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All right. So the second topic is le toes and your foot. It's two components. The leos uh the, the rheumatoid component, rheumatoid foot component is one of the cool topics. It's quite important and the exam, the litos uh is not that much frequent in the exam, but I will quickly go through them. It's one or two pages. That's uh one or two slides I brought them in in the start. So you don't, you don't get lost. Um But they sometimes come in the exam as association. For example, do you have a hallux valgus? And there's a another liho deformity. So it's more like getting more score. But once you've answered the hello as well as you have passed, but you, if you need more school, then you go need to know a bit more about the Latos and deformities, but I will not talk much about them. So this is the content, slightly small slides about the litodes deformities, then rheumatoid will go through the rheumatoid to. So this is the main slide in the for the uh litos deforms. These are the most common deformities starting with the mallet toe. This is a bit less common but the easiest one of them is there is a flection at the D IP joint. The hematose there is affliction at the D. So at the P IP joints and then the low toes is exactly as hemato but with hyperextension at the MTP joint. So if you remember it, the D IP joint is the mallet. The pip joint is the clo the um sorry. So the mallet is D I PPI P is the hamate toe and then MTP joint hyperextension. This is the low to OK. So the treatment is based on the description. Sorry. I again, II don't have the cursor, the option of the cursor here. So I'm just uh gonna go on, on my, on my hand. So for the mallet finger, you just do ad IP fusion. Once you align, you just align the D IP fusion and fuse it and then the, the tool will be straight for the hemato. You're due for VIP fusion and it will be straight. OK? For the clot toe, you do the same as for the hamate toe, you do the pip fusion and then to bring the MTP joint down, you need to do extensor, retinotomy, extensor tendon release, plus or minus capsule, dorsal capsular release. Usually this is enough to bring the, to bring the um the, the to, to, to make the toe straight. Sometimes you can do, you can also decompress the, the um decompress the MTP joint in case of the flow and do the vial ostectomy, which we have seen with uh mister. But um that's all about the leal's deformities. You may find it in association with halo valgus or halos and the patient is straightforward. So um quickly about the etiology, it's more common in women. And probably we know why because of the, probably because of the shoe wear, the ligament is like ST uh but also in the clot m, most likely it can be associated with other conditions like the neuromuscular conditions, compartment syndrome or rheumatoid arthritis. And again, in the management, don't forget about the conservative treatment in the books. The there is mention about whether it is flexible or fixed. OK. However, in practice, I've never seen anyone doing the dividing it this way. So um it's mentioning about extensor to flexor. So, so essentially they split the flexor tendon and burn it around the, the um the the proximal phalanx and attached to the extensor tendon. So it pushes the, it pushes the first, the 1st 12 in down. So the correction, the correction happens, but I've, I've, I've seen it once. It's quite fiddly. Uh I don't use it. I will uh my practice is either fixed or flexible. I just go for the fusion. So that's all about the Latos. I just, it's not that much common in the exam, but uh it can come as, as an additive. Now, rheumatoid thought is a core topic. So if I ask, uh, sometimes this, this topic can take you to rheumatoid, rheumatoid arthritis. So this, this question came to me in the adult pathology station. And I was, I hope once I've, I've seen the, this picture, I went my mind straight away. You went through to the treatment and the complications and all of that. But then the examiner just steered me to the rheumatoid arthritis and turned it into a basic science question. So my, my advice here is just to be as flexible as you can in the exam. Even if you are on other pathology station is fine. We can take you to basic science and or the other way around. So if I ask anyone here, what is rheumatoid arthritis? Can anyone answer please? So it's g no, no, you go, you go, you go. Uh So it's a um autoimmune condition that's characterized by symmetrical polyarthropathy of the small joints. Um and can be diagnosed according to the vise American rheumatoid Association criteria. Excellent, excellent. So have uh one line. This is an inflammatory or autoimmune condition. This is an inflammatory condition characterized by sle and extrascleral manifestation. Done. Keep this line in your mind. If I ask you what is and closing in spondylitis, same thing. It's uh an inflammatory condition characterized by skeletal and extraskeletal manifestations. II ask you about psoriatic arthritis. What is the same thing? So it gives you probably peace of mind for like 10 seconds. You can then focus on what is coming after that. Ok, quick introduction, 16% of the cases of rheumatoid arthritis, they initially present with certain medical problems. So it's quite common, you know, the other problems of the rheumatoid arthritis that comes in the exam is the cervical spine, rheumatoid arthritis and hand rheumatoid arthritis. It's usually in the, the forefoot involvement is twice the involvement of the hind foot and ankle. The pathology is you have proliferative sinusitis. This proliferation of the, the this leads to inflammation. Inflammation leads to secretion of degradative enzymes and this leads to destruction. So the main thing is destruction. Remember this. So when you destroy the ligaments, you're gonna have some luxation. When you destroy the tendons, we're gonna start with inflammation, sinusitis, ritis and then rupture. These two things can lead to, for example, dislocation of the toe uh of the toe, lesser toes giving you some um or foot deformities can lead to flat foot deformity. Remember that all we have the medial arch, the medial arch, there are some stabilizers which is either soft tissue stabilizer or B stabilizers. When you destroy the soft tissue stabilizer, which are the ligaments and the tendons, the tibialis waste, the arms will collapse. Ok. The other way around if you destroy the bone, for example, in Charco, in charco arthropathy or rheumatically shrank injuries without fixation, the will collapse. Ok. So we said the ligaments and tendons can lead to deformities and joints when you destroy the joints, you're gonna have arthritis, erosive arthritis. When you have inflammation of the subcutaneous tissue, you can end up with rheumatoid nodule. When you have inflammation of the bursa, you can have bursitis, which can be a pain source. And in between the intimate tarsal area, you can have intimate tarsal bursitis, you can have vineal bursitis anywhere. Ok. So the clinical picture, as we said, the 4 ft is most commonly affected. So you can have the involvement of the first MTP joint. So you can end up with hallux rigidus as an it said or helix valgus. The halo surgery is due to the arthritis due to the destruction by arthritis. The halos valgus is destruction of the ligaments that lead to stability and then drifting. Remember in halos valgus with rheumatoid arthritis, the treatment is usually is 81 based on the first lecture. Anyone can answer. Would you recons, would you do a scar, uh osteotomy scar for ostectomy or do something else? Fusion, fusion. Excellent. Excellent. Still alive. That's great. Thank you. Thanks. Um So this is the first, the first three, the because of the dislocation, the subluxation, you can end up with clawing with hammering. And as we said, the intermeal bursitis, as you can see in the picture and see the multiple toes deformities. Ok. So with the hind foot, you can have flat foot p planar valgus. So the arch collapses and once the arch collapses, the foot goes into the hind foot goes into valves. So remember the mid foot and high foot or combined together. So any deformities in the mid foot can fit behind foot, you can have arthritis. The arthritis can be widespread in all the joints of the hind foot or can take one joint like the ankle or the subtalar joint or the mid foot joints. And then the soft tissue component, you can have 10 sinusitis and rupture of the tendons, especially the tibia posterior. You can still have peroneal 1010 synovitis and rupture. You can, you can have bursitis, little bursitis or rheumatoid. No. So the management in any complex situations always mentioned in the exam, the MDT. So if you have diabetic foot, go for MDT. If you have complex arthroplasty, go for MDT. If you have revision arthroplasty, you mentioned the MDT. So the here will be the orthopedic surgeon, the rheumatologist, the Ortho podiatrist. Ok. And again, always start with the conservative treatment. One is make sure that the rheumatoid is under control. Medications such as anti-inflammatories do steroids. The biologic a uh fact, uh the biologic treatments, all of these has significantly improved the outcome of the rheumatoid arthritis and prevented many patients from going into deformities either in the hand or in, in feet. And we're not operating these days as we used before. Also the orthotics and shoe wear and make sure that the shoe are nice and comfy. I always, I always send the patients, especially with multiple joint involvement. I usually send them initially for custom made shoes, custom made insoles. So it supports and pad the area, the affected area in the foot and then diagnostic injections. Remember that the the pain can come from multiple sources. You don't know whether it's coming from, for, for example, from the ankle or subtalar joint or coming from the mid foot. You know, there is involvement of it's a systemic disease can be involving multiple segments of the foot. So the diagnostic injection can help you to localize the source of the infection, the the source of the pain. And also remember these patients, they have higher risk of the surgery, the wound infection and go down and these patients can need multiple surgeries. So I feel the diagnostic, the steroid injection can play a big role in management of the rheumatoid arthri, the rheumatoid foot um problems. So we have exhausted all the conservative treatment. The patient still coming with deformities. As you can see in this, in this picture on the left, see the subluxation of the litos, see the hallux valgus deformity. When you have something like this, the answer in the exam is one word is Fowler procedure. What's Fowler procedure? Essentially you fuse the first tray as we agreed with that. And then for the lesser MTP joints, you do excision, arthroplasty, you excise either the metatarsal heads or I do I excise the days of the proximal phal this is called Stree procedure. But let's stay with what is written in the book. It is one Toral incision, one dorsal incision all over the, all the metatarsal heads and you inside the metatarsal heads and then we align it with wires as you can see on the right side. A question here comes, why not fusing the lesser MP joints? Any, any idea would transfer more load into the hind foot and then cause more problems later on uh to the hind foot. You are almost there. Uncle uh it's transform tsalia to diffuse joint. So essentially the big toe, the first rate takes more than 60% of the weight. All right. So you use this because this is your base. You need the litos for more flexibility. OK? If you use one of the litos, the MTP MTP, I'm not saying about the opal. I'm saying about the metatarsophalnageal joint. This will make it a little quite stiff and once you load, it's not gonna, it's not gonna go up and down with the, with the weight bearing, it's gonna stay quite prominent in the, in the, in the plantar respiratory, the foot and gives you metatarsal later on. So you do excision of the plasty to keep the flexibility of the litos. Otherwise you're gonna have pain underneath the joint, the lesser joint that you the lesser MTP joint that you fuse. Mm OK. All right. But uh thanks for uh for your answer. Ok. So we have talked about the forefoot. Now it is the ankle and hind foot. So it's, it's really depends on whether it is a single joint involvement or multiple joint involvements. If you have deformities or, or if you don't have deformities, if you have a single joint involvement, for example, the ankle, you can do as the picture here, just ankle fusion, we can come back to the ankle later on. We can do a tar fusion if this is the source of the pain or if uh if there are multiple, multiple joint involvement or there is a deformity. For example, planovalgus deformity, you can do multiple joints. For example, here on the upper right picture, you can do a triple arthrodesis where you have used the subtalar joint tar and continue cuboid joint or if all the joints involved I in including the ankle, you can do a pantalar orthosis. However, with fusion, especially the, especially the combined fusion, you are there is there's more stressors going to the adjacent joints. You are there, you we're making the foot much more stiffer. And in the same time, the adjacent joint are already involved in involved by the uh the rheumatoid arthritis. See you may be careful before going for the for the fusion. And if you can do single joint fusion, probably better than multiple joint fusions. And this takes us to the second to the second um option, which is the replacement we have now the ankle replacement and it is evolving much better than before. Um And for example, in the isolated ankle arthritis, you can, and instead of fusing the joint and making it stiff, you can provide the option of total ankle arthroplasty. And it shows that the survival rate in rheumatoid arthritis is pretty good. So it's 90% at five years and 80% at 10 years. So this is one of the options. However, the other way the the the the the comes is that it's a bigger procedure, there's a higher risk of infection. And if it fails the ankle replacement or get infected is much, is much bigger procedure than this only fusion. Um last but not least quickly about we go quickly about the preoperative medication adjustment. So remember the methotrexate, you can continue at the preoperative period because it doesn't seem to increase the risk of infection. But it, it decreased the risk of flareups, steroids. You reduce the dose, try to reduce it less than 20 mg a day. The biological agents, you stop it one cycle before the one cycle before the surgery, which is around two weeks and you will start it about two weeks after the surgery. So remember the medication one is, you can continue as, as you are, which is the methotrexate. The other one, the biologic, you stopped and between the steroids you reduce and I'm gonna stop here before I go for a question. If I have a question and, uh, listen to any questions, please.