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Um we're going on this election number five and our instructional foot and anchor course. And we'll discuss today. Uh very important topic very uh commonly to come in the exam, very always missed from uh clinicians. And uh when you start to read foot and anchor, he vision is very common. It's ok. But lesser to conditions, neurological conditions of the foot and tendon conditions are always missed, they are always overlooked and they are very important to understand. Uh Again, my name is Mohamed Hashem. I'm a foot and ankle consultant in Northwest London, uh Wham Park Hospital. And uh this is where I come from. And again, all these educational events will be in my youtube channel, hashim's educational channel and the Ortho be my official channel. Good. So to start with uh Helix rides, we need to understand that Helix rides from. The name is, is that Helix was limited dose Eli. And it's very commonly the commonest cause of this is, is arthritis of the first MTB joint. So Helix rigidus isn't an isn't a, a misnomer, it's actually a good AAA proper number. Um So because the main problem of this patient will be difficult, difficult dose and difficult push off. The main job of your first MTB joint is to help you in the bush office stage of the gate. That's why the hallux rigidus, why we specify as rigidus. Because the main problem you will have is that your hallux is, has a limited dorsiflexion. It couldn't do a proper, um, uh, bush off and this affect your gait and this gives you the pain. So Harri rigidus means arthritis of first MTB joint. And we call the tr that because of the limited range of motion, especially the dorsiflexion range, you need to have at least a 70 degree of dorsiflexion dorsiflexion range. So you can do a proper push of the g. So the patient will come to you with a history of pain. The pain is mainly around the first MTB joint. As you can see, it could be some uh bony prominence here which may be missed as a bunion. As you can see, this is not a bunion. This mainly a dorsal osteophyte bunion will be always on the media side, but this is a dorsal osteophyte. Uh the normal day activities will be affected, especially wearing shoes, especially uh running jogging, whatever he needs, the patient needs. A posh of four will be limited by the surgery. When you start to examine. This patient is very simply kind of spot from here. The dorsal bunion very prominent as you can see in this picture. Um while you seeing the patient from the start, it, it's not uncommon for this patient from the front. It's not uncommon for this patient to be flat. So may have a, a flat feet and uh when you have a flat feet, this is, this is adds to the problem of uh the heart of sts with flat feet, you need more push off, more dorsiflexion of the um of the halo to do a push off. That's why with flat feet, the halo, this problem is more prominent and more symptomatic. When you feel definitely you find some something that is over the first MTB joint. And the most important is to, is to move it to diagnose hallux rigidus. So you need the normal range of motion of the big two, which is normally 70 degree dors to 25 to 30 degree blood of flection. If you have this range of range of motion limited, you have a hay. The main problem will be as we agree, the dorsiflexion will be a bit painful, limited with a difficult push off to diagnose this more. So the range of motion, you need to, to specify where is the pain is the vein at the extreme range of motion. And this means the main articular surface is still, in fact, the problem is mainly in the bra not in the central articular surface or your vein is in the midrange. If the vein is in the midrange mean the joint has gone completely. So when you start to move your first uh MTB or the moving your grade toe, if you move the great toe with the patient, and the pain is in the mid range, this mean the joint has completely gone because this means a central arthritis. But if you move your uh the grade two of the patient and the first MTB is moving, but the pain comes at the exit dose or blunter flexion. This means that the articular surface is worn uh peripherally and the central articular surface is still intact and this is a minimal degree and this is still will benefit from uh preservation surgery. But the one with midrange arthritis or midrange pain, this is the one which you need fusion or replacement. You can do the grain test and you need to understand the grain test. It's a very painful one. So be careful, alarm your patient that you're doing a painful maneuver and basically you exit a compress and start to rotate. It's not this one. No, you basically alarm me. The patient have a look in the face but on the compress the uh uh first MTB joint and start to rotate. So, grinding means compression and rotation. The common cause of pis is definitely osteoarthritis. The most common cause about more than 90%. You may have rheumatoid arthritis or posttraumatic arthritis. So when you classify the headaches, rigidness, we can classify it very simply as I explain you. It's, it's just painful joint with no limitation of range of motion, no joint, space narrowing or any features on the X ray. And this is gate one, this doesn't need anything. Just an operative measures on pain management, maximum and steroid injection, then mild space narrowing and dorsal osteophyte, which will be represented when you examine the patient by painful exit range of motion. And this will benefit from chilomys shaving of the dorsal osteophyte or grade three, which you have complete loss of the joint space, the bin for bin for mid range of motion and this definitely will need either either fusion or replacement. So if we decide on a heart, there's one or two and we will start with non operative treatment or what we need is to give the patient a wider shoes, try to give the patient a specific strength you see on the right side which have what we called Morton's extension or. So this or Insoles Morton's extension, this is get the grade two out of the way. So it doesn't allow the grade two to to do a two off. So there is no dorsiflexion. So there is no vein and most of the time this does control the patients symptoms and give the patient a good relief unless the vision is badly arthritic. So why there are an extra, there's two box number two, Mortons extension, insoles or Ortho this number three, if the patient is in grade two. So we we have the option to do a Chy. So basically chom you just open uh the Georgian dorsally and from when you open the joint dorsally, you go and shave about 20% of the articular surface to get the dorsal osteophyte off. And this allow the joint to move freely again and gives it the normal dorsiflexion. The point is, is uh uh if colectomy needs to be done properly, so it's not just shaving the osteophyte itself, you have to take part of the articular surface. Because with the time when you have a dorsal osteophyte, the proximal phani start to develop another osteophyte, which is what we call the kissing osteophyte. So you have to take a proper bu bunch from the, from the articular surface at least 20% to give you the effect of a proper dorsiflexion. And the patient gets to get the benefit. There's another option of of mobile procedure. I have a photo of it. Yeah. So mo procedure, basically what you do is you get come here and then you do as you can see a dorsal dorsal closing which osteo osteotomy of the proximal pyx. So actually you change the axis of the joint. So rather than the normal axis of the joint here, the right axis of the joint will be here. So basically, rather than rather than uh uh fusing the joint, you need to get more dorsiflexion. So basically, you do this dorsiflexion by bone osteotomy. So you do a closing which dorsal osteotomy of the proximal nix. And this what's called mopper uh procedure, then if both options fail or the patient already in grade three. So the option you have to this joint as that to ar through this replace or excise. So, excision, which is a very old fashioned operation, not, it's not done anymore, which is called killers. Arthroplasty is basically you go take bar to take the, the joint off and just keep the the tof loading. So that's why we keep it for the elderly low demand patients, especially if they have rheumatoid. And there is no um option with a soft tissue, soft tissue are very, in a very bad condition. And there is a specific joint degeneration and what you go, you go and excise the approximate end of the pharynx but and you end by floating to, that's why we don't like this operation at all unless you, you have no other option like the patient have a recurrent infection, recurrent instability. And you, you feel that both implant in this patient will be catastrophic. This is when you go go for killers. And to be honest, I haven't seen it for the last four or five years. So Killers is, is a very old fashioned operation. We do it in very extreme conditions when there is no option to ar through these or uh replace, then the actual treatment of hearts is either to replace the joint or to fuse it and replacement is getting, getting more and more popular at the, at the time at this time, the problem with the replacement, it starts with the, the one on the, uh the, the, the this implant on the right side, which is the cartiva. And the problem with the cartiva, it has a lot. It has mini generation, second generation of it has a catastrophic failure. And this what gives uh uh MTB arthroplasty the bad repetition it has. But nowadays we have the cystic embryon and the X embryon is doing very well. That's why mice start to recommend it as an option for treatment in osteoarthritis and rheumatoid arthritis. It wasn't again an old repetition that the cystic emb caused severe cytos. To be honest, the patient we have, we're doing the new emb at the moment is doing well and it's a very good and valid option for um having this treatment. It still osteologist can happen. It still side effect. That can happen. Yes, but it's not that bad option. So that's why you have to explain your patient. The pros and cons of arthroplasty versus fusion, fusion will end the patient with the patient uh with no movement at the joint. He needs to have the, the IB joint to be sued and it end by the patient with no option to have a high heel. So it has its its own cones. So you have to explain your patient all days. We don't, we don't, we don't um uh explain the arthroplasty. We get the arthroplasty out of the equation because basically the cartiva and the old generation of CYL were back now, the the new generation of cystic embryon is good, very easy to do very quick operation and it is quite successful. That's why nice start to recommend it. And that's why you need now to explain it to your patient as an option of treatment. Fusion. On the other side remains the gold standard. Easy operation, quick. One first operation for any foot and ankle surgeon to do. Um you need to understand where you want to put your fusion, where you want your grade two to be in after fusion. So you need to keep the the the hallux in about five degrees vuls in about 20 degrees dorsiflexion to clear the ground and as much as you can in the uter rotation. So the position of fusion of the first MTB is 0 to 5 degree valgus, 20 degrees dorsiflexion and as much possible, neutral, neutral rotation indication. Definitely if the patient become in a lot of pain is not controlled by non operative measures or the patient already in grade three and symptomatic and cannot manage his normal daily activities. This is the time the patient need fusion or arthroplasty. And you have to explain both options how we do fusion very simply, either you open a media approach, dorsal media approach or dorsal approach, you go inside, you clear the arterial surface with special reamers and then you both your joints together, stick it with a wire. And then if you're happy with the position, you bought a compression screw across the joint, some people do across a screws. Some people do a screw, a screw and plate and a screw and blade is still the standard. So the standard is to both a a can you compression screw just to get the surface together and take an inter blade on top of it. The evidence says there is no difference but in, in, in, in what we see in the practice, the blade and screw is the best option. Screw to compress the articular surface and blade to add to this compression and neutralize all the forces. This patient walks straight away after the operation, you keep him just on, on a heel weight bearing for six weeks, get an x-ray. If the X ray is OK, then this patient go to normal shoes and has no problem. The only problem the patient has to understand that he will depend mainly on the D IV joint for the movement. That's why if, if she is a woman, she cannot use a high heel more than an inch, which is very low, high heel. Ok. So, and the patient need to be aware of this. Patient will have some difficulty walking on uneven service, going up hills. Uh The patient need to understand this very well to under for you to, to explain to the patient clearly what is the problem be? You understand when you try now yourself. So if uh if intentionally you don't intentionally move your toe, the normal movement of the toe comes from one of two joints, not two of them, only one of them, either MTB or D IP or P IP and I'm sorry, IB. So when you move your toe, normally try to move your toe. Now, while I'm I'm speaking to you, you'll find that your mo your toe move up and down normally without intention, either through the MTB or through the IB joint. And because the MTB is fused, the IB would be moving so the patient will not lose the function. So the patient, most of the patient understand that. Oh, I'll diffuse my, my first MTB, my function will be affected. No, because normally imagine now on your foot that you, you stop the movement of your MTB joint, you'll find that the same movement of the toes is happening from the IB joint. And basically we fuse this joint, we are sure that the IB joint is. So the patient is still have the same function he will have from the MTB. So this is we, we now already spoken about all the condition of the Hallux. So we spoke about Hallux virus, falcus hallux virus and Hax Rigidus. And this is most the most common condition of the hallux. We'll check now to speak about the lesser two conditions and there is a condition. Uh you need to be very careful. They are not that uncommon. They, they are common. But the good thing is that the patient respond well to the non operative treatment. And on the other hand, thanks God that the operative treatment of the laser is not the greatest patient with lesser ptosis. All lesser to surgeries is always a problem is always in pain. Lesser to fusions are always prone to non union. That's why thankfully lesser to conditions are responding well to non operative measures. The communist you'll see in the lesser tours is uh the bunion or the tailor bunion. And as you can see, basically, it's a tailor bunion because in the old days, in the Greek days, the tailor said had to send cross leg and when they send, they set cross leg, all the pressure goes to these two points which is the 50 m tarsal hit. So basically the tar bun is prominence of the 50 m tarsal head. This prominence can happen because uh one of three options or one of three causes cause number one, that the head itself is big, which is what we call type one. So the head itself has a deformity, the head is big. That's why it cause a prominent or a a bunion. Number two when there is a deviation in the shaft. So the shaft itself is deformed. The relation between the 4th and 5th meterset is maintained. But the fifth meters sha is deformed or deviated as you can see. And the third type when there is increased intermit angle or when the uh 50 m tarsal is more lateral or more vuls that uh uh compared to the fourth metatarsal. So the types or the causes of uh bunion or the bunion, either deformity of the head itself or deviation of the shaft or increase the intermittent angle between the 4th and 5th. Uh as I explained to you, this can happen from external causes, like compression of the full foot by t shoes or in the old days for the Talos or the cross legs. Or it can happen from intrinsic causes like the the patient has already a congenital deformity could have uh could have it from inflammatory arthros. Yes. And when we judge about this, you need to understand that the normal force fix intermit angle is about 10 degrees. So if the intermit angle about more than 10 degrees, so the patient will have a one unit from type three and this is the most common one. So when we treat the are two condition, you need to understand that as any as any foot and ankle condition, we start always with non operative. So try to give the patient, try to treat the cause of the vision. Give the patient awa two books, ask the patient not to put any pressure on this. Um uh In this point, if he uh if the patient adapt to set clo cross legs, he needs to stop that. You can do some bedding and give, give the vision some uh uh gel beds. Then if the problem is in the 50 metatarsal head, which is a type one, the easiest to go as you can see and do a a condylectomy. So remove a condyle of the first metatarsal head, 50 metatarsal head. So uh just correct the deformity of the head if the patient is type two, which is just deformity of the shaft. The options you have is either doing a or mid media gas. As you can see here, you do a V cut here and then you shift the head to the media side and the shaft to the left side and then you shave this, then you correct the deform, the distant deformity of the metatarsal, which happens in type two. If type three, or aggressive or severe type two, you have the option of doing a scarf osteotomy. That's as a normal scarf. You still do two cuts, one distal, one proximal and then shift the whole me the whole distal metatarsal uh in and definitely because it's a more proximal osteotomy, it has a more powerful collection. So more powerful correction because it's more proximal osteotomy and the correction will correct for you severe type two and type three, there is a distal diaphyseal rotational osteotomy. Um um uh we don't normally practice this. We normally practice Eisen Chevron, uh Chevron if type two or a scar, if type three, and you still have the option of salvage for just to excite the metatarsal head. The problem was abate in whatever the to me do, especially if it's 53 when the intermittent angle is, is gray big is recurrence and the other problem is especially in young females. So when you do a severe bunion for a patient, you need to clearly counsel her. It's mostly a female. It's mostly a hair dresser. Don't ask me why a hair dresser. But this is what happens. I can tell you that most of my patients with bate, we have the results, females have the results in the middle age thirties, forties. You need to uh to tell her especially if she has a type three which is increased intermittent angle. Uh that this is uh the recurrence is very high even if you do a proper scar, right? A question. Yeah, just a question. Uh uh for, for uh according to this. So uh how does the procedure will contribute to the management and control symptoms? So, yeah, basically, if you understand with me, this is the normal joint, imagine this is you, you can see the skin has that. Yeah, this is a normal joint, have a bump up here because of the dorsal osteophyte limiting this dorsiflexion. As I explained you up to grade three when the joint is completely gone, your problem is not in the vein. The pro your problem is mainly in the movement because there is a dorsal osteophyte here. You cannot dorsiflex. OK. So what I will do for you, I'll do a closing w dorsally. So move this up so your normal position will be already dorsiflexion. So imagine that the original joint before I do my osteotomy has 30 degree dorsiflexion and 20 degree blader. OK. When I close the wedge up and move the proximal pharynx by about the proximal pharynx by about 20 degrees. Still, the joint is moving 30 up and 20 down. So 30 plus the 20 I've done. So this dorsiflexion for you become a 50 degrees. Again, this is the joint arthritic and grade two have a dorsal osteophyte which is limiting the dorsiflexion to 30 degree and blunter fraction to 20 degree. What I will do, I will do an osteo closing which osteotomy here dorsally base dorsally. So the the the, the approximal fx, we have this degree of angulation. This is this become the normal for it now, which is about 20 degree and the joint is moving 30 up and 20 that one as it is before the osteotomy. So you have 50 degree of dorsiflex because you're as as if you understand what I said, you have your two off coming from the movement of the distal pharynx. So the distal NYX will be already on 50 degree, 20 degree from my osteotomy and 30 degree which the joint has before the osteotomy. Is that clear? Yeah, I think so. Yeah, it's a, it's a question from Mister Mohammed. I think so. It's here now. Yeah. So joint dorsal with do five limited the dorsiflexion which should be normally 70 to 30 degrees. So move 30 up, 20 down what I do dorsal closing, which I make this this ban deform it by 20 degrees up with a 30 degree movement in the joint. So the distal falx is dorsiflex about 50 degrees 20 from my osteotomy and 30 from the arthritic joint. Yeah. OK. Thank you. No. Uh The second condition you will have from the leos will be the overriding or overlapping fifth toe or cross over to. And to be honest, we see this a lot in the uh young kids and just very young age and only the severe cases which we need something to be done. Other than this, they almost it almost unnoticed is very commonly to be congenital. So the patient is born with it. So basically what happened there is either contraction of the extensor digitorum longus which is boring the two up all the time. That's why it found a way to go immediately because the line, the line of ball of the extensor, if you imagine with this is the foot, the line of both of the extensor is not that it is there. So it aim for it normally, if it does normally go, it always do an extension. If it doesn't normally go, it always do extension. And Vargas again, IV I'm sorry, the line of both of the extensor digitorum is not, is not hair, the extensor digitorum tendon, the common common extender start hair and 10, 4 branches. So the line of all of the extensor is hair, not there. So if this toe is extended and find the space to go and virus, the line of all of the extensor digitorum will be extending and virus. That's why with contraction of the extensor digitorum, you always found this toe is over letting the force or crossing over the other. The other cause if extensor digitorum is not contracted is to lose the blader structure like rupture, var blade, rupture of lateral collateral ligaments. If rupture of var blade or lateral collateral ligaments, there is no strain here. You are. You have to understand that your toes to, to maintain in this position. There is the normal arcade of your toes is like that and it's like that because the tone tone of the extensors is less than the tune of the fixers. That's why the the attitude of the, of the, of the, of the toe is in a bit of flexion. When you have any problem of this balance, either the extensor are taking or overpowering or taking a president or the blunt structure are getting weaker, the var plate and the lateral collas, the situation will be is hyper extension and MTB. And as I told you, because the line of both of the extensor digitorum is not straight. It's coming in varus, the toe will go on crossing over. So the balance for your toes to maintain in this position, have a look in your foot at the moment, your toes will be like that. The lesser toes would be like that. They are like that because the var blade is intact, do the capsule is intact. Extensor tendon is intact. Flexor tendon is intact and all balance it. Normally the flexors are stronger than the extensors. That's why your toe. As you can see, flexors is overpowering. Toe is not like that. Those toeses are like that when you have any disturbance of this balance, either the extensors are taking are getting overpowered and when taking overpower, the hyper extend hair and because the line of ball is coming from the media side, the to go into virus and overlap, the same action will happen if the extensors are normal, but the volar structures get damaged like the rupture of volar plate or lateral collateral. So there is no more restrain in the plantar surface. That's why MTB will go in hyper extension and then the toe will go into virus. It can affect the, the second to overlap the third or the 4th 5th to overlap the fourth. So if the patient starts to complain. Mostly this patient will not complain. But if they start to complain, unfortunately, the only option is to recorrect it by the Bala procedure. And to understand the butler procedure have a look on the image on the right side. This is how the toe will be extended. And inverse. So what you do, you just do a V cut here like a racket incision, then you release the extensor digitorum, You do extensor digitorum, tenotomy and a dorset capsule release. And then what you do, you bow the toe to this side, then your racket incision will become a ay rather than a V. So you start here, you have a V or racket incision, then you release the extensor digitorum, you release the dorsal capsule, you b the to back in place. What will happen? This will make the V into Y, then you close the Y the problem with this, it does very, very good correction. But the problem is a digital visits because you, the, the vessels are adapted to this position for years. When you correct the toe, you do stretch over the media uh over the media, digital vessels. And it's a very risky on the, on the vascularity of the toe. That's why you have to keep an eye on this toe until it's blinking again, until it's back, back pink again. So butler procedure again as va any vy anywhere you do a V incision, a racket incision release extensor digitorum, release dorsal capsule b the toe back in place. This will create from the va Y shape. Then you close the Y shape as you can see here, you have to warn your vision. You have to be careful about the digital vi results because you stretch the digital visits on the media side. And there's a risk of this to, to become ischemic. Then the, the K two and the K two is, it's basically rather than overlapping, is under lapping commonly to having the third or fourth toe. And we see it very, very commonly in the very young chil Children. As you can see these fees underneath all of these patient doesn't complain. And if they start to complain, we just do a tenotomy by a needle. So we need the tenotomy, the tendon here. This will release the, the, the, the, the, the toe and the toe will be back in a normal position. So, rather than overlapping as we ag agreed before the currently toe is under, under lapping. So because it's under lapping again, it's more powerful flexion than extension. And if the patient started to complain, easily, go here and do ateny of the flexor tendon and the toe will be correcting. So then you come to the common uh deformities which happen in the in combination or as a result of the helix valgus especially, or the flat foot especially. And I need you to concentrate a lot on this picture, you need to understand the difference between the three. So mallet toe, exactly like the mallet finger. What you have, what happened? You lost the power of the extensor digitorum longus, either the tendon rupture, either the, the, the dis of the bone, whatever the cause. So all what you have is flection of the distal pyx only. So ma toe is exactly as the ma finger. You have the me finger when the extensor digitorum, L is ruptured or um valve. It so you have a flexion of the, of the D IV only flexion of the distal nix only if the flexion of the Disi is associated with hyper extension in the MTB joint, flexion of the hyper extension, the MDB joint flexion in the B IB joint and extension, the D IB which resemble what's called uh uh Boer deformity. This is what we call a hammer toe. So your hammer toe is flexion at the B IB, not in the D IB with extension at the D IB. And I will explain you clinically. Um I'm sorry, mechanically how this happens. Kloo basically is hyper flection. So you have flexion over B IB and D IB. Again, mallet means loss of the long extensor digitorum, either by avulsion or rupture or whatever the cause. So it has a flexion at the D IB only Kloo is flexion, the D IB and B IB and this is occur when there is over flection bar and I'll explain to you why again now. And Hummer two is the other way around when there is a flexion in the V IB but hyper extension in uh uh the D IB. OK. So to explain you basically, this is very simple man to the extensor digital known as ruptured eval whatever. There is no more extension power in the, in the, in the distal fx. So the the flexor tendon, the long flexor tendon takes over, takes action takes over power. So flex is this uh um distal distal fun with the clo to this is commonly to happen with the neurological conditions. And as we agreed from a minute ago that flexors are normally overpowering the extensors. So when the patient have a neurological conditions, which is causing muscle contracture or muscle overpower, the flexor will stay overpower the extensor. So it will flex the B IB and the B IB and, and as a, as a result, the MTB will be extended. Remember from the first lecture MTB is moved by intrinsics while B IB and D IB are moved by the long flexors because the MTB is not moved by the long flexors or long extensors by the long tendons. It's just by intrinsic muscles. That's why it, it moves just as a compensation for what happens in the D IB and B IB. So when the patient have a neurological condition, there is overpower of the flexors, which is normally overpowering the extensors and this end by the flexor is flexing the B IB and D IB. And as a reflection that MTB joint will be extended, this is how the close to happens come to the hammer two, the hammer two, the commonest cause of it is attenuation of the blunter plate when you have an attenuation of the blunter plate. So there is nothing that restraining the MTB in place. So what happens the MTB go into dorsiflexion and because the MTB is extending, normally, the flexor tendons will, will flex the B IB joint. The problem was that the difference in D IB is because the intrinsics here are not functioning well. So it's always under contraction of the flexors. And that's why the D IB joint is extended. Again, meri toe has a merit finger. All what you lost is the long flex, long extensors. So the long flexors will be overpowered and flexing the D IB and the Disi only clo to happen with neurological conditions when the patient has neurological problem, which is causing muscle contraction or overpower. And because normally the flexors are overpowering the extensors, the toe would be flexed at D IB and D IB joint. And as a compensation, MTB would be extended, this is totally different than the hammer toe when the problem mainly in the MTB blunter blade attenuation. So the there is no more restrained bluntly. So the intrinsics will b the MTB joint dorsally and causing the extensor mechanism to be into action and flexor tendon will B the B IV in flexion. While the intrinsics because of the extension extension uh uh uh the, the extensor pando is extensor mechanism. The D IV will be an extension blunter blade that this is the most important. This is where the, this is very simple for again, the hammer two, the problem is start in the blunter plate, blunter blade attenuation intrinsics because there is no more restrain here, intrinsics will be bing the proximal nix into extension. And at the same time, they both the extensor mechanism into action. That's why the D IB joint will be extended flexor tendon because the MTB has extended, the flexor tendon will be shortened. So it will B on the V IB and causing B IB flexion. And this is how this po deformity or hammer to happens flexion at the B IB and extension at the D IB Hosam. Is this clear? Yes. Yeah, I think so. Yeah. OK. So how we treat this? What's the problem with this patient? The problem with the man toe will be hitting the ground by a distal phoenix. The problem with the cla toe that this part of the toe will be rubbing against the shoes and patient will be unhappy and same for them. Hammer toe. The main problem is uh OC here and, and rubbing against the shoes at the P IP joint. So if the patient is still early, especially with the manic toe. What we will do just a manic splint as you normal do with a male finger. So you bought a man splint which keep the D IB in extension. So give a chance for the tendon to heal or for the avulsion uh for a via fracture to heal or to unite. If the patient is still flexible here or there, the main problem is it's not in the flexor, but the flexor is the main powering deforming force. So what we will do just pectinous F DL tenotomy when you release the F DL here, that there is no more extension. So this will release the power if the patient become in a fixed deformity or dislocated. So the option we have is to do what's called SB procedure. So we excise the distal part of the, of the proximal, the proximal part of the proximal nix. Just to shorten the toe, we release the uh extensors and both the extensors into the blader plate. So maintain the toe floating, but balance it me to early will both just a splint and the splint will maintain the, the IV and extension until the tendon heals, the avulsion fracture unites close to what we will do. We go and we uh release the flexor digitorum longus. And this is we release the whole clot to because the, the main deforming force is the flexor digitorum hammer. To what we will do is early, we release just the flexor lo um uh the extensor digitorum longus. If later, what we will do either we do uh B IV or B IBR or we just Splint, uh uh or we just do A B procedure excise this, bro, bro, on both of the Broman. Next, get release the extensor tendon and attach to the blunter blade. So the toe will be balance it from up and down shorten because of the excision of the plan of the proximal nix. And this will get the hammer toe back to normal when we speak about the hammer two specifically, we merely done everything. It's the most common. Lesser two deformity commonly happens as a result of attenuation of the blunter blade. And this is commonly happens with flat foot and valgus helix vuls the problem as we agreed callosity at the B IB joint because rubbing against the shoes, you have to check if the patient is correctable or not or to do a specific test like the Lachman test in the knee. So you just do a Lachman test. You hold the metatarsal in one hand, hold the approximate pharynx in one hand and do a lament test to ensure if the joint is stable or not. If the joint is still stable, we still have a chance with stenotis. If the vision is not stable, we don't have an option except sts b definitely we start with some non operative treatment. Give the patient some bending white, two box extra deep box. Uh And if the vision doesn't respond, the option we have is a release if still flexible, blunt a blade, especially if the patient is young. And uh it's, it's not rheumatoid. And if nothing of this helps. So we go for either a virus osteotomy or a 10 B to explain you how we do the V. So basically, your problem with the hammer too is if it become inflexible, your problem is this is already the m the MTB joint is already dislocated. So you see the proximal pha is very high up. OK. And all what you need is to b this down, you all this down by I one or two procedure, either you shorten the pyx or you shorten the metatarsal. How you shorten the metatarsal by uh uh virus osteotomy. So basically what you do, you cut here and when you cut here, you slide the head back, so you shorten the metatarsal. So you shorten the whole toe. So you give a chance for all this to come back in place, you stick a wire in. So your, your toe would be back in place. The other option, especially if the patient rheumatoid or the patient is old age or the uh bone quality is not the greatest for osteotomy is to go. As you can see in this picture, cut this part of the Brox Me Fendi, the most approx part of the Brox Me Fendi release the extensor tendon pull the extensor tendon into the uh buller plate or the flexor tendon and just stick a wire in. So the toe will be shortened and straight again. We agree the hammer to, sorry. OK. We agree that the hammer to, if it's still very early, we can do non operative treatment. Y two box, extra depth box, uh silicon back cover whatever you want. If the two is not uh is not flexible anymore, the options we have either we have to get this to short, to take it to make it short. Either we shorten the metatarsal or shorten the proximal phoenix, shortening, the metatarsal will be with virus osteotomy and virus osteotomy. Basically, we do a cut here we go from the upper third of the articular surface and we go in, I'm sorry, parallel to the ground. And because we barrel to the ground, we can slide the meth to and hit back and shorten the toe. And this will release all the will be function all these muscles. So the toe can come back straight and we stick a wire in. If the patient is very old, while we we risky to both osteotomy, there is no, there is a risk of nonunion. You cannot depend on that. So the option you have is to shorten it from the proximal pharynx, cut. The proximal part of the approximate proximal third of the proximal pharynx, release the extensor tendon, both the extensor tendon and attach it to the flexor tendon or the blan plate, this will shorten the toe, make it straight, stick a wire in. And this will end by a floating toe. To be honest, not the greatest operation again, as the killer's arthroplasty uh killers. So that in the halos, because it end by floating to nothing to hold the toe in. Once you remove your wire, the tool is floating and the patient doesn't like it. Wires is much, much better option. But the problem with wires, you have to have a good quality bone for the virus to heal. Otherwise, the vision will be in a problem when we speak about the clot to we agree that clotho is, the problem is mostly neurological. Once you see a clot to, you have to think about neurology, especially if this clotho is associated with uh cavus clotho and cavus equal neurology until proven. Otherwise, this patient has to see a neurologist before you touch him or her vision will come mainly because this is a neurology. There is a lot of muscle action, the muscle, uh the muscle will be exhausted, the patient will come with hold for foot pain and definitely over rubbing of uh the b the flexed B IB against the shoes. The problem of this vision as we agreed is the over overpower of the flexor tendons over the extensors and this is aggravated by the neuromuscular condition. Uh It may happen again as we agreed because of the rheumatoid arthritis and uh um and uh attenuation of the soft tissue happened with the KVAS foot and we explained, explained this already in the cavus foot. Definitely, if you have a previous compartment syndrome and already the uh flexors are contracted, give the, gives you the same uh problem. So the common is to be neuromuscular and contraction or over action of the flexor muscles could be hematoid, could be a cava foot which again, a neurological condition could be a previous compartment of the uh flexors and contraction of the flexors which give you the picture of clots if the clot is still flexible. So it means it's still the muscles just imbalance it. And this is the time you can uh do a tenotomy flex your tono toy and release the tendons and uh get the f the toe straight away uh straight again. Uh or if it become fixed, this means the joint has been damaged because mostly it's a long standing. And this is when you have the option of doing a stent again, either shorten the proximal phx ball, it back, release the tendon and stick a wire in. So, clo two is neurological until proven. Otherwise, this is the most important message about the clo twos. Uh Now we'll go to the neurological condition of the foot. They are always overlooked game. They, if you go back and, and, and compare how many cases have you seen in your practice with a tarsal tunnel compared to a carpal tunnel, you will definitely spot that the tarsal tunnel is very under locked and the carpal tunnel is very, very overlooked. So, uh I can argue how many cases you have seen of tarsal tunnel and I'm sure it's not a lot. So a as we do with the carpal tunnel, you need to understand the anatomy of the tarsal tunnel. Tarsal tunnel is just behind your median Manulis. And uh it's, it's, it's triangular in shape. The anterior for it is the median manus. The lateral for it is a and calcium and the cover of it or the top of it is the flexor retinaculum. It has inside the tip post, flexor, digitorum, artery vein nerve and flexor houses tip post F DL, artery vein nerve and F HL. What the patient will come to complain with. He will mainly complaining from pain mainly in the media side. As you can see, the main compression will be over the tibial nerve and the most affected is the media plantar nerve patient will come with media foot and it's always vague pain, maybe having neurological symptoms like burning paras. And this definitely works with exercise because the muscles if you, if you have seen before, so that F HL and F DL, especially the F HL is muscular, still a very low level. And with exercise, the F HL gets bigger and this is make more combination inside the tunnel. And that's why the symptoms get worse with exercise when you examine exactly at the carpal tunnel. If you put your hand over the tarsal tunnel in the patient, the symptoms would be uh uh uh aggravated. The, the parasthesia and vein will be aggravated. You can do a Tinel sign, you can do uh a failing uh test. Same as you do for a carpal tunnel. The commonest to cause a problem in the tarsal tunnel is either intrinsic or extrinsic. So, intrinsic like a tendon cheese ganglion, ateny, novi lipoma, exostosis, anything. Anything which comes intrinsically from inside the uh the the tunnel, what come from inside the tunnel, tendon ganglion from a tendon sheath, tenosynovitis and inflammation and swelling of the tendon sheath lipoma or exostosis or osteophytes. All these are intrinsics to the tunnel. Other than this, it'd be maybe an extrinsic which like and post scarring if you're operating at this area. And this is definitely very worse prognosis because even releasing the tunnel will not solve the problem because the compression comes from outside the tunnel, not from inside the tunnel. Remember? Uh And this is uh a technical tip. Uh You are not hearing anywhere. The tarsal tunnel is always, always, always uh uh you always miss approximate injury. Oh I'm sorry, approximate lesion. So when you have a tarsal tunnel, don't be distracted by the tarsal tunnel. Only always do a AAA full scan for the vision starting from the knee. It's very, very common to miss approximate lesion or approximate interact or approximal compression and you just uh concentrating on other sub from my experience tarsal tunnel um in itself as an intrinsics is not that common. The common uh is the symptom and the symptom who is there is not only the tarsal tunnel, but it's more commoner to have approximate lesion. OK. Uh Yes. Just a question from uh what is the rule of the tendon transfer and standby procedure? Oh, so, ahmed, if you have a lock in the, I didn't, we didn't do a tendon transfer, but basically, if you release the extensor and, and remember you are not, you are not at the time of putting the wire when you get the wire off and the extensors are already, um, are already to not to 10. So the flexor is only working, what will happen this to would flex you need to have the sens working on the to benefit. So you did turn out to me of the extensor and the flexor is still intact. Once you remove your wire, the flexor will be bowing the 10, the, the toe down and this will make the toe, uh, rubbing against the ground. What you want. What you want to do is to maintain the tendons acting on this uh, toe balance it. That's why the, the, the, the tt the extensor tendon is reattached to the flexor. So when the flexor go into action, after you leave, you release your uh wire, it will be extending and flexing at the same, at the same power. So the, the toe will be balanced. You cut proximal fendi, you get the extensor tendon toat. Once you do a tenotomy of the extensor tendon, the flexor is still intact. Sorry, the flexor is still intact. You both your wire, the toe will be straight once you remove your wire because you have did a tenotomy of extensor without the flexor, the flexor will be pulling the, the, the toe down, especially remember the toe is floating, there is no TB joint anymore. When it pull it down, the problem of the vision will be more because this toe will be rubbing against the ground to avoid this. You just get the distal part of the extensor tendon which you did uh tenotomy, attach it to the blan a plate or the flexor tendon. And because attach it there, it doesn't allow the tendon to flex. So even if the tendon try to flex the toe, the extensor which is attached to the tendon itself or the blader plate will maintain the toe balance it and this is in by the toe floating. Yes. What floating is straight, not flex, it not extended. I hope this is clear. It's not a transfer or what we do is just get the extensor tendon, which is neat back to the flexor tendon or the blader blade, but not to allow the flexor tendon later on after we remove the wire to bolt the toe down or to b the toe into blader uh position because the patient problem would be more in this condition because when the, the flexor tendon blunter, the, the toe will be rubbing against the ground and the patients symptoms will be much, much worse. So all what we do is just attach the extensor which is already uh had a tenotomy to the flexor to maintain the two straight. Ok. Um If you start investigation, same as any sorry, same as as any entrapment syndrome. So any entrapment nerve entrapment syndrome, any other anywhere in the body. What you do, you do a nerve conduction A MG and you do MRI scan to detect any local compression cause. So A MG will be waiting in early stage just for a delayed speed uh and and increase latency and later on if the, the nerves start to be degenerating, the amplitude of the of the of the uh nerve waves will be low. So early stage is just delayed uh grade transmission, which is the nerve is still in neuropraxia. So it will be a decreased beat and a prolonged latency. Uh at later stage, when the nerve, the compression is long standing and the nerve starts to degenerate will be decreasing the amplitude of the, of the uh nerve waves. And my scan will respond to you what is compressing the nerve inside. So we'll show you if there is a ganglion. If there is a lipoma, if there is an exostosis, whatever and the treatment, definitely non operative treatment. If the vision is an early stage, if the patient starts to have motor weakness, especially in the abduction of the hallux, so you have to do and go and surgically release it. Remember, surgical release is very successful. If you're sure that the lesion is in the tarsal tunnel. Don't forget to to check if there is approximate lesion or not. When you ask for an MRI scan, don't ask for MRI scan of the hind foot, ask for MRI scan of the whole leg because it's not uncommon to have approximate in interment or compression and the symptoms are tarsal tunnel uh syndrome symptoms. So, and if you release at with a with with missing approximate lesion vision will not get any benefit. So, remember, proximal compression or entrapment is not uncommon with tarsal tunnel. So always check the nerve approximately before you commit to release the tarsal tunnel. If there is no proximal lesion and you really release and it's, and it's an actual tarsal tunnel in the room. If you release the tarsal tunnel, patient will get benefit in 85%. The other tunnel we have because the the tendon uh the the foot has three retinaculum. So three compartment, posterior, anterior and lateral. So there is flexor extensor and per retinaculum. The other tunnel we have is the anterior tarsal tunnel syndrome. And this is will be compressing the deep peroneal nerve. And um uh again, the car, the anterior tarsal tunnel is a space under the severe extensor retinaculum. As we all agree behind would be the rest the tibia cover will be the extensor, uh severe extensor retinaculum. What moves in is tibia anterior, the A a HL the nerve artery vein, the artery nerve vein, then the um edl, then the it's about one centimeter approximate to your ankle. And uh the cause is again, same as tarsal tunnel. Either something coming from inside the tunnel like a ganglion like a osteophytes, like uh a tumor like a 10 adeno synovitis, same story or extensor, extensor uh exos and Benjamin and mostly either patient using high heat. And because patient vision is using the high heme, the patient is both uh the extensor retinaculum into very stretch position and it's compressing over the nerve. The other one is to have a very tight glasses or uh uh uh ski boots. And if the patient has a trauma to this side, especially if the vision has a recurrent instability of the ankle. Most of the anterior tarsal tunnel are treated conservatively because most of the causes are extrinsic rather than the tarsal tunnel. So all what you need is just show, show modification, ask the patient to stop the activities which is causing the anterior tarsal tunnel. And if there is no, there is no uh improvement with the uh conservative treatment, you can go and release uh the extensive retina clam or remove the osteophyte or treat whatever the cause, which is compressing the deeper nerve mots, neuroma, the most common complaint, the patient come to foot and ankle Clinique, uh very, very common. And unfortunately, it is a misnomer. It's not a neuroma. Basically, Mortons is not a neuroma. It's a synovial thickening and to understand the Mortons, your digital nerve, you have to understand where is the digital nerve running. Yeah, if you see the digital nerve here, so tibial nerve ended by a calcemia branch, medial blunter, which is the major branch and later blunter, medial blunter play the role of the media nerve in the hand. So supply the media three and huffing uh toes. Every digital nerve as you can see comes to this place and spread into two digit, two small digital branches, one for every side of the toe. The point is this digital nerve come underneath the transverse um uh metatarsal ligament. And when you have any cause of 4 ft overloading, you're basically compressing the nerve against the ligament. And that's why the nerve start to have a synovial thickening. And this is what we call ma neuroma. Again, tibia nerve coming from the back have three branches, branch, media, plantar branch is the biggest one. Later planter media blader goes up to the web space and it starts to d to uh divide into two branch, two digital branches going to e either side of the, of the toes. The problem is the nerve, the digital nerve goes underneath the extensor, I'm sorry, the transverse metarsal ligament. So it is between the transverse tarsal ligament and the blan surface. So when you have any cause of overloading the forefoot, flat foot, um uh u using a high heels, uh uh achilles, achilles, uh uh contracture or, or uh gastro contracture. So if you're overloading your forefoot, you with every step, you're compressing the nerve between the extent the, the transverse metatarsal ligament and the ground. And this end by the nerve, synovial seems to thicken and this synovia thickening around the nerve, what's called motors neuroma by mistake. So, the, the the cause of co of, of, of, of uh uh um calling it neuroma is to give the same symptoms, vision will have a pain and cha cha very characteristic pain, the vision will tell you that I feel like it's a foreign body under my foot. When you hear the bo the the complaint of uh foreign body under my foot remembers mortals, neuroma. Then the pain will be burning type or shooting type. It's a nerve type pain, it goes between the toes and it may be associated with something like a numbness and always aggravated by anything which cause forefoot, overloading because this is how the neuroma happens or how the Synovia thickening which we call Mortons neuroma habits. When you examine, you have firstly to examine for the cause to have a look on the foot, ensure there is no flat foot, there is no hallux vuls because if you have any of these, you need to warn your patient that whatever you do for the neuroma risk of recurrence of neuroma is high because we haven't treated the course, which is 4 ft overloading. When you put your hand, there will be tenderness in the we space. The common is, is the third web space. The second common is the second obi space. So it's commonly to have it in the 3rd and 2nd and very rare to have it in the first. When it happen the second or third, it will be tender over the OBY space and when you compress the toes together. So when you compress the toes, you just squeezing the OBY space. And when you the OBY space, the neuroma will pop up or down. So you will hear what's called molders, click and the motor click will be a sound of click and the patient will be uh complaining of pain. And this happens when you squeeze the forefoot with the squeezing the forefoot, you don't leave a space for the neuroma in the open space because you tighten the open space. Neuroma will kept up or down and then the patient will feel pain and you will hear molars click anatomy. As we explained differential diagnosis, any problem in the forefoot, MTB joint, sinusitis, elongated second toe any problem, blunt or war uh metatarsal head, avascular necrosis, stress fracture. So don't take it simply patient come to you complaining of full foot pain under the second metatarsal head. It's just mortals. No Mortons will be specifically, patient will be coming with sensation of foreign body under the foot, uh tenderness in the second or third space wherever the neuroma is and both the mos click and it's still it is a suspicious, not a diagnosis. So don't take it simply always search for other um major causes. All the other causes, all the differentials are risky. Motor neoma is just a pain. It's nothing, nothing risky. But if the patient have a stress fracture, have a AVN of empty of mi and head at any other cause, you have to exclude other causes or you have to have a diagnosis of Mortons by ultrasound or MRI scan before you just relax your mind and say it's I Mortons investigation. The Communist investigation is ultrasound. We send the patient uh for ultrasound to do assessment and we asked them if you find a neuroma believe injected with the steroids, injection with the steroids play two rules rule number one is diagnostic. Uh So if, if the patient being improves this me means definitely it is a neuroma. So ultrasound assessment, if you find a neuroma in injected with the steroids, if the patient improves, this is definitely a neuroma. If the patient, if, if the ultrasound couldn't see it. And the, the all the clinical symptoms are proceeding with uh mortage neuroma. Patient will need an MRI scan treatment. Conservative treatment is, is perfect in treating the moto neuroma. Most of the patient respond to uh uh conservative treatment if they don't have a very clear cause of overloading the forefoot. So our non operative treatment will be in the form of Y two box. Ask the patient not to do any, any uh exercise or something which cause the patient to over foot. The uh overload the forefoot. Uh If patient is not responding, the next step will be ultrasound guided injection in the neuroma. And you can repeat this twice or even three times. And patient do respond very, very, very well to uh ultrasound guided injection of neuromas. If there is no option and you repeated the ultrasound, get injection many times. Patient is still complaining. So the option you have is to excise it and to excise it. Uh uh uh surgically, you have to go from the dorsal service. We avoid the blunter service because the B blan or skin is, is very bad to, to heal. So we avoid any B blann or W we go dorsally between in the, in the whip space, either second or third, whatever the will be space in the neuroma in you go, you put the lamina spreader, you divide the ligament because as we agree, the nerve comes underneath the transmitter ligament, you just divide the ligament, you will see the neuroma when you push from the blan surface, neuroma will come into place. You have to dis stick around the neuroma approximately and distally and try to cut it, cut the nerve as far approximate as you can just to allow the nerve and the tension, especially to allow the nerve to ball back into the muscle. So you don't have some neuroma later on. So again, dorsal incision over the web space, lamina spreader to open the two metatarsal to get the a metatarsal head away and put the ligament under tension, divide the ligament, the neuroma will pop up once neuroma bs. But if it doesn't push it from the bladder surface, it will b in front of you detect approximately as much as you can detect this day to see the two digital nerves. And then I can see you have pictures of that. And um when you cut bone, the neuroma get the nerve under tension and cut very, very proximate as much as you can. So once you cut proximately under tension, nerve will retract inside the, the, the uh the muscles. And once the nerve retract inside the muscle, it will be safe from getting a a stump neuroma. If you leave the nerve long patient will come again with the symptoms, symptoms and it is not a motor neuroma. It, it is a stump neuroma. It's an iatrogenic mo the neuroma you caused because you cut the nerve very distant. So the tricky point here is to cut the nerve as far proximate as you can and under tension to allow the nerve to retract and embed inside the muscle. So there is no stump neuroma. And then you detect the two dial nerve, uh warn your patient that the patient will be numb in this area for a good 3 to 6 months until the other digital nerve on both sides start to cover this area. Most of this patient regain the sensation as normal and if not very small batch of numb or tingly area, which is not appropriate for the patient. Uh Last neurological condition is a foot drop and foot drop. Basically because of the problem with uh tip and is as you know, any cause any neurological cause which will make the tip ant weak will cause a foot drop starting from the brain up all the neuro axial uh the neuroaxis uh problems, stroke, head injury, nerve injury, spinal cord injury, lumbar radiculopathy, compression in the back, uh uh char coitus, whatever neurological cause will end by the the foot dropped. And once the foot dropped, you know that the problem is with the tia and you are not walking. Your main problem will be the gait, you will walk with high ST gait when you flex the knee and have to declare the foot from the ground. And our management to this study was just an Ortho this to keep the foot up physiotherapy. And definitely, if there is no response, the option we have is to transfer the tendon and transferring the tendon should be within 3 to 6 months. More than this. The option you have will be is to fuse the hind foot and keep the foot in a Blute grade position. So to allow the patient to walk normally, last of this lecture, not to be, not to take very long is the tendon problems and the tendon problems I'll be concentrating on the most important. First of them is the peroneal tendon subluxation. It's again, one of the unlocked conditions of the foot patient come to uh complain from a pain uh behind the lateral mars uh after a sudden for eer and the main problem with the patient while he is walking, he feel clicking, he feel instability, he feel like that the, the foot will invert and he feel like a especially with dorsiflexion. This what happened the, the dislocation or subluxation of the veneer tendon. It's either the veneer tendon subluxing from the groove in the lateral mass or there is some and that this is a more difficult if the if the tendons are, are dislocating inside the sheath, when the tendons are moving, are changing their position. So there is an insight to dislocation between the brunneus tos and brevis inside the brunia sheath or the easy. And the frank one is a brunnea tendon subluxation from the groove behind the lateral mas, the problem of this patient because the tendons are not in the normal groove. There was the bow of the, there is no liver. So the the lateral mars for these tendons act as a fal cramp. And if there is no f cramp, the tendons will be weak, there will be weak eer. So uh the problem with this patient will be weak aversion and more prone in inversion. We all know the anatomy. All I need, you know to, to spot from the anatomy is that the Benes is this picture. And if you can see here, the Benne Longus, the bene fungus is just involving in the brunneus brevus Bernes brevis is more anterior and more lateral. And brunneus fungus is more media and more posterior. So basically, Brevi is a be brevis is close to the bone and it's more uh and you can just differentiate them when you open the sheath is the be b is more fleshy to a distal distal end. While the venus fungus is more tendinous. When you open here, the fleshy one will be the venus brevis. The tendinous one will be the fungus both supplied by the superficial perineal nerve, both are maintained in place by uh uh retinaculum, sever and inferior per retinaculum. And both of them bust just over the perineal tubercle of the calcaneum. Before they go to their insertion. The peroneal leave is in, in the basal and per fun in there in the, in the ba and the and the media can with the subluxation patient uh will come to you complaining of instability, clicking, feeling, weak aversion. And uh the diagnosis is with MRI scan. Sometimes it's very difficult to diagnose, especially if the subluxation or dislocation happened inside the sheath. And the only option is to diagnose this is ultrasound treatment if the vision is just an early stage is just maintain the vision in both or cast. And this definitely doesn't help a lot. The surgical option is to go and repair the lump if it is repairable and it's not repairable. It is to deepen the groove, the perineal groove just to make them uh more deeper in the bone. And then you can replace this uh with uh uh athesis just to get the plantaris to reconstruct to do the job of the of the veneer retinaculum if you end by no option. So the option is to make them into one tendon. So basically get attached the longest to the previous because the previous action is more important. If you have no option to reconstruct or repair. Uh the retinaculum, retrocalcaneal, this is the other tendon which has um symptoms and problems with the foot is uh the, the achilles and retro bursitis is basically, as we explained in the first lecture, is the inflammation of the bursa between the achilles and the calia. So achilles bone calcaneum, there is hair uh uh bursa which we call the retro bursa between the calcium and the achilles. This on the long standing may be a hagland deformity which is bony prominence of the severity prostate of the calcaneum or what you need to do for a patient with bursitis. Just keep the patient as much relaxed as possible. Uh Patient have a wheel bending in the shoes or whatever he bought and send the patient for ultrasound. If they found that bursitis, they can inject it with steroids, patient need to do um uh uh uh stitch exercises for the he is. And definitely in the later stage, if the vision start to complain, you have to go remove the bursa and the h when we speak about the achilles tendinopathy, you need to understand that achilles adenopathy, the patient will come to explain you pain in the achilles, unresisted, blunt affliction. If especially if the patient starts to stand tiptoe or something like that or, or the patient profession like ad or something um needs the patient to stand on tiptoe, the patient will be complaining of being on resistant blood reflection. Uh As I need you to understand this anatomy. Very, very importantly. So as you can see, the achilles is, is, is formed by the triceps sui which as we agreed before, it is triceps because gastro has median and lateral head and the soleus. So media head of estro of and so up in the lake, the sun, I move the anterior to the gastrocnemius and when they become dis they move 90 degrees as you can see here. And the f the, the anterior which is the celeus become media and the posterior which is the gastroc become lateral. So this area of the tendon, the tendon rotates 90 degrees from anterior and posterior to a median and laterally. So normally the solar is anterior to the gastroc in the approximal length. When you come to the insertion, because of 90 degrees turn this area of turn, the sole become median and the gastro gastro become lateral because of 90 degrees turn, this has a lot of ations, a lot of of effect. This turn in the tendons. Why, why, why uh God gives us this turn in the tendon? Basically, this allow the tendon to elongate and at the same time allow the the tendon to release in stored energy if he needs. So, if the tendon needs to elongate, basically, because it has it turn, if you go and stretch the tendon more than enough, this turn will correct. And this gives the tendon more less. And at the same time allow the tendon to store energy un until it needs it. The problem of this, this is the benefit. The problem of this is it's a watershed area because of this turn, this area has the least blood supply and this is the commonest area to rupture with uh injury. And this is a common area to have a tendinopathy or pathological tendon, achilles, tendinopathy is either insertional at the site of insertion of the achilles in the calcaneum or non insertional. And the mechanism be pathological mechanism behind that, that the tendon has uh the, if the tendon is a lot of action, this tendon will have microtrauma and with the repetitive trauma will have, it will will, will have a micro and micro will end micro tears will end by a degeneration. So, overaction, repetitive trauma, micro tears and will micro tears will be uh degeneration commonly to having 2 to 6 centimeter above the kinia in section where the turn happens, which is a watershed hypovascular area. How we treat the achilles tendon? Obviously see if it's non insertional. Don't worry, both the patient and air cast, the boot have give the patient something to raise the hand. So relax the achilles tendon and get the patient to do eccentric training or eccentric stretch exercises by physio. And they normally respond very well with the insertional achilles tendon. Obviously, the patient has to have may have some uh uh shockwave therapy and this is when we intervene with um surgical options. Surgical options are prone to give a good results with insertional rather than non insertional, non insertional means the tendinopathy or the pathology is in the midsubstance of the tendon and this is very difficult to treat and the results of this is not the greatest. But insertional means is uh is is an ent. So this is an problem with at the insertion of the tendon, which is easy to treat surgically what we do surgically, we go debride the tendon. If this debride in just a minimal area, we can do this arthroscopically, we can do this open. But, and if we find the Hagland, we can remove the Hagland, we can remove uh the um retrocalcaneal bursa or bursitis. If it's a big area of divide, we can deinsert the tendon and reinsert it. Using what we call the speed bridge. Speed bridge is a special device from Athrix which allow us to put four limbs inside four limbs in an eight configuration which uh by four anchors which hold the tendon very strongly back to the, to the calcium. Because if you do a proper debridement of Hagland, a proper debridement of the tendon, you will end by the tendon completely uh detach it and you need a strong device to hold it back to the calcium. And this is the speed bridge. If the problem is not insertion, as I told you, surgery is not the greatest because you have to go and do uh omy or debridement and your debridement will end by a big gap. And this big gap in the midsubstance, the only option you have is to get the F HL to do the job for it. So, Achilles interruption, uh you are not undergraduate anymore. So you need to ignore the simmons um test you have now what's called simmons triad. So to diagnose an achilles tendon rupture is not the simmons or Thompson test. It's the simmons triad and Simons triad means you feel a B bubble gap, the the position, the resting position of the foot is not blunter flexion compared to the other side. And you have a positive test, which means when you squeeze the uh the cuff, the, the foot doesn't blunter flex. So to diagnose, if you ask in the exam about achilles tendon rupture, don't say Thomson positive. No, you have to mention simmons triad. This is the the new term and simmons triad is a available gap at the achilles rupture site is abnormal resting position of the foot. So your foot will be resting in more dorsiflexion than the other side. And the third is when you squeeze or when uh your, your, your uh yeah, when you squeeze the cuff, then the foot will not bla the flex again in the exam. If you have a case, intermediate case of a kidney rupture or a viva, you need to remember that the risk factors. You have to ask about the steroids, you have to ask about the quinones. You have to ask about the we end wi wi which is the people who are keen on doing an extra extern activities over the weekend. So if the patient is, is, is, is lax all the week and uh doing whatever he is doing with no exercise and come to the week and doing very strenuous exercise and very uh uh uh uh very, very, very uh strong exertion. Uh This is at high risk of rupture in the achilles. Uh Number two patient on long term steroids. Number three patient on recent course of chemo loans because all three of them get the tendon weaker and prone to uh rupture rupture. We're having again at the same area where the the the rotation having 2 to 6 centimeter from the insertion. And our treatment for this concentrate with me because I have a lot of questions about this. Our treatment for this, your achilles will heal in either situation, non operative or operative. And you have to be very clear with your patient, achilles will heal with non operative or operative. The problem is the quality of the healing and time to healing. So with non operative measures, healing will happen. Yes, it will happen. Whatever the gap is. Yes. Whatever the gap is, the problem is with the gap more than a centimeter, this is will elongate the tendon and this will end by the muscle, very weak and the healing itself weaker and it takes more time. So the patient will be in risk of free rupture again, to be clear to your patient tendon. Will he was he with operative or non operative measures? With non operative measures, the healing, especially if the gap is big, the healing will be weaker the healing will be taking longer. The healing will end by the tendon elongated because all the gap has filled with, with fibrous tissue. So the tendon elongates. So the muscle is weak as a function will be a functional deficit. And at the end, because of all of this, the risk of rupture was not over 50 this higher on the other side, the surgical treatment carries a risk of nerve injury, especially the shoulder nerve and the risk of wound problems because as we agreed before the skin in this area is getting blood supply from perforators from the tendon. And when you dis take the tendon from the skin, you devoid you, you just you, yeah, you devoid the skin from its blood supply. And the risk of all problems is very, very high. When you decide that you will treat this patient non operatively, you have a lot of protocols, North Hamilton Protocol, Copenhagen protocol. But the commonest and the most um most commonly used in the NHS is the smart protocol, which is Swansea Morriston Achilles up treatment and this is published about 2008. It is very, very common protocol nowadays um used everywhere on the left side. This is a protocol when you see the patient in the emergency department, patient has to go uh in an equine aspa lab, not only bearing with vte prophylaxis, he has to be seen in the fracture clinic within three days when he is seen in the fracture of the clinic. This is where the debate, some people advise ultrasound for every patient and some people use the clinical sense to fill the gap. I use the clinical sense based on how my boss uh taught me. So just fill the gap. If the gap to me less than a centimeter, this patient can go on non operative treatment. If more than a centimeter, this patient will need an operative treatment unless the patient function needs are high. So if the patient is athlete, if the patient is doing any job which she needs tiptoeing, this patient will go straight away to surgical treatment. I will not depend on the gap side. GCI the patient is not athlete, his patient is not that young. His patient is not doing any function which is depend on tiptoeing. I will clinically see the patient within three days. Have a look on the gap. If the gap, I feel clinically is less than a centimeter, I will straight away put this patient to the back of the protocol which I will explain to you in a minute. Um If more than a centimeter, this is the time I will ask for ultrasound. So if the patient is generally OK, we and fit less than 5 55 centimeter but complete eruption and the gap is more than a centimeter. The smart protocol says operative uh if not conservative, conservative will be the VVI protocol and accelerated rehabil vision. My own way as I explained to you is still the smart protocol. But in a different way, I use my clinical before I need an ultrasound just to shorten the time the vision will have a decision. So the back of the protocol you see it on the right side, this is my my own practice. Oh, sorry. So basically patient in the first two weeks is in bluster. He go for uh VT for the first six weeks in total. Then at two weeks, he's nonweightbearing anticoagulation going on. Then from uh two weeks onward, he is in a va boot and this boot has wedges in the back. It started with 30 degree plantar flexion and patient starts to weight, bear as normal. And then I bought him to physio service to see him at six weeks from the injury time. Then patients start the, the, the blood test technician uh or the physiotherapy or whoever in your hospital or the Achilles Achilles Synd Clinic, uh um Podiatrist teach the patient how to reduce the angle of blood flexion. So the patient reduce the angle five degrees and normally five degrees every five days. So get it from 30 to 25 5 days then or a week, 25 to 2020 to uh sorry, 20 5 to 2020 to 1515 to to, to uh 1010 to 5. Then patient at six weeks should be in a zero degree on neutral dorsiflexion, weight bearing on his foot, starting physiotherapy to do uh eccentric um stretch exercises and carry on on that. You need to remember and remember your vision that the risk of rupture is the highest after 10 weeks. So from 10 to 21 weeks, this is the time where the rerupture will happen. That's why the patient need to be in a boot and this time carrying on his normal daily activities with if you decide for operative. So this is the protocol for non operative. If you decide for operative, your incision has to be just poster median, avoid to have a direct posterior incision over the achilles because risk of of all the problems is very, very high go poster median. Be careful about the shoulder nerve. Remember that the shoulder nerve is going from posterolateral and it crosses the midline about 10 centimeters above the calcaneum. Then it goes about two centimeter lateral to the calcaneum at the lower uh at the insertion of the achilles. Remember that the main, the main strength of your repair depend on the core sutures. The more co sutures you take, the more stronger is your repair. So 70% of your repair depend on how many core sutures you have. So either you using a Kesler or, or whatever you have, you need to use, not absorbable suture and it needs to be uh uh very, very strong, then you go uh baratin in repair and this gives you the, the the remaining 30% of strengths. So to get your uh repair is strong, you need to increase the number of course suture. You need to repair your Baratin couture's number. More than four, give you 70% strong strength and Baroin repair give you 30% strength. You have 100% strength when you weight bear a or late with bearing. The evidence says no difference between early and late weight bearing. Our current common practice is to start using very simple, very easy. If you train trained on it in a, in a wet lab or a cat lab, you will have it, you will do it very easily. We use. Now the bar system from athletes and it's very easy to do what the meta analysis, what the evidence says, the meta analysis says that operative versus non operative as I you from the start operative will have a less risk of rupture because of proper uh cooptation cooption of or of the of the end of the tendon risk of eruption is 3% compared to 13% and non operative. On the other side, the risk of infection is about 4% and risk of disturbing the the skin s instability and the wound problem is higher with the operative treatment function, bracing and a accelerated rehab protocol has an equivalent result to the surgery without complication based on you choose the right vision. So vision, not that that active, not doing any bo of activity like tennis or football or whatever uh vision is, is not formally athlete. Um Other than other than this, uh we have done a retrospective review recently about uh our vision and we found that the aed that we have using the back with protocol have a comparable result to the surgery, accepted athletes. So all the athletes were doing bad, they are not back to normal activity or function because of the weakness of the muscle. Remember I'm doing at the moment, a very big review article uh with a systematic review and a retrospective review of what Achilles tendon. And in the next 2 to 3 months, I will come out with a full review article with an a aggressive how to treat the achilles tendon for the people who sent to ask me uh about where to read the achilles tendon rupture treatment from give me 2 to 3 months and I will come to you with a very good evidence based approach to how to treat your achilles tendon ruptures if the rupture is chronic. So primary repair is uh is is become very, very, very low chance to to happen. Uh If the gap is after you go and debride the the entry of the tender refresh the end of the tender. If the gap is less than three centimeter, you still have the option to stretch the tender and direct repair if less than three, if more than three centimeters 3 to 5 centimeter. You have the option to do a VY or a turn down flap. If more than five centimeter, you definitely need to get to do an F HL transfer the VY advancement. You need to understand that the V, the avix of the V is up and down as you can see on this right side. So you do a V up, you b the tendon, just the superficial part of the tendon. This will end by a, a wire rather than a V and you close it F HL graft or it's not a graft F HL transfer. I'm sorry, this is uh misri F HL transfer is more than five centimeter. And what you do, you, you get the F HL from as distant as you can around the north of Henry and brought it up, make a tunnel in the calcium, insert the F HL and then repair the achilles over it. So the F HL is not only doing the job of the achilles, but the F HL will be making a good vascular bit for the achilles. The chronic achilles rupture to heal, tip and rupture. Remember tip, ant doesn't lacerate tip. Uh I'm sorry, uh doesn't lacerate tip and always degenerate a HL, lacerate but tip and degenerate. So when you have a tip and rupture is very, very uncommon to be traumatic option. It's mostly a degeneration rupture. So the problem is pathology of the tendon, not the trauma Yeah, there is a precipitating trauma but not traumatic. Common is to have a trauma, traumatic rupture of E hr but tip and is commonly to have a pathological eruption, not a traumatic rupture. And actually, you know, more than me, you have the tip and a beer. This is the normal tension of the tendon. If you see in the picture, commonly this happen in the middle grade, uh mid I'm sorry, middle aged people. And as I told you, it's minimal trauma, eccentric, uh uh looting on a degenerated tip ant. It's very, very uncommon to see the tip ant uh lacerated unless direct injury, cut it with a knife. It's very uncommon for the tip ant is very, very thick, strong tendon. So it's very, very rare to be traumatically isolated. Unless direct injury, it's common to be degenerated and a minor trauma precipitated the the rupture, the classic triad. You will find that rather than this clear tendon, you have a pseudotumor here, just some swelling here. Patient, the this contour of the tendon will be lost and the patient will be having a a weak dorsiflexion. And for dorsiflexion to have the, the the the patient will recruit the extensor tendons of the toes. That's why you will find the toes in hyperextension, how to treat it acutely within the first six weeks. All what you do is go and directly repair it and you need to do a proper bearing with a proper suturing if it's a chronic rupture, the option is to reconstruct. And in the problem, free construction is difficult to find the muscle which is doing the same action and in the same line of pull. But the options, we have either the E HL or the blunter F HL posology as the last one. So commonly, the F HL posology is the problem you will see with uh austrinum with atrium. There is a prominence of the posterior uh the between the media and lateral uh tubercle of the uh posterior tubercle of the talus. And there is where the F HL groove is. So it's always impinging there. And uh the rupture happened at this site. If a child come from the back, very flic until the end, then go across go posterior to the terra in the posterior in the groove between media and later tubercles, then go underneath uh the uh media ma list. Then at the note of Henry in the blunter side of the foot goes dos to uh the FF DL patient will be uh at this side of not of Henry. There is a, a lot of close connection between FDA and F DL. That's why if you harvest the F DL or F HL approximate to the not of Henry, the same act, the same function will be maintained because one tendon can do the job of two, definitely not by the same power, but at least the patient will have the function. So when you harvest the F HL or F DL, you need to be sure that this happens before not of Henry to maintain this course connections, getting the two tendons to act commonest cause of the problem of F HL is the atrium. And this is commonly happened with the people who bought the anchor number of plantar flexion like the gym, the dancers especially and the athletes, what the patient will complain. If the patient, if there is an F HL posology or F HLT Cynotis, the patient will have clicking and locking when you move the great toe, triggering, clicking and locking of when you move the great toe, you will diagnose it easily by MRI scan, it will show you the, you know cynos and and the tendon uh signal inside the tendon and the treatment firstly, to release that by an arch support. And if there is no option is go and release the F HL from the, from the fibro os stunning in the back. Thank you so much. I'm sorry, but a bit longer now. So we nearly done. So all what we need um all what we will do next time is we still have uh we still have the accessory and then accessory bones and then we'll go for trauma and trauma will be interesting, more interesting than the pathology. But it's very, very important for you to know that um uh foot and ankle is very, very enjoyable. But the people who doesn't do how no, doesn't normally do uh, foot and ankle. They feel that this, oh, all that. It is very, very simple. There's a lot of mechanics. Remember there is 28 bones in the, in the, in the, in the, in the foot. A lot of joints and you need to understand the mechanics very well to deal with the foot and ankle problems. Next lecture, maximum, maximum two lectures we've done with this, with this um project with this uh course. Next time we'll have uh the accessory bones and the trauma, maybe one or maximum uh one long lecture and one short lecture or two short lectures on the next over the next two Fridays and we're done with this and then we can think about another topic to um to, to go through and make a course about uh seven questions. Are they all done? Uh no more, no questions. No uh MRI scan. Uh MRI scan has a rule. Yes, it has a rule, but the point is uh we don't do MRI scan except if the chronic rupture with acute rupture. No, with chronic rupture of achilles. We do an MRI scan. Firstly to show us probably the tendon uh and the situation of the tendon. And we need to check the F HL as well because with a chronic rupture, there is a good chance we do an F HL transfer and we need to be sure that the F HL transfer uh that F HL is OK to do a transfer on the MRI scan has a rule only if there is a chronic rupture of activity uh or ture of acute traumatic rupture. MRI has no role. OK. Any more questions guys. OK, good. If you uh if this all, so this all for me and um again, recording will be available on all for all uh registered and um you'll receive a feedback from, uh you'll receive feedback from uh is what your feedback. It is very, very important for me to improve decision after se uh feel free to say whatever you feel, what's good, what's bad, all your comments uh are appreciated are, are will be taken on board. Um And you will receive a certificate once uh medical approve it. Uh I'm still waiting a a good primary approval for the credit hours and uh I'm waiting for the Royal College to confirm the credit hours a medication for this course. Uh the point you know that we are, we have a holiday season so everything is delayed in the UK. But yeah, as soon I will have the accretion for this uh course and all your certificates will be having a credit hours, a credit for in um Again, thank you so much for attendance and thank you so much for uh staying for more than 1.5 hours. Uh Sorry for the long lecture. And uh we are nearly there. Good luck with your exams and, uh, have a good evening. And, uh, yeah, nothing. That's ok, s any comments. Uh, thank you. Thank you. Thank you so much. Have a good evening and see you next Friday. Bye. Thank you, bye-bye.