knows. Right. You look at genealogy of feet, what this is happening. So you see different type of foot shapes and it's gonna be the epidemiology thing. They looked at it and it's not 100% scientific, but there is a generality of things, I suppose as the, as the, as the humans evolving more, more this kind of classic thing is more mixed up as well. So gen genealogy is more mixed up now. But here, you know, anthropology is amazing. So, you know, if you believe in evolution, if you went, when we went from a quad quadris to bipedal humans, the foot has lost his body. So it has to kind of adapt to that function. So to make you walk forward, it has to be um you know, like a mobile unit and also a rigid unit as well. If it's not rigid, it can't push you off on one leg at the same time and you uneven ground, it needs to be mobile enough to adapt to that uneven ground. And so it is, it has its ligaments in the muscles to do that, the bones again have a particular shape to accommodate that all that function. So so and because of all that, it can go wrong as well in in many ways. And when we look at heel shapes again, some people have valgus heels, varus heels. We used to think of everyone needs to have valgus heels. But now we know this is a safe range and there's an unsafe range. When you go into unsafe range. It is when pathology happens and things, ok. Um, when you assess the foot has a lot of things, you need to think about it as a congenital. It's a quiet thing. Where is the problem starting? Is in the hind foot? Is it the midfoot? Is the forefoot patient might be complaining of forefoot problem. Actually, the older problem is getting the hind foot. So it becomes a chicken or the egg question. What started at first if you treat the end point and then you might not get a happy patient because you, you still got the problem in the first place. Then you need to think about like, how am I going to correct this or is it correctable or is it too rigid? Then, you know, then it's a neurological causing it a vascular causing it? I'm going to show you some pictures but later on or some funky feet and this are talking about um this picture illustrates like the different pathology that you get. So, you know, there's so many things in the foot. The one good way of assessing feet, foot stuff. Ask the patient with one finger point where they have more worse pain is and they'll point to one side or hopefully one or two sides and then, then you can um narrow down your differential and ask you more question pertaining to that uh pathology thinking of what's going on. And so there's a lot of, a lot of uh pathology that can happen in the feet. The hip surgeon, they only got two things, they got hip arthritis and young uh lab cast and that's all they have. So when you, this is for any medical specialty or any surgical specialty, really. So when patient comes in, you know, you have a massive number of differential in your head with the person to complain, then as you take a history that differential to should narrow, narrow, narrow, narrow down and when you come to the examination, but ideally, you should have one or two. Um and then by the end of the examination, be good to have one, but you could have two or three. That's when you can investigate to see how you know, which exactly um what exactly is going on, then you come up with a diagnosis, the reason I emphasize this. But if you don't get the diagnosis right, your treatment is gonna be absolutely wrong and your patient is gonna gonna have an unhappy patient. And this is what happened in foot before people have misdiagnosed, things treated that misdiagnosis and patient had poor outcome. So surgical outcomes and back in the day for various foot procedures were used to be bad and then it used to be thought of foot surgery doesn't work. Just now we understand it's because of that diagnosis, initial assessment and diagnosis was wrong and that led to the everything else being wrong for that patient. So, you know, as a foot surgeon, I see a lot of deformities variation, like I said earlier, there's, there's no normal as such. So you see foot like that normal foot again, what is normal? And I have the first picture, then you see all this funky picture like there with the second toe crossing over to the other one. Then this complex deformity and the third picture there at the top, you know, the complex ca we deformity, congenital deformity. Then you see this hallux varus deformity where the big toes kind of go on in the way, which is very unusual, it can happen after surgery, but unusual for to have presented like that in the first instance. And the last one projects well, but this lady has got a quite a contracted um hind foot and the forefoot as well from a neurological problem. We'll come back to that one bit later on. So you see all sort of uh different pathologies and things. So you don't know what's coming through your door. Um When you do, when you do a new patient clinic, then he also sees some monkey stuff as well like the diabetic stuff. So as a foot surgeon. I deal with that. That's what surgeons do. But I do too because it needs to be MDD kind of work here. So I also see some funky stuff like this. This guy came with uh awful deformity. He had it for a year or two and before and he um presented to us then this is a very bad also here as well. Uh Again, he presented by late and this is a 4 ft necrosis that's been ongoing for nearly six months to a year before you presented to me. So you see some um exciting stuff in the clinic, uh turning up to your clinic. And um you know, as I said, as a first surgeon, I work with various people. So podiatrist, um I work closely with them. Uh The physiotherapist, obviously, um diabetologist infection unit, doctors, vascular surgeons and um other orthopedic surgeons as well. Actually, it's quite a good um amount of people or orthotics and the other one I forgot about orthotics. So there's a variety of people that you work with and they're all trying to help this patient in front of you. And, and also there's a variety and operations as well. You do, you know, this is like half the less and more of the most common things I do in my day to day practice. And so as you can see, we'll go through each one of these later on, I'll show you some X rays and things. So there's a little variety of operations I can do. That's what excite me as a foot surgeon because I don't have a list full of hip hip replacements or a knee replacements have, you know, two, probably two of the same thing on one list. Every single operation is a slightly different operation. So keep you excited although you get bored in life. And so I get these big tools, little tools and I get these uh nice soft tissue, soft tissue procedures. I get the ankle replacement. I used to get, I get to the funky plates uh all over the place. And um uh I also do some frames as well. And if you've seen any of these, these are called circular frames. Uh these are for complex deformity corrections and stuff that again, it is a different um feel all together. And as a foot surgeon, it's a quite a good one to have in my uh in my toolbox because I see a complex deformity and especially infected deformities as well. And I can't put any metal work to stabilize it. And this is a great device in that uh kind of scenario. Um And it was soft tissue surgery. Uh This lady I said earlier, so this lady uh with the foot there like that. So she had a uh a brain in brain injury, been in it for a long time and had a significant contracture of that foot. And that is fixed. I think. I, so her foot like straight down ask, how are you, how are you gonna immobilize that? So, the rehab, we really struggling to mobilize them. Um They try some orthotics but it's not, it's not easy to put orthotics on that, isn't it? Because the foot or toes are almost on, on point on point. And so end up doing a massive release of a soft tissues. Um you know, that picture there is a release of a gastric muscles and um achilles tendon in the back, all the medial structures released. And at the end of the operation, got a nice flat foot, a forefoot still got deformities but got a nice flat foot. Now, the orthotics can work on that. They can get a shoe on or get, get a brace on much easier for it to transfer from, you know, back to chair and things. So and so this, you know, this, that's the kind of the rewarding side of things when you get a foot like that at the start and you get this at the end of the operation, it's great. And then there's no foot surgeon has done a bunion. The bunion is a common one of the commonest operation you do. Yeah, you think, oh people are wanting to get their, get their nice shoes uh to fit their feet. So I know um one of my colleagues makes fun of me and goes, oh, you, you guys just break the fee to fit the shoe. But it's not, you know, there are some people do have bad, um, pain and they do, especially the bumps over the, uh, the medial prominency. It can be quite irritating and all occasion. It does ulcerate and it causes a problem. Uh, there are some, I'm saying some people are for some people, it is a cosmetic procedure but a lot of them do have functional problem. And the foot, remember talk about before the foot is such a complex structure for it to kind of work. It works like a tripod. So your big toe, your little toe and your heel acts like a tripod. So in this, in a bunion, uh the, the big toe is out of place, isn't it? So that means the rest of that tripod has to do a bit of work to compensate for that. And some patients come in the bunion, but they don't have any bunion problem. They have other foot problems because of that bunion. Leading to that thing. You have to address the whole foot to sort out the issue and then you'll be fine. You'll find, you know, this picture on the right here and some people live like, live with that for like long decades, you know, especially um all women, I see them come in with this kind of deformity and they just um got on with life and they have no, they don't have any, any complaints. The main complaint will be the ulceration on the top of that second toe is being irritated, irritated and that's what, uh, brought them in eventually. Um, so for them, you know, uh, I'll tell them, well, if you want me to correct it, I've got a good operation to correct it. So, you know, and I don, I don't just cut the bump off. You can, if you got the, just the bump off, it'll come back. So I have to break the bone to correct it. So you can zigzag it, correct it and shift that bone back into where it belongs. So you can see in the picture, the first metatarsal metatarsal goes out of place. You have to reshift it back to where it belongs. So when you do that, you had good results from that. So I just get that for. There you go. So you fix that. You're nice and straight for most people. You get good cosmetic appearance, functionally, very good. Uh It's a sore operation, but most people are happy to go through that if they want to, they want that foot collected and stuff. So it's a nice uh um operation to do the other common things we see arthritis, you know, big toe joint, you know, gait. So your last push off is your big toe, isn't it? So that's when the final push off comes in and that you get a lot of arthritis in that big toe uh, you know, some people don't have any symptoms at all despite extra change that they won't have any symptoms. But quite a lot do and they have a lot of bumps and lumps growing. And then, um, so when they come to see me that, that endstage arthritis, but again, I got a good solution, I can just, um, stiffen that joint. It's all stiff anyway. So I'm just gonna, it, but it's got a tiny bit of movement. That's what generating all the pain. So I take the lumps and bumps out, put a plate and screws in and that sorts out the pain. Again, you get great satisfaction uh, from patients and things following that. Ankle arthritis. Again, such a common, common thing to see. Ankle doesn't like trauma because it is, you know, ankle, ankle fractures are one of the commonest injuries that we see, especially when it snows, when the, when the weather great. You get a lot of ankle injuries. Inversion of pains are very common out there because human, human feet, ankle are not stable units. So you can easy go over it. Most people get away with a simple sprain and some will get bad fractures. And then those are the ones that's gonna go on to get arthritic changes. Ankle doesn't tolerate, uh, uh trauma very well. So almost all arthritic changes I see in an ankle, either posttraumatic or inflammatory changes. You don't get pure osteoarthritis in the ankle. It's very, very uncommon. And so again, as you can see the first picture, this patient had a lateral ligament instability. So they've been uh injuring that ankle over the years. So your lateral ligament is gonna eventually gone and the ankle is gonna tilted, tilted, tilted, tilted and now it's engaged on the medial side and it's going to become arthritic. So what do you do? Correct that deformity, um prep prepare the joint, put a couple of squeeze in to hold it and that fuses the joint. That's what we call a fusion operation. Still the commonest thing we do for a lot of patients, but there's option of echo doing an ankle replacement as well. So again, we pick our patients carefully for that. But yeah, you can do an ancho replacement to preserve the joint and that OK, then you come to this complex deformities. You know, as a question, I remember seeing patients with like a like like what's going on here, you have to like scratch your head, what's what's happened here? So a complex cavo V deformity if I break it down and I mean, the arch got very high in step, see the in the picture there and then Varus, the heels in Varus. So the the heels are pointing in the way. So and so there's a complex deformity caused most likely caused by a could be caused by neurological elements. So whenever you see that foot, you need to always need to rule out a neurological course, it tells you there's some kind of imbalance going in between the flexors and extensors and the inverters and the s and so there's a battle going on and the flexor are one and become called, you can see the toes as well starting to go that here. So there's an imbalance of muscles here. Sometimes it can be theopathy. Uh, but you need to rule out a neurological course. Now, always have a look at the back in this case just to make sure there's nothing in there that's causing the problem. Ok. But to correct it, you know, if they, especially with this kind of a problem, they'll have, they come with you with symptoms. You know, the the common symptom will be inversion, sprains. They have a lot of uh they'll easily go over the ankle and or they have arthritic changes as they get older. And when you get x rays of um this um uh these feet, these, these see see these kind of images and how much experience you have actually at x-ray. But you can see these, these are normal looking foot, x rays. Ok. So you shouldn't be able to see all of the five rays on the lateral view of the ankle. And you also shouldn't be able to see an ap profile of the ankle on a lateral foot, X ray. So which means the whole thing is twisted. That's what else you and so, it, it, um, quite interesting x rays and stuff and to correct it and it's not as simple. There's a lot of deformities going on. A lot of imbalances, there's a muscle imbalance, there's a bone imbalance. So, to correct it, uh, you almost have dismantled the foot and recorrect it and surgically. And so, you know, uh, these are kind of multiple procedure we do for these patients. So these are pretty much, most of them have to do probably about 323 quarter of them. I think I have to do for each patient. Some patient gets all, all of them. Uh, but most of them, you do have to do a fair bit of a fair bit of surgery to that foot to it. So it's a lot of trauma to the foot as well. So you only do it when orthotics and everything fail and to accommodate or support that foot. And as the deformity progresses, it does become difficult to put a simple orthotics into these uh feet. So you need to get back, get people back to function. So, and then you get feet that go the other way. So you get plain of valgus feet where you get flatness of the heel of the flattening of the arch and the heel goes in the opposite direction to the valgus. This is a little bit more common and you know, is there more in women as well in the 5th and 6th decade, the first start to flatten out and the heels start turning in shape that again. It is a pathological thing when the heels start better and the arch start to flatten. If they already had a flat arch from birth, that's normal. As long as pain lasts, it's not normal when you get this some, this kind of deformity. But you'll find as time goes on, they'll start putting strain on your knee and your hip because your loading changes your gait pattern changes and the weight goes through various part of the joints and it, they get arthritic. So you may need to do something at the bottom to recorrect that mechanical alignment of the limb, challenging feet. And you can see here the x rays. So the foot is totally flattened out, the ankle start to uh go into valgus position as well. A lot of arthritis everywhere. So you can, you can do it again. Uh Same kind of operation we do but opposite the opposite direction. So we push everything the other way, move tendons around and break certain bones to get the archer reconstituted, correct the heel, correct the achilles tendon as well. Um Again, you have to dismantle the whole foot to get that uh corrected. So again, you only do that when you have, when the orthotics can't um correct that fit. Ok. So these are the complex eyebrow stuff. Then this is a funny uh the, this is the little less exciting but more um unforgiving stuff. The toe deformities, a lot of toe deformities and have you heard of hammer toes? There's clo toes, there's mallet toes and there's various types of uh toe deformities. Like uh this one here. You know, they are just do, how much can they, how much problem can they cause? But they can be quite annoying for patients, especially if in a shoe wearing population. It can be very annoying. Then you get this callus forming this ulcera. And if you get a diabetic patient, if these ulcerate is a big problem for them because they're immune compromised already bucks track in, uh just track right up the foot and it causes infection. And if they get, they could get septic and die or, or lose a leg and then die. So it can be quite problematic. I think a simple problem that can be a big problem for in some patient groups and stuff. And so again, as a foot surgeon, I'll correct them. There's various things you can do minimally invasive surgery is a great thing for this kind of thing. So, less trauma to the foot from a surgeon. But you can get beautiful deformity collection by putting screws in through tiny cuts and correcting the deformity by breaking the bones and everything. So it's quite a satisfying thing to do, but it's a lesser dose. So we only do it if you really have to if they don't behave sometime the way, especially the fourth and the fifth dose, you have to counsel the patient appropriately before you embark on any surgery on the lesser dose. And you get other funky toes like this and, you know, crossing over toes, um, and then kind of coronal deformities. These are kind of tricky ones that it's usually a posttraumatic ones or post surgical ones that, um, you know, got injury to some of the ligaments on the side and then allow the toe to drift into funny positions and everything. So there are good options you can do. We go back to the guy you had earlier. So this is the guy that came in, came with this said he for amputation, he's a diabetic and this also for a year. Um You know, I think the GP said he needs an amputation. So I spoke to him and he said, he said, I don't want an amputation, trouble working as a drive. So I still need my foot. So I spoke to the vascular guy. They said, oh, he's got good pulses. There's no compromise um of that. So he scanned them. He does have deep infection into that thing. So take him to theater chopped the, all the dead bone out some antibiotics and put one of these frames on. Um and he had that frame for about six months or so. So we need to get the infection under control, get the, but now the foot is back under, under the, the knee, the ulcer had time to heal and we also excised all that uh infectious stuff. So that gave it a good chance for it to heal. It's a diabetic, but it's a good diabetic. It's a controlled diabetic. So at the end of six months frame came off and you can see all that bit chopped off at the bottom. So it's tibia on the heel bone. So there's no talus or uh fibular left, distal fibular left because all were diseased. Uh I was hoping that will fuse, but I think it formed some kind of fibrous union. So enough for him to get a, a shoe on, a brace on. So now that's him now, now about a year ago now. So he's gonna straight looking leg. Now you can get uh orthotics on that and uh can get back to his driving really? So his ulcer is gone. It's not the prettiest foot. It's a functional foot. He had a chakra deformity of his midfoot here. That's why you can see this rock bottom uh sole, but he can accommodate that easily in, in uh orthotics. So, orthotics have taken him over and then, you know, he's happy. So he's, he kept his leg and his back working. So you can do a lot of things to uh improve the patient life um with, with good, with good planned operations and stuff. The other thing we don't see nowadays is rheumatoid fi the old ones come through, rheumatoid fi are the challenging one again or like the hands, the, they all go all over the place, the tendons go all over the place, the bones and you can see all these cystic changes everywhere. Arthritic changes and they come out with, they come with horrendous deformities with the biological agents. Uh Now we are seeing less and less of these coming through to the surgeons because the, the biologics are so good as controlling the disease. Now and then you get the odd ones like this lady turned out with the big toe pointing up, uh like a little periscope and almost turned 90 degrees and looking back at the ankle, uh what she did was she uh she made a cut a hole in the shoe and just lived with that for like, I think 20 years or something. And the only reason she came was that someone said to go and get it looked at. So I end up, um, fusing the lose it, but she managed to fuse it straight. She was quite happy that she did not cut a hole in her shoe anymore. So she's got delighted with that and you get these funky little things like this one here. I have no idea what happened there. It's, it's some kind of cone plaster at the bottom of the foot and that seemed to rupture the tendon. I think that's what happened. I haven't done anything to him yet. He has, he had a hole in the bottom of the toe there. So, so they gave him some antibodies, had deep osteomyelitis there. So we'll get that to settle again. He's been reluctant to lose the big toe and you don't wanna lose the big toe in old people because that'll make them lose balance. And that can cause obviously, uh, injuries and whatnot, that can have detrimental consequences for these patients. So you wanna try and preserve it if you can. And so you want to correct it. So we'll wait for the infection to settle, then we'll correct that too. So as you can see, foot and ankle is tough, it's not like, you know, straightforward uh hip and knee operations and there's a lot of, a lot of um things you can do. One thing I didn't have much about achilles tendon surgeries are you can do a lot of to, to start with the achilles tendon again. It's quite um yeah, interesting and fascinating to uh do the stuff, the stuff. Uh My other half the job is I'm a trauma surgeon as well. I'm a general adult trauma surgeon. So even though I'm a general adult trauma surgeon, I see a lot of fractures, low limb fractures coming to be so like ankle fractures, complex ankle fractures, calcaneal fractures, midfoot fractures. So, obviously, my colleagues, we all do our trauma together and so some of specialize in shoulders, some are hands and whatnot. And so they'll do that bit. So when I'm on call, if I see any shoulder stuff, I'll send it to them and it's a straightforward wrist, I will fix that. And so we share our trauma load. So, you know, so you get to do all sorts of stuff. So, you know, the top, top fracture, top line there is all fracture. I deal with calcaneal fractures, ankle fractures and the bottom bit is I also do it because as a general trauma surgeon, you wanna keep your skills, you do wanna get uh do some hip fractures, wrist fracture and that kind of thing. So, orthopedic surgery is a good thing if you get to do a lot of different um operation in various parts of the body of the limb. And as a trauma foot surgeon and I get this kind of thing referred to me, some, you know, this lady had a fracture and ages ago and someone fixed it and everything went to the mal union. You can see the kink in the leg and the distal tibia, it's just gone quite a bit um angulated inside. And so she's young, she's struggling to immobilize with that and she got a wonky leg as you can see from the outside and she got knee pain, hip pain again just because the loading is different. So only option I got is to take all that uh some of that plate out and put a frame on to correct it and she had that frame on for four months or so. And, and now she got a, you know, it's still got a bit of a kink in it, but now her foot is right under that knee now. So now she's pretty good. Um, because the hip pain, the knee pain has disappeared, you know, much straighter leg that will also reduce the chance of things getting arthritic as well. So, if you got malaligned limb, you're more likely to where that joints are, but they're not, they're not loading in the way they should. So it's quite a rewarding one to see uh the deformity erections. And so, um, yeah, it's not, it's not all great, you know, sometimes things go wrong badly wrong as well. Um, touch you. I, I'm not, I've had complications with infections and things falling apart, but thankfully, I haven't lost any legs yet and, or, you know, by the more you do more likely gonna run into problem, you know, we always worry about infection, uh failure of metal work and um, you know, loss of limbs or loss of light. Uh um, but it's not the best thing you can do, get the diagnosis, do the right thing for that patient and counsel the patient appropriately. So you need, it's a, it's a, it's a mutual agreement of what you're planning to do. Just the patient understand what you're trying to achieve. Is that what they want if they, if, if they have any concern, that's all they concern. If you do, you get very happy patients and stuff? Ok. And just to finish off. Um, so why do I want to do for an ankle surgery is a variety. Like pick N mix, isn't it? Um, like a mix and pick n mix things. You got so many different things I can do. And I've got so many different operations, uh, in my, in my, uh, the list. And it's kind of fascinating and a lot of my stuff are daycare stuff as well. Apart from the big stuff, a lot of stuff are decay. So I know there's not in patients so I can see them on the day, operate on them and they go home the same day or even the next morning, they might go home and intellectually, I find it quite challenging and to diagnose the problem and then to actually do the operation operation. So I didn't, what I didn't say. Was it quite fine surgery? Fine bone surgery? So, you got a lot of soft tissue there. Nerves close to you. So, when you're walking around, you need to know where the structures are. And so it's quite intellectually, quite challenging and it's fun to teach my registrars to do that as well. And it's overall, it's fun, fun, fun operating in the foot. Uh, right. I think that's all my talk. Right. Thank you for your talk. That was really fascinating to find out about your word of surgery. That's, I mean, I'm sure a lot of people in here have lots of uh questions in their head, but maybe they haven't been able to put them down, but I can maybe start off by asking. Uh, have you used any minimally invasive surgical techniques in your practice and how that help cases such as achilles tendon rupture? Yeah. So the, mm, I talk about two separately. So a minimally nasal surgery is a fairly, fairly, it's been there for a while, but it's been less adopted across the for world. And it was seen as a dark art uh him for ankle surgery because you're doing stuff without actually seeing the anatomy. So you're relying on your uh the field thing. You're relying on an X ray. While you do minimally invasive correction, you can do a cal cal oy minimally invasive. So you put a tiny two millimeter hole using like a dental but to calculate the calcaneum, you know, it's a big bone to break and you can't see what you're doing. So the old, you know, um as if anything, when you take things come along, people are always a bit hesitant. You get the earlier doctors, then you get the, the people who just watch and see what's happening uh before the doctor and that once you start taking off and there's no complication, then you get later doctors going on minimal in a funny one. So it's been earlier, do a lot of doctors in Australia, for example, the very earlier doctor has been very slow to pick that up. And all, all of a sudden now there's a increase, there's quite a late later doctors. Now, now looking at things, actually, there is some me in this. So when I trained in Aberdeen, we never did any of this in Glasgow. Totally. No. And so when I went to Australia, the guy who worked there, he's one of the early pioneers. So M foot and ankle surgeon, I like I learned a lot and when I came back and so I set up my practice with mis surgery for lesser toes for bunions. And also for, again, uh for osteotomies and things, the achilles tendon is a, is a different kind of art there. So achilles tendon rupture still debated in orthopedic wall, how you manage them, whether you do uh surgical repair or not. So, mm. And if you go to some center, they'll, they'll fix everything. All the achilles tendon, some um centers w won't do um anything I think like they will manage everything non operatively which most centers now in NHS practice do non operative management. The reason is that there's good evidence to say non operative management of Achilles tendon is as good as a functional treatment, as good as non operative management. So why are you, why do you put the patient to the risk of uh an operation where things can go wrong and you can manage non operatively. So, you know, if I get a patient, I give them my usual spiel about rupture rates and what, you know, risk and benefit of surgery and what are they trying to achieve by, um, you know, with an operation stuff? So most patients then choose not to have an operation apart from high level athletes, you know, because especially if they need high push off the final push off power and things, then maybe uh they need an operation to make sure that I get that strength back. But majority, if it's my ankle, I would, I would marry non operatively. And from the MRI S technique specifically to achilles tendon, it has been around, but there's a lot of complication reported as well with that because, you know, looking at it basically a minimal in naive technique involves small cut. You get put this jig around through the skin, you put this tendon there with the sutures in and you tie it together. The, the sural nerve is so close by. If it gets caught up it in annoys the hell out of patient because you get a bad neuroma. So I don't tend to do it. If I'm going to open it, I'll open it. The incision is only about uh you know, a few centimeters anyway. So it's not a big deal um to open up and do the at least 10 Thank you. Uh We have a question in the chat. Uh It says thank you for your presentation. Would you say foot and ankle is more ideal suitable for female to subspecialise in compared to hip and knee? No, not to be sexist. No, absolutely not. I mean, I think orthopedics in general nowadays, I would say for any man or women, to be honest, it's all, it's not all about bruise strength to be in orthopedics. There is some, some skin, some bit. Yes, there is. But even hip and knees and stuff, it's not bruise strength. Uh We've got female consultant. Um, I work with female, like tiny as anything. Uh, but they actually absolutely fine doing hip replacement, knee replacements. Uh So it's all about what, what peaks your interest. You know, when you, when you pick your specialty, you need to make sure the 80% you do, you have to enjoy it. If you do, if you enjoy doing a hip hip replacement go for it because you're not gonna be happy in the foot while if you, uh if you do hip replacements and you want to do feet. And so, you know, men, men, it's not about that. It's about how, you know, build up your strength if you need, you think you, you don't have enough strength to knock a hip out, build up your strength. And I mean, we got one of our consultants. She's as strong as any, any of the guys in the department. She's very good. So, it, it's not about female thing. Thank you. Um Another question, how do you see foot and ankle surgery management evolving over the next 10 to 20 years? Thank you for your presentation. That's from Rachel Min. All right. Thanks very much Rachel. And yeah, the foot and like I said, the foot, foot, the understanding of the biomechanics is changing every day and we understanding more and more about the mechanics, how exactly it works. There's so much variability in people as well. So rather than coming from the medical side, actually, a lot of research is coming from the podiatry medicine site. They understand the biomechanics a lot better than we do. For example, that's a surgeon. I was taught, this is what it is, this is what you restore it to. But now I changed a little bit of that thing. Actually, it's not why you restore it to. You should restore to what normal for that patient rather than what's in the textbook. And so that, that, that that kind of thinking, wasn't that a few years ago? That's again, coming to the orthopedic or Vern wall. The other thing will change I think is about um implants and techniques as well as things evolve. We talk about minimal invasive surgery that again is a great, great improvement in or introduction to facial surgery and that revolutionized some treatment um in toe surgery. I think the robot will come into play as well. Especially with the ankle replacements. The, one of the problems with the ankle replacement is that the reason they haven't taken on, even though they've been around for 4050 years is the longitude of them. They don't last long as hip and knee replacement. Hip, uh, hip replacement last for good, good. 2030 years nowadays. Uh, well done hip, uh, in a knee maybe, uh, 1520 years, ankle, probably 1015, a good replacement will back 1015. But again, it's not biomechanics, it, it doesn't have that support from the muscles in the ankle and also getting the alignment right is quite tricky. You almost have the eyeball. It's your personal surgical experience that allow you to do that, you know. So if you, if you don't have much experience, you're going to get that wrong. I think that's where the robot robot will come in to reduce that variability. You'll be able to get perfect mechanical alignment right? With the ankle replacement. Hopefully, hopefully that will improve things, uh, in terms of outcome for these patients and things. Thank you, uh, Mister Abraham, asking for your, how do you find your work life, balance, work? Uh, yes, I'm a, I'm a bit of a workaholic. Um, maybe that's not, I, I'm in orthopedic surgeon. Uh, orthopedic surgery in general is, um, it's a, quite a difficult, not difficult. It's a, it's a hard working specialty because we have, we have trauma surgery. Most of us do trauma and it can be called in the middle of the night. You know. So when there's a trauma, a road traffic accident with poly traumas coming in as a consultant, you have to come in and so yourself, general surgeons will be in the middle of the night operating or to come to the, to the call. So it can be quite heavy, especially if you work in big major trauma centers, you'd be in all night operating and stuff. So it can be quite hectic and myself, I have two kids and so we, we do have some time to spend with them. But I have to say as, as you go to your consultant care, you pick up a little things here and there and it gets busy but you still have your weekends and things to um you know, see spend time with them and things. Um So it's about how you a doctor rather than your work, the work work is there. So you, it's how much you pick up personally and how much you spend. So, yeah, my wife, I have to admit my wife does a lot more for my kids than I do and she's a doctor as well, but she does a lot more for my kids than I do. Um But yeah, it's about how you adapt to the work life balance. Thank you, Gaya from Edinburgh. He firstly, thanks for your talk he also meant asking about regenerative medicine, tissue engineering in foot and ankle reconstruction, especially for athletes who are looking for quick recoveries. And we know things like cartilage do not really have a good vascularization. Do you really see that could be something that be implemented in the future? Uh Absolutely. I mean, there's been a lot of trials in um, orthopedic, not just for an ankle and knee, we talk about OCDS, osteochondral defect. So when you get an osteochondral defect, when the cartilage and, and the bit of the bone kind of comes off the joint, it's difficult to sort that problem out unless there's a massive hole when you're going to fuse that joint. Um, it difficult to plug that a little bit. So people have tried various things over the years. One thing I would do sometime in a younger person initially, I would go and kind of um, uh break down the bone a little bit, allow the blood to come in and form a scar cartilage because the body doesn't have the technology to put cartilage back. And we don't have the technology to have yet to have put it back. So there is something. No, not so you can put stem cells in that area, problem is containing it. That is the problem we have. So there, there, there are membrane that uh some companies are produced now. So which I use. So if you were a young patient, they tried all the simple measures and the bri didn't work. Then I would, what I would do take a bit of stem cell from the uh pelvis and plug that into the gap and to get the seal and put a membrane in that seemed to regenerate some cartilage, we don't do that many. The reason is, is partly because it's quite expensive as well to get the stuff. So NHS back, you know, we don't really have that and I've done a physio not long ago after I started and he did very well actually. And so II had a scan of him after he had this done and a year later, and if you feel it kind of quietly filled in, not perfect looking normal cartilage, but it's, it's kind of something has form to there. I think it will be a big explosion in the field. A lot of research going on around the world in looking at that region of technology. The big thing about PRP, you know, some people are taking fat stem cells from the belly and spinning it and injecting into joints as well. It's called Lipogen. So that the theory is that fat is only tissue that regenerates in the body even when you get older. And so there must be good potent stem cells in there that could potentially uh become cartilage. I think the problem is we don't have the technology to, to send a message to the stem cells to say form this in this place. You know, we can harvest it all we can, but we can't sell it to do. We don't understand the mechanics at the moment. I'm sure that will change as time goes on a couple more questions. Uh I know it's been 730 now. But are you happy to continue answering more questions? Go uh wrong asking. Thank you for the great talk, Mr San, considering the intricacies of foot surgery, how effective is the surgical correction of foot deformities? Exactly. And to what extent could locomotor function of the foot and ankle be restored? Well, it's a, that's a very good question. So when, when you start think about deformities, you have to think, right? What is normal for that patient first? And what am I trying to achieve here? Have they got deformed? What, what exact impact are they having? So then you have to think right. So, you know, ii think what we call the complex CV is deformed. Some people live with that for all, all years and all of a sudden they come and see you because something has gone wrong or something, stop them being, uh, be able to normal again. So we have to find out what that is. So usually what I find is the calf that become tight heel has gone in a way, in a way in the way and the calves become tight that then stopped the orthotics they have been using all their life from working. So in that case, I'll co counsel that patient and say, what do you want me to do here? I can do a muscle operation to break the whole foot. Bring you, get you back into kind of normal neutral looking foot. I'll break the arch, break everything, but it's a big or do you want me to just go and lengthen the calf? Give you a bit of normal calf length, get you back to what you were like before. So you can go back to using orthotics and some patients will say, oh, actually, yes, just do that for me because I was fine before. So I'll just do a little operation to lengthen the calf and um, they'll go back to orthotics and they'll be fine for another few, you know, a good few years, hopefully a decade or two. And then in that case, ok, so you can do simple stuff and it's again by expectations, someone come and say, oh, my foot's all of a sudden done this. I don't want that anymore. I want the foot to look like the other foot. Then you think about like, how am I going to correct that? Then you correct that deformity. Absolutely. It's very difficult to get the, the, the correction. Perfect. You always have to tell our patients that you're not, you're not a magician. So you try to get that functional foot. So goal of foot surgery to get a functional foot that is 90 degrees or plan grade that you can brace. So if you got a foot that's in that position, you can't brace that or you need to use a lot of energy to walk around. So you need to get that to 90 degrees and get a foot that you can put a brace on. Um, so that is the kind of the aim of any foot surgery. And like I said, it's by expectation, you need to lay down with the expectation of the patient. You know, you're not trying to achieve a model feet here. Um, but like I said, when you think about it, you can, you can get it almost nearly there, uh with the, with the surgery and stuff. Ok, you have to think about it intellectually, think about it. Well, the surgeons can do what they can do best and hope for the best. It's not really ideal world. Yeah. Well, the problem with the foot as well, the one more thing I have to say is when you walk, when you stand your foot changes shape to when you're lying down. And so when you're operating, you've got your patient lying down. So that is a offloaded position. So you have to have a mental picture in your, in your head, what the foot was in a loaded position because that's what they want because that's the loading position. So you have to get restored to that. So that's where the the trickiness come in or? Thank you. He go ask him for the use of platelet, which plasma in treatments of injuries are you using it in NHS? Yeah. So we do in NHS. So we do it for certain so it license for certain things. So the guys use a lot in tennis elbow. There's good evidence that it works better than the steroids. So they usually inject for that knee. Well, there there's evidence coming out saying arthritic knees, uh the young arthritic knees, they inject it that helps. So in the end, we do that for the achilles, tendon and plantar fascia are the two that been debated whether they should use it or not achilles has been not been proven to work effectively as good as anything you. But so it not really good evidence for that plantar fascia. There is some evidence that it does help better than steroids and stuff. Steroids. Steroids are great for the first time around. And after that, it doesn't work if anything, it has a negative effect. So the the PRP has some beneficial in that way. The problem with the P RP studies is that every company has a slightly different mix of the PRP of the platelets. So different concentrate and then the studies lump all that together. And so it comparing apple and oranges. So some great great results and other centers don't the system and review come out saying, oh, it doesn't work because this guy said it doesn't work. So the evidence is a little bit sketchy at the moment just because it's, everyone's comparing different things. I think it's the right patient. Yes, it's a, it's a bit expensive. Um, but I, it might be the right thing to do in some conditions. Evidence is as far as I know the evidence is only there in tennis, elbows and uh, knees at the moment. Um For this. OK. Thank you. One last question from the audience. Uh Thank you for your talk. I wanted to ask as vasculopathy is common in conditions like diabetes, PBD, et cetera. Would the responsibility of revascularization fall on you? Absolutely. No, I'm, I'm, I'm just a joiner. Uh So I need a plumber for this job, isn't it? So, uh no, this is like with the MDT. So every month we have an MDT with the vascular surgeon. So I do my Ortho from I, I'm there from the orthopedic site and uh Mr Max is one of the consultant from the vascular side and dermatologist there and the podiatrist there. And so we all kind of work together in this uh environment. So if I got a patient that got, you know, poor pulses, then I'll send it to the vascular center, there's no point in me doing something to the foot when there's no blood supply coming down, the whole thing is going to die. So I have to make sure this revasc properly before I can intervene. And it's quite good. So you built up that team, um, uh working and similarly, if they have a patient with body problem, they'll refer me to have sorted out. So we work well together. So you need, you need the right person in your team to get a good outcome for the patients. Thank you very much and uh fun final bonus question for anyone who stand back. Do you have any ideas of? One couple of uh hot topics in research for foot and ankle surgery? Anyone interested in publications or anything that would be hard to on top? Yes. You know, foot and ankle surgery is like there's a vast variety of things in foot surgery. You know, for foot pain is one of these dilemmas in foot, ankle surgery, patient present with 4 ft pain, still want to diagnose, still want to sometimes treat you. So, understanding the mechanics of 4 ft overload, I think is the hot topic in for an ankle surgery. And that's one thing to look at. Um, like I said, there's a lot of stuff in achilles. Tendinopathy is a common thing. Again, a variety of treatments out there. Normally people have done studies on non operative management for this. A lot of people have done studies on operative management for achilles problem. I'm talking about tenopathy, not achilles ruptures. There's no any studies at all on non operative management with how it works. Like shockwave treatment, high volume saline injections and even like simple, simple exercise programs. Yes, but not for these other intervention stuff. Again. Plantar fascia is another one of them. A lot of people do P RP or needling for these shock favor, but there's no evidence, good evidence out there for it to say. So. Uh the, those are the kind of the wishy washy topics, but they are quite good by, you know, quite common topics that uh, you see, thank you so much for having us mister. I'm sure everyone have really enjoyed your talk and also the Q and A after all. Um I appreciate everyone fill in the feedback form and then your certificate will be sent after. Thank you so much for having us. Bye for now. Thank you very much. Bye now. Thank you.