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Hi guys. Uh we are going to talk about uh the virus for today, also called us has CAS. Now, you know, these cases are just lying around and uh they can come and exam. Although I would say most of us, uh when we, we are examining you on for an exam, we just want to know about the principles, you know, most of us uh in DGH uh we any severe that gave us cases to uh university hospitals or our tertiary hospitals, uh what we deal with is mainly subtle or I would say less severe deformity. So I would like you to uh you know, participate if you can uh if you can identify the deformities and go through some pictures, then it will be useful, you know, it will be useful uh to pick them up uh here on the pictures and then you'll be able to identify them in vi or an exam scenario. So make it inactive if you don't understand anything, then ask me. So, Kus foot is the high arch foot where the arch does not flatten. When the patient walks, deformity can be located either in forefoot, midfoot or hind foot or it will, it could be a combination of these sites. So you can see in these pictures that 4 ft deformities are clawing of the toes. It is either of the big toe and or blowing of the lesser toes. When the clawing of the big toe is severe, then it becomes cock up. Like you see in this picture, midfoot, there is increased arch and it's circulated. Do you, do you guys understand what's ation? So, supination essentially, if you see the foot is pointing towards the inside, it's open on the inside. So it's a high step gate when it's pronated, it's other way around in past planus. So there is increased arch and there is supination which means the medial side is lifted off like that in hind foot, there is varus of ankle, which means that the heel is tilted in and there is increased calcaneal pitch. So Calcaneum is pointing up rather than pointing horizontal. So other deformities or other problems are called of plantar facia and gastrocnemius. The most common uh cause of KVAS foot is underlying neurological problem. So, one of the common diseases is Charcot foot disease, which is called CMT. The other causes are various spinal conditions. Uh you can go through the list but you never remember these things. So, muscle dystrophy, spinal dysraphism, polyneuritis, tumors, poo cerebral palsy. Essentially, if there is a patient with new onset unilateral Lyor, but without trauma, it must be evaluated for spinal tumor. Another uh rare cause of Ks foot is dual club foot. Uh Other less common causes are mild union of calcaneal talar fractures, burns, compartment syndrome, diabetic neuropathy. Some cases are idiopathic and it could be nonprogressive but usually it's progressive. So this is an important slide uh for you to understand or for you to remember an exam. They are reciprocal muscles in the foot. So, anterior tibialis, anterior reciprocates uh with Peroneus longus and posterior tibial or tibialis, posterior reciprocates with peroneous bre. So when the tibialis, anterior muscle is weak, the per Peroneus longus pulls the down causes plantar flexion in the first week. The posterior tibial muscles, it pulls harder than peroneous brevis causing 4 ft adduction. So if you go back to that picture, the last picture again. So you see how the foot is turning. So it's adapted and inverted. So because anterior tibial muscle is weak, the Peroneus longus pulls the first ray down causing plantar flection in the first week. And because the peroneous brevis is weak, the posterior tibial muscle pulses pulls it harder, causing inversion, 4 ft election in the forefoot, the intrinsic muscles are weak. So, EDL causes hyperextension at the MTP and F DL causes flexion of the P IP and D IP, same as in hand. So overall deformity with the forefoot induction and hind foot varus, there is increased distress placed on the lateral side and the lateral ligaments slowly becomes less and the ankle instability occur. There is exaggeration of the brainless mechanism. So anybody wants to, you know, go through the deformities. This is the right time to revise them. Yeah, we're happy to give it a go. Um OK, go, go start with either hind foot or 4 ft and go, you know, likewise, OK. From back, side, forward or, or from 4 ft to foot. Yeah. So uh this is a clinical photograph where I'm looking at the foot from the back. The most obvious abnormality is that I can see um a peekaboo sign. Um And looking at the heel, I can see that the patient has hind foot, varus um moving on to the arch, I can see that they have a high riding arch. Um And if I were to put my fingers under the medial arch, I would most likely be able to clearly reach over to the other side. Um I can also see that there's some evidence of s uh to the midfoot. Um And I can see moving on to the forefoot that there is some auction and a um hyperflexion clawing like deformity that I can see to the uh appears to the big toe and possibly the second. But I can't obviously see that from the back. So I'd now look uh at the patient from the front um Presuming this was the same patient. Um There are different patients. Yeah, looks like find a picture of the same patient. Yeah. But, you know, just to revise the deformities. Yeah. So, uh looking at the clinical photograph on the right side of the screen, um I can see that there appears to be a uh cock up deformity, uh which appears to be present actually to the halo of the right foot. Um And I can see that there is clawing of the remainder of the toes and the forefoot. Um So overall this would fit with the picture of bilateral um pes cavus which appears cava sorry, which appears to be more significant on the left foot. Um Looking at this diagram good. OK. So remember the whole foot is kind of facing medially and because it's inverted, there is more overload on the lateral border. Yeah, you see the picture that the patient we be at the base of the fifth metatarsal. OK. So specifically in polio, it's very rare. Nowadays, you don't see polio. So let's miss this slide. I don't think it's important for you presentation, either it could be one deformity or a combination of deformity. And the presentation depends upon what is the deformity. So if it's a full fledged deformity, like 4 ft, mid foot and hind foot, they can point load in the base of the fifth metatarsal and they could have a cozy at the fifth metatarsal or very, very rarely if it's neglected, you can see a non healing ulcer, metatarsalgia is a frequent symptom when it is uh in the forefoot, uh ankle instability is the presenting symptoms uh in, in the ankle problem, especially you see them at the age of 1314, they come with the ankle instability and that's the first time. Uh they noticed that they have got deformity. Uh patients with neuromuscular diseases can complain of weakness and fatigue. So in work up, uh you will take family history. Some of the neurological conditions like CMT are autosomal dominant. You will do a neurological examination in my practice. If I see a kvass foot, I always take a neurological opinion before I do the surgery, I also get emg and nerve conduction studies. You MRI the entire spine uh to see if there is any spinal problem, which is the cause of KVAS foot. So uh this is a Coleman block test. The hind foot virus in cavers foot is driven by the plantarflexed big toe. So if you drop the big toe down, then the virus correct. And this is what this Coleman block test shows. Yeah, you're able to understand that on the left is the picture with the patient standing from behind, then you put a block and let the big toe drop down and that allows the heel to correct. I hope you got this. Ok. So in x-rays, you need some standing x rays of the feet to look at the Calcaneal pitch and plantar effect first ray. So Calcaneal pitch is the angle from the floor to the lower border or the inferior border of the Calcaneum. So I'll draw a line along the blan aspect of the Calcaneus in the ground. And the greater than 30 degree is significant for high foot virus. So, e essentially 0 to 20 is normal and anything more than 20 indicates towards subtle CVAs and more than 30 is, you know, very obvious gave us. So let's uh draw these angles. So this, this is Calcaneal pitch angle one which is uh B so that line and that line that's Calcaneal pitching and Mary's ankle, you also use in flat foot. So it's the long axis of the talus and long axis of the first metarsal. So normally the long axis of talus should go through the long axis of the first metarsal. When it's plantarflexed, there will be an angle, the other angles uh you don't need to remember. So uh here, the goal of treatment, as long as you remember this line, you know, the goal of treatment is to produce a plantigrade foot that allows even distribution of weight. That would be a good opening sentence if a slide of Ks foot is in the second important thing is you aim for deformity correction rather than fusion. So you try to keep the foot as flexible as possible. So always start with non surgical treatment, uh physiotherapy to stretch the tight muscle and strengthen the weak muscles, orthotics to try and you know, distribute things evenly. Uh lateral wedge insoles to improve uh the function there. Uh bracing of the subtle deformities, insoles to support the Coote. No. So again, goal of surgery is again to produce a planted red foot and pain relief. It is a progressive condition. So sometimes you require repeated surgical procedures and often when you are correcting, uh you know, the va score, you require surgeries at various sites, you know, hind foot, mid foot, forefoot. So all goes together. So again, procedure depends upon what patient is presenting with some patients present with ankle instability only. So you just stabilize their ankle, you do a Calcaneal osteotomy, lateral ligament reconstruction. Uh and that should be enough for them. Some patient presents with say ulcer underneath the fifth metatarsal or big glos underneath the fifth metatarsal. They probably need uh say ostectomy of the fifth metatarsal. Sometimes they need fifth. Uh they need tibialis, posterior transport dorsum in the forefoot. If the deformity is in the lesser toes, then it needs lesser toe correction. If it's in the big toe, it needs big toe correction. The mantra is try to avoid arthrodesis if possible, try to correct the deformity by balancing the foot by tendon, transverse and doing osteotomies. So, uh all these treatment, you know, which is uh say guided towards the ankle or midfoot or forefoot uh is associated with the APL tightness. So you release the a tendon, there is also plantar fascia tightness. So you release the plantar fascia, uh So, depending upon the deformity, you decide the treatment. So for 4 ft in the lesser dose, if the deformity uh is flexible, you can consider mis correction or metatarsal basal elevation osteotomy or metatarsal shortening osteotomy. If it is fixed or flexor to extensive tendon transfers used to be done. But nowadays, uh most of us, you know, uh I, I've not seen flexor to extensive transfer um in last 10 years, uh V uh V deformity could either be at the big toe uh which is causing irritation at the VIP joint, uh sorry, VIP joint. And if that happens, you do what is called a Jones procedure. If it's the plantar flexed big toe and the pain is there and the ball of the phosphoral, then you do a dorsiflexion, osteotomy midfoot. You do a biplanar dorsal wedge. This is a complex operation. It needs to be planned properly. Uh Nowadays, uh if patient needs, uh you know, uh a bit me and I send them to apex hospital, they do 3 3d printing and they plan to me with 3D printing, usually uh it should be done. It's not a common procedure. So it should be done in places where, where they have more numbers, hind foot, uh Calcaneal osteotomy and lateral ligament reconstruction. This is one of the commonest presentation, especially in central cava foot. So this we do quite commonly. Uh We discussed that in addition, you do plantar FCI leave very, very rarely if the deformity is severe, you do tip post transfer to dorsum. At the same time, you notice the peroneous lumbar to gravis. Sometimes they put an X ray of non union of Fifth Meats and exam. And often if you, you know, ask few questions to examine her, you'll find out that it's a triad of heel, ankle stability and a non unitive stress fracture of fifth mesal. Do you understand what, what this is? So this is essentially a cava foot patient which is loading at the base of the fifth metatarsal and the stress fracture is not healing. Ok. So just to revise again, uh adult patients with complex foot, you start with plantar fal release, then do tendon transfer aosis like Peroneus longus to brevis. Then if the deformity is in the heel, you do calcaneal osteotomy. If it's in the mid foot, you do metatarsal osteotomy. Uh if there's arthritis, you do ar arthrodesis and then for the for the forefoot Jones procedure. If Jones procedure, if the toe, big toe is clogged and impinging on the D IP joint and dorsiflexion of me. If the pain is at the ball of the big toe and lesser toe surgery, if there is significant grow and metatarsal elevation of if there is metatarsalgia. So we look at some cases to, you know, to just revise over what we have discussed. These are complex things uh difficult to remember if you have seen patients. If you've seen pictures, you tend to remember a few things. So any one of you can help me out, it's a Kvas foot with nonhealing fracture. So where would be the deformity predominantly? No. So, um uh you, you, for this, you, you'd assume there'd be a 4 ft um deformity, um tipping the, the foot into super and loading onto the fifth metatarsal, which is where I'd expect the, the non healing fracture to be. Yeah. So they, they would be uh you can say uh you know, high arch. Uh so uh the weight, less mechanism would be exaggerated and uh the f the mid foot would be inverted or circulated and that would lower the fifth metarsal. So uh that's the affected foot and you can see the big toe. Uh it's difficult to make it touch the ground. And what do you see here at the base of the fifth metarsal? Yeah, it's a stress fracture in zone two looks looks like. So what's the prior? So it's a stress fracture. Um a stress fracture, eight lateral ligament, um uh rupture and uh uh very, very, yeah, very soon. Yeah. So remember that, try it. OK. Wear heel, ankle instability. So they come and say to you, my ankle rolled over, I can't walk on the unsta you know, I irregular surface. So what should be the treatment plan here? So um uh start off with non operative measures. So, physiotherapy stretching exercises, uh offloading orthotics to offload that uh lateral way. So, so a lateral wedge on the, on the, on the hind foot and then surgical options. Um it will depend on whether we have a flexible or um a rigid um uh uh deformity. So, it's a, it's a young uh 20 year old patient. You see the foot, uh you know, no arthritis. Ok. In the foot. Ok. Correct. Correct. Ok. So, um you can do soft tissue procedures. So um you can do uh yeah, you can do a um as long as a brevis uh transfer a Bostrom reconstruction. And uh you'd also want to fix the fifth metatarsal uh stress fracture as well with the screw. Um And then uh reassess there. You, you can then um augment that with a tip post transfer to the dorsum of the foot. Again, what's the driving force, you know, muscles? Uh There, there is muscle weakness. II agree with you. Yeah. But there is also deformity now. Hm. So your slide as well. So I'll do, I'll do of. So what would you do me slide or natural wedge? I would do a later slide actually. Uh that. Yeah. So if you have seen later slide, it is very difficult to slide the calcaneum laterally. Usually you have to take the wedge out. OK. Yeah. So you did, you do lateralizing it, it's safer to call it, call it lateralizing calcaneal oy. OK. Right. So essentially the lateral structures are weak, you will later do an lateralizing calcaneal oy, you will reach the lateral ligaments. You'll probably use an internal brace to, you know, augment it. Uh you will excise that base of the fifth me. So you know, prominent area, you will stitch the peroneous gravis, uh you know, whatever you can here or you can do tenodesis, actually tenodesis will be much better here. So you do peroneous longest to peroneous vis tenodesis. Uh So the main complaint is the hind foot and this fifth meara that will take care of it. I mean, all this will take about 2.5, 3 hours. So in a patient like this, if they don't have much problem in the forefoot, you can stage the treatment. Mhm So that was done uh Calcaneal osteotomy, lateral ligament. Uh after doing all that, I thought that ii cannot make the big toe touch the ground. So I have to do a osteotomy there as well. So this is uh something very rare. Uh This was this is the case uh when I was working in India this young uh I think he was 12 years old and this guy had an abscess uh in the leg and somebody drained the abscess and damaged the nerve. So he has developed deformity. The peroneal nerve is damaged and he has developed this deformity. So what do you think? Which muscle is working here? You know, the foot is inverted. TT post is being overworked. Yeah, I inverters and inverters are working and 10 is working. So in this dye, there was no significant heel deformity. This was because of the nerve damage, which happened about a year ago. So we did a tendo release VCU dye release and transferred the tip post to the dorsum and he got better. So this was pre op, this is in plaster postop and this was when the plaster came off at six weeks. So he did well with that charcoal disease. Uh anybody wants to read the deformities and then we go through. So you see the problem here is in the forefoot. So these patients have significant intrinsic uh loss. Um So as a result of that, they tend to have a clawing deformity, particularly affecting the forefoot. Um So you can see here that we have a hyperextension deformity at the metatarsophalangeal joint, uh a flexion deformity uh at the uh P IP joint. Um and um the uh IP joint, um the they can also have similar deformities in the hand. So it's really important to look for intrinsic wasting in the hand in these patients. And they tend to have this bilateral picture that you can see here, which suggests more of a neurological or central cause. Um In this case, um we know it's autosomal dominant, I believe. So we'd want to also check family history in this patient uh to see if obviously anyone else in the family had had similar presentations good. So, it's, it's the forefoot, deformity and forefoot is driving probably the hind foot and the mid foot. Now see the big toe, uh, the big toe is flawed. So if they present with a colo hair at the D IP joint, then they need Jones procedure. Do you, do you understand what is Jones procedure? So, I believe it's when you bring your, uh, flexors over, um, and they act as an extensor moment instead. So it's transferring that flexion that you're getting at your, um IP joints and bringing them around so that they act as an extensor. So you're changing that. Uh, so that's flexor to extensor, transfer it to flex. So this would be, is it extensor to flexor then to help with the hyperextension? So, uh, let me describe it and then we can decide. So you take the extensor dilator Longus at the IP joint, you open the IP joint and you fuse the IP joint. So make it straight because this because of this acute flexion, this is rubbing over the, sorry to interrupt. It's EHL, not Edl E HL. Correct. Yeah. So you take the EHL from here and pull it out at the neck and you know these to the neck to lift the metatarsal shaft up. So you are dealing with this deformity and also helping the big toe to come up because it's plan Toflex and Jones is indicated when there is Coote over the IP joint. If however, they have pain on the big toe, ball of the big toe and there is coos on the underside. Then you just do do the dorsiflexion osteotomy as you saw the previous patient. Yeah. So patients symptoms decide which surgery you will do again. Lottos. Uh if there is metatarsal, which is coos underneath the metatarsal heads, you do the metatarsal elevation of your knees. If the problem is here, then if it is flexible, you do flexion, flexor to extensor tendon transverse, which is uh I don't know the name but tendon transverse here or if it is fixed, then you can do the joint fusions. Nowadays, even if there is significant deformity, you can do Mr S shortening of the metatarsal and you know, do some corrections here and even though there is not full correction, it is corrected enough to take the pain off. So uh plan in this patient uh release a it is type Calcaneal Oy Peroneus longus to brevis transfer lateral ligament reconstruction depending upon the deformity t post transfer. So you start with this. If you still have re deformity, you do the post transfer and plantar facci release. This is the same patient after correction. Uh We haven't corrected the fourth foot, we have just corrected the mid foot and the hind foot. You can see the fore foot is still blur. Another patient uh with not healing ulcer under the fifth metarsal. Uh He has Syringomyelia, I can't play the videos uh he had post transfer, the deformity was quite severe. So you see uh when deformity is really, really severe, it doesn't correct by Calcaneal osteotomy and Tenodesis. And that's when the transfer helps to get this uh plan grade. This is the same guy once uh you know, I think this was three months, post surgery, his foot is flat. So I don't know if you can see from there. This is a young patient who's presenting with metatarsalgia. There are coos underneath all the metatarsal. So, colo when you see the patient, you will see hard skin and patient will come presenting with pain over this area. So uh the plan here was the dorsiflexion osteotomy of the first vitaral and basal elevation osteotomy, also called BRT of second to fifth. So in summary, your treatment, your aim of the treatment is to get the plantigrade foot and to redistribute the weight surgery will be directed towards whatever is the presenting symptom. If the presenting symptom is ankle instability, you will correct the heel by calcaneum osteotomy and lateral ligament reconstruction and Peroneus longus turanus hemodes. If it is the fifth metatarsal base, then you can either consider the midfoot, midtarsal osteo or tip post transfer depending upon the flexibility of the foot. If it is 4 ft, then big toe, if it is flexed at IP joint and the patient is getting pain at the IP joint, then Jones, if the pain is here at the ball, then you lift it up with a dorsal flexion osteotomy. If the pain is here, then basal elevation osteotomy of the metatarsal. If there are plateaus, then depending upon whether they are fixed or flexible, you decide these. So if this much you remember, uh that would be enough to pass the exam in practice. Uh In DGH, we most commonly see subtle cava both and they present with ankle instability. Uh and once you correct their heel wear, they get better. So, complication of these procedures as with any bony procedure, you know, uh is the list we put in the consent form, non Imune malum infection, undercorrection, overcorrection. Uh In addition, you tell these patients that the deformities are progressive. So despite surgery, they can reoccur and they may need surgery in future. I think that's all uh I have to say regarding if there are any questions or if you want to revise anything, I can go back to those slides. I just wanted to clarify one thing um before the exam just because um when you're looking at it, obviously, you've got your Planovalgus deformities and you've got your um your cavovarus deformities for your cavovarus when you're doing your colon block test. The main thing that you're differentiating here is obviously whether it's forefoot driven or not. Um So it's not, you know, like, similarly where you do your tiptoes of valgus for fixed and flexible for this, it doesn't really determine the fixed or flexible nature? Does it, is it more just determining whether it's forefoot or hind foot driven? So, you know, which part to kind of correct with your procedures and then you get radiographs and examine the patient to look at the flexibility of the joints. Is that, is that correct? From my understanding? So, uh Goldman block test uh is essentially, you know, it will only be possible if it's a flexible hind foot. Yeah. So this uh this thing about fixed and flexible hind foot is more uh you know, it, it pertains more to the flat foot, you know, planus deform. Yeah. Yeah. Yeah. Usually the KVAS foot patients, you see, they are the younger group. Mhm. Yeah. The flat foot patients you see are the older group. Mhm. So they have more chances of arthritis. Most of the KVAS foot patients, the slides are shown they are all less than uh you know, 25. Yes. So if you do a common block test on that patient and the heel isn't correctable. Um Then in those patients, would you stick more to your bony procedures? So, like your Calcaneal slide, et cetera. Because what I was just thinking is that if, if that, if you were to do, for example, a um a tendon transfer or a Tenodesis, then if the, if, if it was a fixed deformity that wouldn't correct or can you still consider them in these patients? So if it is fixed varus Yeah, it doesn't correct with block test. Yeah. And an X ray or a CT scan will guide you if there is significant arthritis. Ok. Yeah. So your imaging is what would guide you? Yeah. Yeah. If there is significant arthritis then doing fusions is an option. Um-hum. Yeah. However, remember you have to balance the foot without, you know, before undertaking any fusion. Yes. If you don't balance the foot, then they fused with a deformed ankle. Ok. Yeah. One of the common things we see in DGH is that patient had significant varus deformity and surgeon has fused the ankle without picking up the muscle imbalance. Ok. So it's still important to do your transfers to try and balance your muscles even if the joint is not a flexible joint because you don't want it to end up healing with like in a deformity. Balancing comes before fusion. Yeah. Yeah. Yeah. If you don't balance the, the patient will never be happy. Yeah. And there are very high chances of non, if you try to fuse uh unbalanced foot or yes. So for exam, your balancing comes first, then if there is arthritis, you do fusion. Yeah, that's great. Ok. Thank you. Very welcome.