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X-ray get a weight bearing x-ray in the weight bearing X ray. I want you to just mention that there is a halos valgus deformity or severe halos valgus deformity don't get bothered by the numbers. Don't say there is a halos valgus deformity about 30 degrees or, and the ins angle is more than 20 degree, don't get bothered about about it the the most at the most. If they gonna trick you, they gonna ask you about the normal, the normal um the nor the normal amount of the angles. So the helios angle is less than 15. The intermetatarsal angle is 10, the interphalangeal angle is 10. So remember it's 1015, 10, OK. There's something al also called DM, which is less than 10. I'm gonna come later on about it. So when you describe the X ray say this is a weight bearing X ray, there is a halo s deformity or there's a severe helos deformity, there is a systemoid subluxation and look for the joint. Look for any arthritis or incongruity here, the DMMA angle which is the essentially the relation of the joint to the metatarsal shaft. So in this, in this case I, in the, in the case on the right, the joint I the joint is incongruent which is the lesion of the helos valgus. While on the image on the left side, the the problem is in the joint alignment, it itself it is slightly offset to the to the metatarsal axis. The first metatarsal axis, the way to measure it is that you drew a line through the metatarsal axis and then ano another line perpendicular to it. And so this is the first line. The, the, the first line is the line perpendicular to the metatarsal axis, which is so uh the, the, the cursor is not, is, is not um is not present. So bear with me. And so this is the first line. The other line is the line going with the joint itself. And the angle here should be less than 10. The this is usually come, comes in the M CS. Sometimes it, it's not that important in the viva cases. But uh essentially with the, if the DM uh if the DM MA is large than 10, this is called congruent deformity. So essentially the dr the, the whole joint is the, the whole joint alignment is different. So what you need is you, you do the osteotomy to correct the deformity. You don't need um soft tissue release. While on the image on the right side, you may need lateral soft tissue release to realign the joint to each other. OK. So the management always remember to start with the conservative treatment. I remember in my exam there was a little contracture and um I went straight straight away. I was quite excited. I started talking about the limited vasectomy and needle fasciotomy and all of these things. And then the examiner told me the patient is asymptomatic. So I should have started with the conservative treatment. You have to give the patient the option of conservative treatment, conservative treatment in the form of shoe wear modification. Always, um if they, if they can have some um shoes that have a wide toolbox, sometimes uh some patients uh are having just with having of the painful areas. So for example, having the medial bunion or have um um some spaces between the toes, if they are rubbing against each other, that's maybe the whole treatment that you need. Ok. The first. So this is the first component, which is the conservative treatment. The second option is operative treatment. There are in the books. There are many, many osteotomies more. I remember more than 15 osteotomies in the books, but I'll give you three points. If you, if you know it, then that's more than enough. So for the standard Hallux valgus, you do either these scars or Chevron mastectomy. So we can, can you hear me? Yeah. OK. So for, for the, for the standard Valgus, you do either the scar or Chevron Mo due to me most uh I mean, I've seen the scarf is, is a bit more popular, but that's fine. Some people are happy with the Chevron Atriotomy plus or minus a ostectomy plus or minus lateral release and will come in a second for to, to go through these uh or this or this treatment. So this is for the standard halo swells, you either do scarf or Chevron plus or minus the others. The second, the second halos valgus treatment is if you have a hypermobile midfoot. In this case, you do first TNT fusion. The third, the third case, if you have an MTP arthritis with 100 fungus. In this case, you're gonna do a first MTP arthrodesis and the first MTP arthrodesis will come in the second talk with the heart surgery, right? So the third, the third, the third, the third pains where you have arthritis in the first MTP joint if you have inflammatory arthritis because the, the the the ligaments are not good enough. So you can have recurrence if you just do helix valgus correction with a scar ectomy. The neuromuscular diseases like CP or um or o or other neuromuscular diseases, there is a muscle imbalance. So if you just go with um with the valgus correction, you're gonna have a recurrence. So just you just need to fuse the first. So again, this is I want you to, to be aware about how to manage the helix valgus with surgery. If it is a standard helo valgus before scar or, or Chevron, if it is high Mo Mobile T and T join, then first T and TF if the first MTP joint is arthritic, then go for first MTP Arthrodesis. Sorry, Mister G. Just a quick question with the Hypomobile TMT. I haven't seen the T MT Arthrodesis before. Do you just, is it just on clinical examination? You find that? Yeah. So I II I'll, I'll, I'll, I'll come back and still, I'm gonna, I'm gonna, I'm gonna talk about the first two intensities. Um And the third one will come in the second talk with uh Mister um Emmett. Sure. Thank you. No problem. So now the scar falls due to me, the scar falls due to me. You need, you, you need to know that it is az shaped osteotomy. OK. The first, it's quite versatile. Uh Most people I've seen use the, the scar ostectomy. So if you, if you know only this ostectomy, this is more than enough. If you want to know the chair as well, that's, that's great. But I've seen the scar ostectomy. I do it for the mild, moderate and severe cases. OK. It's quite versatile. So it is az shaped osteotomy. The horizontal limb is parallel to the ground, not the first metatarsal axis. OK? The vertical limbs, I do them perpendicular to the second metatarsal axis. OK. So the, the proximal uh both the proximal and distal limbs are parallel and both of them are perpendicular to the second metal axis. OK. Now, just to remember, always remember that the distal limb is Bolson D with D and the proximal limb is planum pee with pee. Always remember this. OK. I always, and when I do a, a scar scro I just scope for a second and make sure the proximal is planting and this is, is to OK. And then you shift the osteo to me and then fix it with two screws. You need to know this osteotomy and it's a good practice in the exam if you get asked about it to draw it while talking. OK. So the vertical limb and the two horizontal limbs, OK. The other, the other ostectomy is Chevron osteotomy. Um Some people usually it is used for mild and moderate hallux valgus. I've seen some people doing it for the halo uh the, the severe hallux valgus, but I feel it is not versatile as the scar goes through to me. That is absolutely fine to know it. Um So essentially it is a V shape. Uh osteotomy. The first, the first limb is slightly the, the, the sorry, the plantar limb is almost parallel to the ground and the, the, the Toral limb is perpendicular to the second Toral shaft and then you displace the displace the ostectomy about 50% and fix it with a single screw, the lateral release or the modified MacBride procedure. Some people do it. Some people they don't, but it is good to know it. And therefore, if you say it, you have to know it. OK. So essentially you cut two structures. One is the abductal tendon as shown in the picture and the other tendon is the suspensor systemoid ligament. So it is in the, you can see it in the transverse cut where you cut the, the um dispensary ligament. So you can position the systemoid down the uh the metatarsal shaft. By the way, I have to say the, the SIDS are actually not dislocated. It's actually the, the first metatarsal shaft is the one which has moved. But the Samos are usually in position. OK. And it is called modified MacBride because the original MacBride operation or technique was to even remove the lateral sisamo, the fibular systemoid. But this is a bit quite complex and it can lead to Halo virus the other way around. So now the lad is fusion or the when you have a mental instability or instability between the uh in the T MT in the first T MT joint, how to identify it? One is by the clinical examination, you're gonna find, if you stress the T MT joints, you're gonna find some laxity. OK. And usually you can find that the intermetatarsal angle is quite significant as in this case. So um you do the la fusion, which is fusion of the first T MT joint to correct the intimate angle. I usually add um an AO for me as well. So the all the pictures are from the internet. These are not my pictures. The problem with the lapidus fusion is the rate of nonunion. You have about 10 to 15% of nonunion uh incidence in the Lady Fusion. So one of the things that I really want you to know and remember is this management scheme if you have a standard scarf or Chevron, if you have hypermobile T MT, then first T MT fusion, if you have MTP arthritis, inflammatory arthritis or neuromuscular condition, go for first MTP oral desis. One small talk about the halo valgus in adolescent population. This is a bit problematic because there is a high recurrence rate. So um it's an advice to wait until they have full skeletal maturity and always look for the first T MT hypermobility because this is probably the cause of recurrence. And I will stop here for a second if there's any questions and then we'll go for a va case.