Computer generated transcript

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

Um but we'll see how that goes. So, um, Clubfoot is a congenital deformity. So these babies are born with Clubfoot, the foot's twisted in. And I think most orthopedic trainees, most orthopedic surgeons would recognize Clubfoot in graph like the ones on these slides, but we're going to hopefully take you one step beyond that. So Clubfoot is now the accepted term for what was variably called congenital Talipes equina virus, a complete mouthful nightmare for patients and parents and Children. Um So Clubfoot as a term has replaced that. And um, there's a push to use Club Foot as the global terminology in terms of prevalence, we're talking about 1.18 per 1000 births, um slightly lower in developed countries, slightly higher in low and middle income countries. Uh So for the population and live birth rate for the UK, you're looking at uh just under 800 babies born each year with Clubfoot in the UK, but worldwide, 100 and 76.5 1000 born with Clubfoot. So this is a uh reasonable sized global health problem that's not going anywhere. And this is what happens if you don't treat Clubfoot. So it causes a painful deformity that limits uh mobility and limits employability and access to education. And clearly, we don't want Children in the UK to or adults indeed to suffer at this level of deformity. This is an image taken from the World Health Organization website. Um And they have recognized Clubfoot as a priority area for treatment. So why is it important for your exam? So Clubfoot is one of those conditions where there's a globally recognized gold standard for its treatment. Um And not only that, but there are clear UK standards which are endorsed by our National society published free to read. Um and therefore that makes it really easily testable material. So in the exam, they're not meant to ask you about local or UK standards. But if there's a global standard, I think that's fair game. Um And really knowing the details of club foot management is therefore very important. It's also a condition you'll see later where we're following these Children to skeletal maturity. So we have clinics and clinics full of Children with a common and relatively pain free condition. So if you're to meet a child in the exam, they may well have a club foot. Ok. So we need to be able to recognize and describe a club foot. Um not just look at it in a photograph and say that's a club foot, be be able to break that down into its component deformities. And this is where perhaps it gets a little bit confusing because the terminology relates to different parts of the feet. But we, I would recommend learning it in this order and I'll explain why. So there is cus of the foot and that's to do with the mid foot and is driven by plantar flexion of the first ray. There is a ductus of the forefoot, varus of the heel, an equinus of the ankle. So cavus adductus, varus and equinus and all of these deformities are rigid. So if these deformities are there, but they're fully correctable and flexible, then that's not a true clubfoot. It's only a club foot if there is rigid deformity. So if you learn that as a cave pneumonic, that will stand you in good stead because that's the order that we correct um these different components of the deformity when we treat with ponseti. But when you are sitting in the exam, and more importantly, when you're sitting in your clinics, you need to take a holistic view of the child. So you need to start off by taking a full history and examination of that child. And if we're lucky, we may have met these parents in an antenatal setting and they may have already had some time to absorb club foot as a potential diagnosis and have had some time to read about some of the treatments, but not all um babies where a club foot is seen on antenatal exam, have a club feet and not all club feet are picked up. So this may be the first time you're meeting the family, you need to ask them about the pregnancy. Um and you need to ask them about the health of parents, other siblings, other family members. Um and then you need to do a top to toe examination. This is your opportunity to find out if the club foot is part of a syndrome or if the club foot is an idiopathic clubfoot not known to be associated with the syndrome. And the syndromes that we tend to see include spina bifida. And the picture I've chosen to represent, this shows the before and after um fetal surgery and the last two Children I treated with spina BDA had both had fetal surgery. So this does improve some of the elements of spina BDA, but unfortunately, it does not uh eliminate clubfoot in these Children. Um And so you'll be looking at the whole spine, looking for hairy patches, clefts, uh lipomas, evidence of previous surgery. We also see lots of Children with arthrogryposis. And here there may be an antenatal history of reduced fetal movements. The baby may be born with absent fraction, uh creases and the baby may have dislocated hips and in fact, dislocated knees. The other syndrome we have many in our going through our Clubfoot clinic is M multiple Pteridin syndrome. Uh these Children uh sometimes have congenital vertical tali but also frequently have club foot. Uh they characteristically have uh webbing behind the knees, uh and also uh at the elbows and then, um where I've given little red stars, these are elements of the examination that are endorsed by the Bisco er, and the Clubfoot Consensus Statement standards. So this is unambiguous, testable, auditable, this should be part of your examination. So once you've done a full examination and looked for evidence of syndromes, you need to be booking a hip ultrasound scan and that's not because the club foot is necessarily caused by a packaging defect. It's more complicated than that and, and known not to be a pure packaging defect, but it's because the syndromes that can be associated with club foot can also be associated with a dislocated hip. So it's a standard of care. We need to be thinking about the hips. And then the other thing uh that our standards recommend is peri scoring should be used at both the initial assessment and then at each visit and stage of treatment. So we'll talk about that a little bit more and it's worth just pausing to think. So this is a scoring system that is endorsed by national standards. So you learn loads and loads of classifications for the exam, but there are not many that are endorsed by national standards. Um And Guy Atherton who taught me in Bristol, he's about to be President of Bisco and he has examined for many years said that the pirani score is a pass fail element of Clubfoot questions in the exam. So for all those reasons, we really need to get our head around it. And I found it a complete nightmare. When I was a trainee, there are six elements to it and it is split into the midfoot score and the hind foot score. You can see that each element you can score either 0.5 or one. So zero is essentially a normal foot and one is a severe club foot. So the components of the midfoot score include a medial crease. And when we're talking about creases, if you have multiple fine creases, that's normal. If you will have one clear visible crease, but you can see the bottom, that would be 0.5 and then a deep crease where you can't see the bottom scores a one and that's the same for the next crease. We talk about. The next component is the curve lateral border. I like this picture of the scoring system cos it shows real life with lots of different pens in the clinic, any straight object. And then the third part of the midfoot score is palpation of um the lateral talar head and this is crucial in assessment of your ongoing ponseti management. So to find the talar head, you find the lateral malleolus and then gently uh move your thumb anterior inferior and the talar head is the next bony prominence. OK? And this is gonna be important as we go forwards, the hindfoot score is made up of uh rigid Equus, which is a movement exam. So you're loosely holding the foot in, it's comfortable maximum equinus. And then that's when you make your score, posterior crease and the crease described in the same way as before and empty heel. And when you think about the empty heel, it's similar to those lumps and bumps examination in medical school. So hard is pressing your chin, intermediate is pressing on your nose and soft is pressing on your cheek. Ok. Complete nightmare. Still a complete nightmare. Even if you've gone through each bit individually, the only way I could remember this and not get five out of six or four out of six and get in a muddle was to break it down into the way that I'd examine it. And in fact, how you examine any patient. So there are three elements you look for two that you feel for and one that you move. So 321 look, feel move and then you can arbitrarily divide it up into the hindfoot and midfoot score afterwards. But if you're struggling to remember it, I commend you do it this way. So you're looking for the medial crease, you're looking for the posterior crease. You're looking for the curved lateral border, your feeling for the empty heel and the uncovered lateral head of the talus. And then you've one element to move and that's the rigid equinus. So see if that's a better way to remember it. And why is it so important? Why is it in the standards and guidelines? And why does everyone use it? Because in most conditions, there are lots of different competing classifications. And the reason is that it actually guides up on setting management. So if you look at this graph, the total score is the solid line. Um The large dashes with the crosses are the hindfoot score and the fine dots with the squares are the midfoot score. And you can see that each week signifies a cast change and that by week four, the midfoot score has come down to zero and then stays at zero. We need the midfoot score to have reached zero before it's safe to proceed with the Tono toy. And you can see that once the Tono toy is performed at week five, the residual 2.5 points for the hindfoot score drops down to zero as well. But there are feet that don't uh behave quite normally with bonti casting and sometimes these only become apparent once you've started casting and they're referred to as atypical club feet as to having atypical features. And the main uh feature we see very commonly in these feet is a deep transverse crease that runs all the way across the foot. So not just a medial crease, it runs all the way across to the lateral border. The second common feature is the hyperextended great toe. And this is in fact because the first ray is so planta fed. And in fact, all the metatarsals are so planta fex that it gives this abnormal appearance. The feet tend to look short and fat. And this picture at the bottom shows a foot that has slipped during cast treatment. And these feet are particularly prone to that. This is a foot that um shows typical features of a slip. So it's red, it looks angry, it looks painful. There might be a little bit of skin breakdown and that deep flexion crack. Um So if you ever see a cast that slip slipped really scrutinize it and ask, is this an atypical foot? And if it is, you need to subtly modify your ponseti treatment or seek help from someone who knows how to. So we're gonna talk about ponseti next. So, er, Doctor Ponseti worked in um the United States. Uh He developed the ponseti treatment uh and this was exported to the UK in the early two thousands. And it's a very exacting uh technique of manipulation. And once you've manipulated the foot, you hold it in a cast and the cast are changed serially every 4 to 7 days. Um The a standard part of the treatment is the Achilles Tono toy. Uh And then once the foot is fully corrected, the child is treated with a maintenance regime and that maintenance regime lasts until the baby or the child is five years old. Um Casting is typically started when babies are two weeks old and it works because it utilizes the kinematics of the subtalar joint. So uh six casts are standard, the deformity is corrected in the order of the cave mnemonic. That's why that's the best way of learning the components of club foot. And the first cast addresses the cavus and then cast 2 to 5 correct the adduction and varus together using four hind foot coupling. And then the last part of the treatment is the tono which fully uh deals with the Equus and then the foot is helped held with the sixth cast. You can see that these are plaster of Paris cast, they're applied above the knee as far up into the groin as you can. And the knee is positioned with over 90 degrees of flexion. So this is uh a photo of the first cast, remember the first cast deals with the cavus. Um And the Cavus is driven by plantar flexion of the first ray. So in the first cast, what you're aiming to do is elevate the first ray so that it's then in line with the other metatarsals. And you can see that these are all lined up in the sagittal plane. Um And it's important to warn, warn the parents that sometimes the foot looks a little worse with this first cast than it did before. Um You can see just how high the plaster cast goes up right up to the nappy edge and that's important. So, cast 2 to 5, this is where you're using the tail head as the fulcrum and then the forefoot to drive a gentle reduction with hindfoot and forefoot coupling. It's really important not to touch the heel. And the endpoint is where the tail head is fully covered with an aim of 75 degrees of abduction. So before ponseti, there were other attempts at manipulation um and probably the most popularized was the kite method. Um and the Clubfoot models, which are really useful for you to understand the deformity. Most children's hospital will, will have one. So hunted out have got this big capital. No on them. And this is there because this is where kite tried to do his manipulation with a fulcrum at the anterior part of the calcaneum. But what that did was to block the link between the forefoot and the hind foot. And what it created was an iatrogenic midfoot break. So Ponseti realized that you needed to use the tailor head as the fulcrum. So you're not allowed to use this area, your thumb must be on the tailor head. And we know that this works because we look at this when we examine people every single day in clinic. So clubfoot treatment is taking the feet from uh this um inverted position where the heels sit in physiological varus. And during the clubfoot treatment, you're gradually bringing the forefoot from inversion to e version. And as you do that, the heel will swing from varus into valgus. So we know it works, we see it every day in our grown patients. OK. Uh And this is Pontis original dissection and you can see here the tail head, that's what you're feeling for. So uh later lateral malleolus um coming forwards, talar head and the navicular just falling off. And then this, this is uh the model based on that. Um So um tailor head is the fulcrum. I can't stress that enough. The heel is not touched during manipulation or um uh and care not to um disrupt it during casting. And then um the couple between the forefront and the hindfoot will uh correct uh the heel position without you uh directly touching it. So by the end of cast, five, the talar head should be fully covered, you can feel the anterior part of the calcaneus coming up and instead of a little round ball, like you can imagine from the dissection specimen, it feels more like a little rigid line. Um And you're aiming for 70 to 75 degrees of abduction, which looks, looks crazy if the knee is pointing towards you in the picture. That's, that's a wild amount of abduction, but that's what um the baby needs, the child needs to be able to comfortably fit into the boots and bars. So, um once you've achieved that, uh it's time to do your percutaneous Toomy. Um Our standard suggests that it's required in 85 to 90% of patients. Our local audit standard is for 90% of our patients to have a toomy. And this is a complete toomy. You're completely cutting the achilles tendon. Uh It completely reforms and you'd never known, uh it is, it had ever been done. Um Once you've done your Toomy, you need 15 degrees of dorsiflexion at the end of that correction. And if you haven't got 15 degrees of dorsiflexion, you need to be suspicious that you haven't fully released the tendon. So we do this procedure procedure routinely awake in the plaster room. The babies are treated with either ametop or lat gel. Um, over the area, we plan to not, we use local anesthetic infiltration after we've cut the tendon. If you put the local anesthetic in before it disrupts your ability to feel the tendon, uh, and potentially makes the procedure more risky, put local anesthetic in afterwards so that the baby can settle quickly for that final cast. Um, our parents stay in the room while we do it and that comforts the baby helps the baby relax. And as soon as we've done the toomy, we pop a small dressing on and then that's followed by the sixth cast, uh, which the baby wears for two weeks. Um, once, uh, that two week period is up, uh, babies are transitioned into the boots and bars. Um, you can see that these are very soft soas boots, uh, with a very soft, uh, leather, uh, upper and straps, um, for bilateral club foot. Um, both boots are set to 60 to 70 degrees. If you've got a unilateral club foot, the normal foot, uh, the angle is set to 30 to 40 degrees. And you can see in the photo below that both uh have 10 degrees of dorsiflexion. The boots are worn for 23 hours of the day or full time for the first three months. And then the boots and bars are worn at nighttime and for nap time until the child's five years of age. So again, it's worth a pause there, nighttime and nap time until they're five years old. So those of you who are listening, who are already parents just think about what a commitment that is and what we're asking uh our parents to achieve. Um the way I try to explain it to our parents is it's about consistency. Um They need to think of it like a seatbelt in the car. There's no way they would put their precious newborn baby uh into a car without the seatbelt on. They need to view putting them to bed at night without the boots and bar on. Uh as the same, same seriousness. I'd love to say treat it as the same seriousness as cleaning your teeth. But our newborn babies don't have any teeth. Uh and our parents ability to get their older Children to clean their teeth is perhaps also limited. So um we should mention relapse. Now, there's some good news about relapse for the Fr CS in that, when you're describing a relapse, you're describing any of the Clubfoot deformity elements appearing. So you've already learned that for describing the initial deformities. So cavus a ductus, varus and equinus and we see Children continuously in clinic looking for these elements coming back. If you read the literature around club feet be mindful that there's a slightly different diagnosis, which is any deformity that required additional casting or surgical intervention. So make sure you're not comparing apples with oranges. Uh and you know what you're talking about if you're quoting literature. Um but there is wide evidence that our families that can't maintain compliance with boots and bars are those Children who run into trouble with relapse. And we know that if you don't comply with the maintenance phase, um you're very likely to have a relapse. And um but that's not the only reason that you may suffer a relapse unfortunately, with club foot. Um And again, um recognized standards are that even after you finish the foot abduction brace at five years old, these are Children that should be followed up to skeletal maturity. Um So you may uh sort of say, well why they've done the treatment, they've complied with treatment, they've got near normal looking feet, but we know that these feet are at risk of relapse during rapid periods of growth. There's quite a big growth spurt, in fact, around nine years old. And then obviously, you have your teenage growth spurt and clubfoot is not just a deform to the foot. You can see in this photograph, it affects all the muscles below the knee. Um and um can be associated with a variable leg length discrepancy, internal tibial torsion. And uh if you have a unilateral club foot, quite a problematic shoe size difference in some of these Children. Um And this is uh a sort of more basic science evidence to really just confirm that uh the muscle and the tissues in the whole leg are affected. So these are controls and these are Children in club feet and really interestingly on these MRI scans, even the suspected uninvolved leg or less involved leg has some muscle changes. So it's a spectrum of muscle vasculature and nerve abnormalities that have been found. Um Certain families have a very strong uh uh inherited element of club feet. And in these families, uh some of the genes involved in limb development have been found, but in most idiopathic club feet, uh the background is polygenic and therefore, we don't routinely refer our Children with club feet to genetics unless there are uh other uh features that suggest the syndrome. Ok. So, um this is nearly my last slide. Um This is the other procedure which is considered a standard part of ponseti management So there are many other treatment options we resort to in Clubfoot for relapsed, complicated, complex atypical club feet. But this is part of your standard ponseti management. So I think it's again fair game for the exam. So ponseti uh knew that some Children would require this. Uh And he suggested it would be required in 20 to 40% of all club feet. So you can see the clinical photograph. This is a six year old child. And so they've been out of their boots and bars uh for just about a year, you can see they've got skinny legs bilaterally so well corrected bilateral club feet. But when you ask them to rock back on their heels in a penguin walking position, um the toes instead of coming up straight, come up into inversion. And that suggests that the tibialis anterior is out competing the muscles on the lateral side of the leg. So this is a static uh test for what we see when Children are walking and you need to try and go to your comfort clinic and try and spot these Children. So when this girl walks every swing phase step, she takes her foot will flick in and it's quite a subtle sign, but it tends to suggest risk of relapse because the muscles are weak on the outside. And so the way we treat this is to move the insertion of the tibialis anterior tendon. So you can see it coming down uh to insert just under the base of the first ray. Uh So we uh tono it, attach it, we place a whipstitch on it and then feed it um across the top of the foot to insert into the lateral can form in line with the third metatarsal. And you can see the little guidewire there just prior to us drilling a hole, the tendons fed through a hole in the form. And then I use a biotin screw to just secure that and tie the sutures under the foot over a dental roll. Um So this to a degree Rebalances the muscle pull uh in the lower leg. Um and hopefully reduces these children's risk of recurrence. So this is something we do in Children who have not had a relapse, but we feel who are at risk of a relapse. But centers where they struggle with their population's compliance for a whole variety of socioeconomic reasons will have a higher rate of tibialis anterior tendon transfer. So there is a link to compliance there. OK. And then um last slide. So where can you as trainees in the UK? Find out more. Uh So there are lots of very dedicated trainers in the UK who volunteer their time to teach on courses run by the Global Club Foot Initiative. Um It's a very organized standardized course uh adapted from the Africa Club Foot training model. There were two courses. Level one and level two. Level one would be appropriate for any orthopedic trainee, uh, especially one who might have an interest in foot and ankle surgery or pediatrics in the future. Level. The level two course is really for people regularly treating club foot. Uh, and then there's a pathway where you can then go on to become an instructor. So, do consider that course it is the, uh, messy play course of all courses for orthopedics. There's lots of plastering, it's very hands on. It's not all book worker. So yeah, uh do investigate that. Uh And that was all I was gonna say, step. Um I do have some questions but maybe Darius wants to give his a talk. And what does I mean, I mean, the last time we offered to do 5, 10 minutes of five minute practice, this is a perfect opportunity. If you would like to, I can come back if you want to cover all the lectures first and people can tune out. Thank you very much. I mean, that was absolutely brilliant. So if anybody wants to think over the next half an hour or so is going to do his presentation, CP she was at the time. But likewise, if people don't want to put themselves forward on this platform, I appreciate there's a lot of people on and there's no pressure but the opportunity is there. Thanks. Thank you very much for an excellent on conflict. So we have a presentation. So we always have a presentation. So if you just give us a minute to get us. Thank you very much for the second chance I can see. We have 68 people now we have 66. That's good. Let's see. By the end of the talk we're gonna have. But thanks for being with us guys that was really, really informative. Uh I liked it and I listened to every second of it. Thanks. Um I'm just gonna uh share uh this again. OK. Um No, OK. She uh I'm just gonna share this PDF. Is that better or you can see it now? I can see myself as well. So I think uh the PDF version is, is actually slightly better and I don't have any. Uh that's brilliant. Thank you. Uh But that's not the one anyway, right? OK. Um Good. So, um second chances, it's always good to have second chances life. Um So I'm not sure what time I kind of stopped. Uh II was just rambling. Thankfully again, you gave me a call um to let me know that I'm talking to myself. Uh Right. So this is a um a standard like uh vi a question that you might get in your Fr CS. And uh you're gonna be presented with this x-ray, you're gonna tell your examiners. Uh This is a uh ap uh radiograph of a sly mature child. Uh And the most obvious uh issue is the uh displacement of the left uh cap femoral um uh epiphysis uh in relation to the pelvis, which is uh dysplastic and this could be like 1000 things, you know, you could have um uh D DH you can have uh uh trauma, infection, tumor dysplasia in your muscular. We'll come back to that. What's really important is to never kind of commit yourself to one thing, especially when you're like in the open cause it could be lots of things, you know. Um So you just wanna obviously this the topic is, is uh cerebral palsy and cerebral palsy is a huge, huge book. You know, we're not gonna talk about everything, but we're just gonna focus on some little things that might really be a mention at the exam. Um One would be the hips, you know, everyone in the community will refer you hips. Um because that's the main thing that people were worried about when they're talking about CP. The other thing is um uh gait analysis, which is good to know a little bit about. Not too much. And I really like was looking at the questions how they were. People reply to the er er what color is the, the the right represented on the gait analysis graph. And I could see that it is like almost 50 50 but uh the majority got it right. And then uh what what causes uh what is cerebral palsy? And this is if you say, oh that thing that most likely diagnosis based on the clinical history presented to me is cero palsy. And they're gonna ask you obviously, what is cerebral palsy? And you're gonna say it's uh uh something that doesn't get worse, you know, and it affects the brain. Uh it, it, it, it's secondary to trauma to the brain in the immature stages of life where it is birth and the most common is hypoxic brain injury or whether it's in the very early stages of life through I know infection, stroke, uh trauma, uh shaking a baby. Uh So NRI so everything can uh cause injury to the, to the very sensitive uh of brain matter. And then uh what is, you know, in terms of uh introduction a little bit about CP, um it mostly affects the hips and the, you know, it varies from um uh issues presenting with subluxation or full on dislocation. And what is the problem with that? You know, every joint that becomes out of place and you walk on it or you stand on it with time, it will develop degenerative changes, but it's not just the hips, it's the knees, it's the ankles, et cetera, et cetera. So every joint because you know, the the the the moments of forces the tendons that go around every uh every joint in the body will be affected by, by the spasticity or changes of tone, permanent tone changes in, in, in relation to those joints. And um what is really a key is, they might ask you what, how does a hip uh um x-ray look at ACP child compared to a DDA child. Ok. And obviously the difference is big because the CCP child would be born with normal hip development, uh will look normal, it will not be dysplastic or uh when as whereas ad DH will always be dysplastic at birth. Uh And what causes this uh progressive dysplasia is the imbalances of force is what I said. And the problems are ultimately the setting uh the gait, uh the uh hygiene issues and ultimately the pain and quality of life. Um you know, ideology, you know, we know that um incidence of hip dysplasia in patients with CP is, is ranges and it depends on the uh neurological involvement and how bad the kids are affected. You know, the bad, the kids that walk, we know that they, they do well, the kids that don't walk in their dependent wheelchair um and are in a permanent uh disable state, they will very likely because of the hip position in the wheelchair and how the drivers of the force, uh the force that drive the, the hip uh backwards will progressively displace the um the acetabulum that will become ultimately deficient towards the back and that will promote dislocation. OK. And then, you know, uh how do we classify uh um CP so the growth mode functions uh uh scale um um is uh something that was devised by um physiotherapist in the US. Uh and that classifies them into five categories and I most, most of you got it right. It was uh number three in the, in the M CQ. So a child that walks with a handheld mobility device but is dependent uh going upstairs and uh on assistive devices on a banister and someone to assist them directly is a GMC S level three to it. It's very good to have this uh classification system. A lot of us in, in the field use it because it, it helps us in the community, whether you're pediatrician, a physiotherapist or orthopedic surgeon to understand kind of just immediately what we are talking about. Uh This is just a little depiction of the scale, there's other um Australian uh uh score that was developed. Uh uh that is a little bit more detailed in terms of how it describes function for these Children based on five 50 or 500 m and how they, they they walk for research purposes. I think I would, if I were to be asked in an exam setting, I would say uh the uh most recognized uh G MST S. However, the FMS can be used as a, a research uh tool. OK. So once the hip became, becomes subluxated uh and depends on the age, it will rarely improve without treatment. And we know now that if the hip is gone beyond 50% it will not reduce no matter what, how, how, how much we pray, the uh greater risk of dislocation. It's in the very early stages. So, if you like, uh before going to school, kind of idea, and then the second hit is just before, uh, you know, uh kind of year, uh three year four in primary school and the, the, the hips that come out will become painful. And unless we put them back and the, the more you wait, the more difficult it is to actually make them painless when coming back. Um That's kind of how a hip l look like in a very young child. And this is a child that's about eight or nine presenting with uh uh hip stability because this child is uh is, is walking and standing. Whereas a child that's not walking and uh bound, bound and wheelchair bound will um eventually, especially in the young, very young stages of light will eventually migrate down. So what causes the hips to come out? It's that imbalance of forces the spastic, the constant pull, the constant tone that cannot be um relaxed at the um, and it's driven by the upper motor neuron um disease and causing the AUC tendons to pull um uh inward uh media, the source muscle to flex. Um and the child standing in a, in a sitting position, uh sitting in, er, being in a sitting position for a very long time and that eventually will in response to the, er you know, the, the wolf's law in the socket in the triad cartilage, the um er will deficiently, um uh the, the, the, the, the back of the acetabulum will def uh become deficient and uh the hip will come out in time. Um, physical examination. Um I think a child needs a, you know, especially in the context of CPI will need at least 30 to 45 minutes as a self. Uh you know, first patient, uh, first appointment to ACP clinic. You need really good time to talk about. Take the history, uh, discuss with the family, the family needs to trust you and that trust process takes some time and then you need at least 10, 15 minutes for a fixed examination, which ideally should be done in a MDT complex, uh, setting with, uh, your physiotherapist and your occupational therapist because it's really important to have that ability to, uh, really, um, feel the family, feel the child and a and, and create a bond because you're gonna see that child for a very long time from that moment onwards. Um, that's, this is another test which I find quite helpful, especially in the hemiplegics and the walking Children to determine if there's any, um, rectus from, um, spasticity, uh, investigations. We always get this, uh, ap standardized x-ray which the radiologist should be very familiar, uh, with. And, um, uh, that would give us an idea and we need to see the acetabulum in a position, these hips, these kids, you can see most of the time they got flexed, uh fixed, flexed, uh deformities of their hips. And they need to sit in that pelvic tilt position to, for us to be able to measure this uh index of migration. OK. Uh The role of gait analysis. Um it's been something that's been really popularized um in the last uh uh 20 years and it's become uh something that was uh initially not really looked at. It was mostly uh birthday surgery and all these Children would come the first year of tiptoes, then you get second year, they would come with the scars. You got uh uh tight hamstrings, they would get surgery for the hamstrings and then eventually they would get the, the source length thing. So every time they would come for one thing rather than having the whole thing done at the same time. And then we would never know what's causing the problems. You know, it was a, you know, the human eye is not trained to look at many, many things at the same time unless you're really experienced, which, you know, obviously I'm not. So you have to be really, really good at picking up multiple things at the same time in a setting of a clinic where your child is walking at normal speed. So a, a 3D gait analysis has a very good role in especially in the walking Children, the hemiplegic Children, especially when you're not sure what's actually driving these, the, the problem and then you might have an idea. Er, um, and then you, you ask your colleagues, er, er, in the um er, special gate lab laboratories that run across the country to help you out with uh an idea and that could help you in the sense of uh producing some valuable information for your patients. So this is an 11 year old boy GS, he has three with slums degree of er about 30 degrees of um migration, er percent migration of the, of the er hip on that side. And uh patella alta and rectal spasticity on the examination. The the report uh mentions a few things and I just wanna go through uh that with you a little bit and you know what, this is something that's standard, you know, the the report comes back to you and you said the diagnosis is this, we referred uh that's the refer. So what, what's, what's happening? This is my question to them. Uh and our opinion is that we think we should do that and what they think we should do and then they present a history a little bit about that child um and what they do, what their normal life is and then they do examination and gait analysis data and then they send us a report with lots of graphs. So just a little bit to describe the gait cycle. So this is a gait cycle. So from, you're looking at blue, which is the right side and red is the left leg. OK? The gray usually is gray or this uh area here is the standard uh rotation of uh of um a normal population. OK? You're looking at um initial uh uh contact, we don't say yeah, heel strike anymore. So it's initial contact to uh uh a foot off uh for that same foot and then initial contact for the contralateral side and then toe off for the, the same side. And then this is this area is where they are uh both in contact with the floor. Ok. So, uh but you can see that on the left side, uh the, the, the clinic is actually says the excessive hip, internal rotation, femoral and division are reduced on the left. But actually, it's the right. OK. So this is something that's kind of already, you know, being picked up by the graph that it's actually opposite to what you actually thought by looking at it. And then another one hip a deduction. Uh So scissoring, you can see that it's uh it's a deduction is limited 20 degrees. Yes, the graph grease on the right side especially it's quite a doted and it's uh uh a lot more than, than on the, on the left. And another one is the knee flexion. You can see that in the initial uh face of uh stances. So this is, this is stances and this is swing, right? This is stances, this is swing and initial face, uh initial faces of uh of uh of stents. Uh The knee does not extend, uh and which you should. Uh and it keeps that flex position throughout and throughout and throughout and does not extend. Um So that's, that's the kind of general gist of it. Uh uh is to have an idea about if they ask if they show you a graph, you can tell this is a gay cycle from um initial contact to off initial contact of the other foot uh and to off of the other foot. And this is the normal uh um appearance of grafts in the, in, in, in of, of knee flexion in the general population. Uh red is uh left, uh blue is uh uh right. And uh that's kind of the idea and the rest just kind of follows, you can see degrees here, some graphs will have third degrees. It all depends on how the lab works really. And why does it matter because it has improved a lot about our knowledge about gay pathology, what's causing it. Um And the drivers, the multiple drivers that can have influence on the, on the gait. And we know that if we do get analysis before and after we'll provide objective measurement of changes, however, it doesn't provide any, there's no evidence that use of g gait analysis itself uh makes er, er things better we know that it will and I'll show you in the next slide that will actually influence the surgeon's decision clearly. And uh we don't know if the parameters are good indicators of function and we need a bit more information uh into the future. And this is something it's, that is being done. So what we just kind of show you uh what it did in the years, uh initial years before the gait analysis that surgeons were operating a lot on these kids. However, after introduction of the gait analysis, we were operating a lot less. OK. And that's because the gate lab in the recommendations will tell you you should not er er er aim for that er treatment. Perhaps you, you could do this instead so that or just observe. So hence this is what the gate lab actually provided was. Uh these are some, just some apps that we use in the community um that help us uh a lot in establishing whether we, what we do is good thing. Um It's about this is an app that calculates the migration risk uh uh based on gym FC scale. The next CHEANG and the current mi migration percentage and age of the child hip screening is an app that tells you if you really take, take it easy and make, make sure you put the uh the x- perfectly centered in the in the camera, it will tell you the uh displacement uh percentage but you know, ultimately old school works. But ee everyone's gonna try to make an app about other things, isn't it? Uh So management for CP uh I think every time you have a child in your clinic, you should always uh um uh be prepared to offer and document that the non surgical management is the, is, is something to consider. Um uh because sometimes not doing any, uh anything is actually better. Um, physical therapy has always been the mainstay of, of treatment. I have a friend who has uh my age and he is uh with cere palsy uh diagnosed as a baby. And uh we, you know, we talked about the fact that when he was a teenager, everybody wanted to operate on him and the family said no, and they invest a lot of, of uh and still he still does a lot of physical therapy um privately. And that has had the biggest impact, positive impact on his development and that has had the, the, the, the, the has been crucial in him having a AAA good life uh uh the way he does and he's successful in what he does. Um bracing helps orthotics really good. Having a good relationship with your orthotic specialist is, is quintessential. Um Botox is something that's uh very commonly used in, in both the er, tertiary level and also in the community. Um neurologists and pediatric orthopedic surgeons uh feel a slightly, a little bit different in terms of its use and the times we use it, um, at a British Society for Cere Palsy surgery, we find that the use of uh of, of Botox within especially lower limb pathology has become less uh um used compared to what we used to do in the upper limbs. It has a very good, um, um, you know, it still is being used on a large scale. What it tends to do is give you a diagnostic and therapeutic initial um um aid and it helps uh determining which Children might actually do well with certain other uh perhaps neurosurgical types of treatments such as selected dorsal rhizotomy. Um They might ask you in the Fr CS, what does it do? Well, it prevents the release of the neurotransmitter acetylcholine in uh from the accident and things at the neuromuscular junction. Oh and it gives you a winter opportunity to perform a physical therapy or bracing uh for Children. Ok. Uh We need to keep an eye on these kids and I'll tell you a little bit about more about this. This is something that's been done in the community, the physical therapist, in the community, the pediatric, in the community, their role is to monitor these children's development and there's show any problems uh then referred to a tertiary center where Children can then be managed uh surgical management. You have the early treatment, the uh or the versus delayed treatment. Uh the early you treat whether it's physical therapy, surgery, uh, soft tissue balancing surgery. Um, I think the best, uh, I, the outcome, um, we know from, uh, the COVID Times that, uh, the Children that did not have an assessment, whether it's through the school where they get the best amount of treatment. By the way, from a physical therapy point of view, we found that these Children, uh, did not, um, uh, end up well and a lot of them that did not have any sort of treatment whatsoever had the worst outcome, post pandemic. Um surgical management can involve uh um uh releases or transfers of spastic muscles to give them another job. Uh the child um can have soft tissue lengthening and that can be done as soon as a progressive hip, hip luxation is recognized uh or damaged by the acetal uh into the acetal uh uh posterior wall. Um What we do is um AAA combination of Doctor Longus releases plus minus Botox gracilis release and uh Doctor Brevis release. This can be done either percutaneous or open. My preferred stage cni is to doing an open depending on the uh severity of neurodisability. I prefer to be less invasive for uh walking Children um as they need the AUC at tendons um uh and the risk of injury to the branch of the operative nerve. Uh if you damage that uh which is very easy to do uh in your dissection. Um they, they can have an abduct, a abd abductor contracture and um uh lose the ability to have a, a correct gait. Um The success of soft tissue lengthening closely to the degree of subluxation we know from the uh uh Scottish Edinburgh paper uh by Mark Gaston that the um hip uh has a point of no return and that's uh uh uh a 42% migration. Um So tendon, there's a combination of, uh as mentioned, you do, do you got doctors, you get sores and then uh the lengthening of the hamstring tendons uh in the nonambulatory patients. Ok. In the ambulatory patients, it's very risky to lengthen uh hamstrings as the gait treat. Uh will most of the times tell you it's not actually the, the um uh the hamstrings that are the issue at hand. Uh but al but it's actually the hip flexors which cause the uh and the uh rectal spasticity that can cause the apparent uh knee flexion, thick flexion deformities. Um Again, yes. Yes, you're not. Uh you ideally you should not uh damage the in the ambulatory patients, the anterior branch of the optic nerve and soft tissue releases. What do they entail following the surgery? Uh A combination of um drugs, um laxatives er, that the pediatrician can help with or the specialized nurses on the ward which were very privileged uh about uh to have in Southampton uh guided growth. It's a topic that we're at a society level. Very keen on delivering. So guided growth means basically tethering the growth plate on one side to prevent, prevent uh dislocation and migration of the femoral heads. It's still in the early stages. We're collecting evidence now, but the permanent results are quite promising again for the knees. This is something that we are doing. Uh again, cardio growth, we used to be doing these with eight plates. Uh but they would be intraarticular and prevent uh hip flexion and um uh decrease mobility of kids. So we're doing them with extra articular screws, tethering again, the growth plate. Uh Again, this is the sorry, the uh migration index, 46%. So 42 5 to 42 but 46%. That is the point of no return. I think it's very difficult to measure. Um uh the interobserver reliability can be a little bit tricky to get it perfectly. Uh Right. But uh so half, half, if they go on, half the way out, they are unlikely to come back and you will need to do surgery on them, uh surgical indications uh for reconstruction. Um um If the child is uh older, uh it is likely that you can do the full on works uh including uh dirt osteotomies, uh V osteotomies in the younger child. We know that if you do that quite early before the age of five, it is very likely uh approximately a third of the patients will need a repeat VDR O later on in life because of further displacement. Um uh Reconstruction involves uh a bilateral procedure, uh which is a stage procedure. A la carte. You do um uh soft tissue releases and then the uh virus uh and the irritation osteotomy. And then you proceed to a uh ad osteotomy which the volume reducing posterior covering osteotomy, which changes at the tri radial cartilage. You can even do it in older kids. Uh It, it mostly crashes the, the roof and not, doesn't really hinge anywhere but it still works and it still provides a coverage for the femoral head. You should always try to contain a femoral head. You should always attempt to get a coverage of the femoral head. Uh However, in certain situations where the femoral head is very dysplastic, it's unlikely this will work and create actually more problems. So this is an example of the er d osteotomy with a femoral er block wedge that was taken for the femur and just placed that this is bilateral procedure, uh salvage procedures when everything fails and he, the kid is very painful and usually an adult. Uh I think it's uh II don't think I would ever try a hip replacement in a, a disabled uh wheel, uh he uh wheelchair bound child. However, I might try something like trit sparing um similar to this kid who's 19 osteotomy. So tr sparing uh proximal uh femur excision or plasty. And what are the concerns obviously uh very important to make sure that these kids are really looked at from a static point of view with epidurals, uh morphine and uh excellent care, postoperatively with dedicated nurses that can monitor every pressure area possible. Uh All these kids are very sick. We need to really look after in HD U setting and some don't pick you setting. Um Yeah, so these are just the usual stuff, you know, the the diagnosis is just one, a four paper. Um But this is another thing I'd really like to talk to you about. So this is something that uh will probably come in the FR CS, they might say what is uh uh being done across the country. And you can say there is a very um uh up and coming established method of monitoring these Children and that's called the CPI P, the Serero Integrated Pathway uh which is uh monitored and performed at a community level by the PED, by the pediatric um um uh physiotherapist and referred to a tertiary level um which are centers dedicated to managing these Children. And we know that that is um up and coming and it's been at a society level quite uh well promoted. And there is a uh the second CPI P meeting was held in Edinburgh in September. Uh The future, we hope that every center, every trust will be integrated in this uh in South, in the Westex area. We have uh in the last three years, we had uh 200 almost 300 Children added the to the platform, which is very promising. Um again. So going back to the initial picture. So actually, this looks, this is a th a two year old, you would say it every time this is D DH, right. However, uh six months before it was exactly the same, six months before that, it was actually the same. Um However, at birth, it was completely normal and the child has a, a syndromic picture um uh with se severe neurodisability. So, in the context of the normal uh birth and six weeks ultrasound scan, which this child had and the physical examination and family history and uh history of the presenting concern. It is likely to be a um a neurogenic uh induced migration of the femoral head and, and a summary, just uh print screen, the earliest you ask uh you, you get in on top of this, the better nonsurgical managers have not have, have not been successful in preventing progression in the Children that have subluxation. And it's important uh to manage hip dysplasia because without it, the kids will end up having hip pain and uh uh further disabilities in need of uh uh more extensive uh interventions later on in life. That's it, I'm done. Did I keep the time? I think I close. Yeah. Thank you very much. II am happy to, to stay on a little bit more if anyone has any questions? The 61 people that 60 sorry that have had uh that, that's pretty good. Can you guys hear me? I think I also had technical issues. Yeah. Yeah. Ok, great. Thank you. Yeah. Thank you both. That's absolutely brilliant. And thank you to the audience for bearing with us with our technical issues. You got to love technology, haven't you? But we've had two fantastic talks. That's great. Um Darius, can I ask you a question, please? Um Were you asked anything about CP in the exam or any of your colleagues or um a guest trainees when you were going through the exam? Can you remember anyone being asked about CP? Cos it's quite, it's a scary topic for the exam, I think um as a differential, you have to mention it. Uh I II don't, I personally didn't have any uh CP question I had at piece question uh a vertical sell us, but I didn't have any, any, any um question on CP. But I think it has if you are taking that route because you can easily make your way into ACP environment by the answers that you give. Um But I II don't know, I think that um II don't know that come out, but I do know it comes up in our mock exam. I know that I know that it can come up is how I put it. So I do think it's, it's worth, I agree perhaps your D DH or something like that might be slightly more prevalent, but I do think it's something worth preparing for and being able to go, go off on that tangent as well. Mm. II think I, um, I think Darius makes a really good point that, um, it would be very easy to get onto a topic of CP. Um, and, and exactly how you started your talk was brilliant. I thought with the D DH slide because um um it's very easy to uh sort of gently push the examiners into a different area of interest and they will probably have heard the same answers several times. So they'll be quite happy to hear a little bit of variety. Um But, um, but yeah, I think I was asked about neurofibromatosis and adolescent scoliosis. Um But, but I think it would be a very reasonable question for the exam. I suspect it would be hopefully starting off very straightforward. And for like basic science, they might ask you about G analysis. So I thought I'll just mention a graph because it's so, you know, you look over graphs from GNAS, but as a trainee, you look at the recommendation cos it's just Mumma Jumbo a little bit and, and you, no one really sits down with you to really talk to you about, about this, like, see if he, it's the one that you're like, oh God, it's fair game. Unfortunately, I'm gonna put a link, uh a QR code, let me see if I can get a QR code um of a, of a, of a talk on youtube about this. I found it very nice. It's from a, uh Salford University in Manchester, a professor of Get analysis. It's very simple. Um Anyway, I'll, I'll put it in the, I'll send it to you and then you can send it to the, I don't know if there's a link there. She can go up in the chat. That'd be great. Um Edward, there's a question, a rough guide for when you do a video by age. I think that specifically you're asking. So, yes, a good question. I think if you're seeing a child that's, uh, gone already hips out, um, no matter what the age is, you have to do it. Um, any, anything from two to, I don't know, 12, 13, uh, the reason I said 12, 13, you still have, need to have that, uh, tolerated cartilage ideally open to give you that ability to get the, er, cos mostly most of the times these hips will be out completely and you need to provide a head coverage. Uh, the problem I, and I touched on the subject in my presentation that if you do it too early, be ex expected to come out again and then you have to do it again later on in life and, and discuss that with the family that this is not a curative issue. Unfortunately, we know that if they come out really early and we put them back in through the VD, it is likely with time that they might come out a third of the cases do. Right. So, and Alex, if you, they ever improve GMS ES score, no, it does not improve the, the score. Um But uh one thing you can, you c ideally should not score them with the gym scale before the age of six. And uh you should uh not think that or promote that. It makes it, it, it, it upgrades their gene skill. Um what they can, they will always be in the same scale and one day once they uh grow, they will deteriorate in terms of their contractures, their joint ranges of movement and become more dependent on assisted devices. Does that make sense? Ultimately? Yes, you can say that it'll, they, they become more by becoming more dependent on the wheelchair. They, they deteriorate but um once they, they, once they're er categorized into a scale, er, they do not routinely um get downgraded to another scale if that makes sense to from, let's say, from 3 to 4, but they can get worse in terms of mobility and function, which is not necessarily related to the G MFC S scale. A maturity. I'm very confused but uh yeah. Right. Steph, my VR are on the end of my talk slide. Shall I put my talk back up and scroll through to the end. Um Yeah. Can you hear me? Uh I've lost you. I'm gonna do that. I can hear you. Um I'm try, I'm trying to invite now and Alex to the, the platform. Oh, so they can do that. That would be a nice, I don't know if you're able to help with that because it doesn't seem to be doing it. A lot of n is currently on. I did, I did do that that too. So basically, guys, we just invite you to the platform so that you can talk as well. Um It's just a bit easier than doing it all to chat. That makes sense. So I hope you're happy with that. And uh when we've got you both up, um I don't know. You wanna do it with two. Do you wanna just question about or? Um Well, so, so I think there's, I think there's four slides with questions so they could perhaps take turns. They're really straightforward, but that's very purposeful because my memory of the vi was, well, this is, this is actually OK. This is straightforward. Um And all of the examiners are desperately trying to help you show off the knowledge you have and, and get you through the day. So does somebody want to speak? So I can just tell I can hear their voice. Na, na na, I can hear you, Alex. Oh Alex. Amazing, Alex. OK. So do you want to go first? I'm not sure where is OK. Now, the way I've structured these slidess are there's a prompt uh and in the virus stations, even when I did it being fairly old, they had ipads with pictures on them. Um The questions are written because coming out of COVID when we were doing VR online, people found that useful just in case the audio wasn't very good. So the questions are just written there. OK. So Alex, what condition does this baby have this on with this image? It appears this patient has bilateral club foot. Ok. So can you describe the components of that deformity? Yeah. So uh it's a CVAs deformity of the mid foot. Um, an adduction of the forefoot, uh a varus of the hind foot and an equinus of the ankle. Ok. And um when you're examining the foot, what or the child, how are you going to approach them in the clinic? So, just with the examination because I would like to take a full history, including birth history and family history. Yeah. Um asking the parents. So I'd like to have a chat with the parents about the, the child's, er, the um, sorry, the pregnancy, the delivery, er, was it a um, er, multiple um, pregnancy? Er, I'd like to ask if there's anyone in the family who has had uh something similar. I'd like to ask if you've noticed anything else about the child. Um, if they're under, under care of any other um specialties within the hospital, for example, if they had been diagnosed as having um, er, a meningocele and have pre op er, sorry, prebirth surgery, neonatal surgery, um, fetal surgery, I meant sorry. Um, and then in terms of the, I would move on as well to examination of the patient. So they examining the patient by looking first, I looked for a medial crease on the sole. I'd looked for um, the curve of the lateral border of the foot. Um And I'd look for a uh posterior mm, posterior crease as well. Mhm I would like to feel the tailor head to see how uncovered the tailor head is. Yeah. Um And then I'd also like to 00 feel for empty heel, sorry as well. And then finally, I'd like to assess the Linus contracture and see if it's fixed if it's flexible. So if I can get them to dorsiflex, if I can't get them to neutral, if I can't get them anywhere at all, near neutral, very good. And so I'm just gonna move on. So you described very nicely all six components of uh a scoring system. And so the second question on this sheet, do you know the name of the scoring system? No, it's a pirani. I should have said it out loud. Um So, and how does, how, why is that important in your initial assessment? And how are you gonna use it moving forward? Er So it's important to assess the severity first of all of the club foot deformity, each one is scored from 0 to 1 with one being the worst and six being sorry, zero being the best for each component with the worst score of being six. Yep. Um, it's relevant because you all, it allows you to, um, assess your, er, treatment for the club foot deformity and to assess whether they, um are improving with ponseti casting. And then also you can use it longer term to assess if they are having reoccurrence of their symptoms. So when they go into their bar boots and bars later on, you can assess to see if they are having reoccurrence. Yeah. So, so, so that's correct. It's, it's less common to use the peri score. Um, once, once the foot has gone through its initial correction, but it, it's possible but not so widely used. So really just around the time of the initial casting. But, um, but I think everything else I said is very correct. So I'm sure there are some centers that would then, uh, continue, um, to do this going. So maybe that wasn't clear in my talk. So it really is. This first initial correction is when you should be using the score on every appointment and then once the baby's established into boots and bars, you're just looking for those elements of the, the club foot deformity coming back. Ok. And no, you did very well. Um, and so, um, tell us about the gold standard treatment for this condition. So the gold standard treatment for this condition is to correct the um deformities in in order using ponseti casting, er, the idea of ponseti casting is you correct the CVAs of the foot by elevating the first ray and only when you've obliterated the medial crease, do you move on to the next step? Then the next step is to abduct the forefoot, um using your tailor head as your full crm to get it to 75 degrees of abduction of the forefoot. And then once that is complete, only then can you move on to correct the equinus deformity? Um And that will require further casting. You're changing the casting, the cast, sorry, once a week. Um And ensuring that the um parents know what to do with it if the cast slips. So it's a constant monitoring from the parents. And you have quite a lot of buying there to ensure a good correction and your final correction with the equinus uh correcting the equinus. You might need to do a Tono toy which can be performed in clinic. Mhm. And um what um would you anticipate uh a Toomy uh rate target would be for your local clinic? So, if they had a standard to audit against, what, what do you think they might pick as a standard for Tono toy rates? So it's between 85 and 95. Yeah. Ok. Um And once the casting is completed. Do you know uh, how we treat these babies moving forward? In fact, let me, in terms of further treatment, you go on to belts. So, boots and bar, um, and with your boot and bar you're aiming to hold the effect of foot out, um, externally rotated, er, f to, um, well, a, a abducted to, er, 60 degrees. Um, and initially it's warm pretty much all the time, 23 hours a day. Um, when you say initially, could you quantify that more than initially? Oh, sorry. Yeah, from the time of the ponseti casting is complete. Yeah, up until, um, three months old, uh, you use belt, a boot and bar. No, it's longer than that. I know. So, so that's, um, you've got some of the right numbers in there but, but I didn't explain that clearly enough. So you're quite right that the foot abduction brace, the boots and bars start, um, from two weeks after the stott. So that last sixth cast is on for two weeks and then the child's put immediately into the boots and bars, usually in the clinic and those boots and bars are then worn for three months from that date. So it's not until they're three months old, it's three months of full time boots and bars use, um, at whatever age the baby's at. Got you and then that's it. And then it, it drops down to naps and night time, 10 to 12 hours a day up until the child is five. Yeah. And that up until five, the, there was lots of, uh, sort of research about, should it be longer? Should it be less? Um, and no one has ever found better evidence than doing it till five. There is evidence to support up until five. and that's what the standards suggest in the UK. So there's a couple of features you can see on this photo, which is perhaps slightly better than the one in my talk. Can you see there's a little circular hole at the heel? I think that might be for it. It's kind of like the similar sort of thing when you're doing a DHS. Um, and you have them on the traction table. So, you know that the heel is down, um, in the boots and, you know, it's been fitted correctly. Exactly. So it's, it's an important part of the boots to help the parents check that they've got the feet in the right position. Ok. Um, and if you imagine Steph or I are the parents, what, what would you explain to them about the boots and bars? Um, so the boots and bars are important to maintain the, the, the correction of the Ponseti Ponzetti cast of the serial cast that you've had over the last few weeks. So they're really important to keep the foot in that position. And so when your, for this first three months, we're gonna need to have, um, the little one in this boots and bars for 23 hours a day, which understandably is quite difficult to do. Um, but it is equivalent to putting it into your daily routine to ensure that the, the child is always wearing them to maintain the, the, the correction. Because essentially if they don't wear the boots and bars, according to, um, the stage of their treatment, there's a higher chance of their foot, their feet going back to the position they were when they were born. Yeah, very good. So, so there's, there's nearly 100% recurrence rate if no boots and bars ever go anywhere near the child. Um, and I'm just thinking, Miss Piece is there are further questions I think now also available. Yeah. Do you want to swap over? So thank you very much. Well done, Alex. Yeah. No, you, you did very well. You did very well. So where's hello? I'm here. Ok. Yeah, you here. Ok. So now what I'm going to suggest, um, you were just, were you just listening to Alex also? Yes, there was. Ok. So, um, there's nothing wrong with repetition. So have a go at, um, answering the questions on this page. So what can you see in the picture? Um So this is a picture for your child wearing, um, uh, boots and bars. Um, I believe both are in a 70 degrees of abduction which means it's a bilateral deformity. Um, I can see it's well fitted. Um, I assume this patient is in his, um, second phase of treatment of the boots and bars. What? Uh, so you mean they within the maintenance phase of treatment? Yes. Yes. Um, and so which condition do you think we're treating with this? It's a club foot. It's a uh congenital tabs quino uh virus, uh which is cus uh a deduction virus and equinus. Um, and it's have, um known now it's a manufacturer, um a manufacturing uh condition rather than a positional uh condition. Um and uh Poti have reu the treatment by um understanding the ace table and p this concept and um using the creed, the Vesico eas uh properties and maintaining kind of um progressive deformation under constant stresses over time by doing the serial cost. Ok. And so, um so could you just describe what the ponseti treatment is and how it works? So, you've, you have described the scientific basis of it, describe how it works in practice. So, in practice, um um first of all, it's um the first step is to correct the first ray uh by Sating or uh dorsiflex, the first ray to um um kind of um level the forefoot uh together um then a, a full crim around the talus and uh correcting the a deduction deformity without touching the heel. And this will correct the virus automatically uh beside correcting the cavus as well, reaching a Beran score of zero at the mid foot is the turning point where we can now do the tono and put it in a two week or a three week cast and a dorsiflexion of 15 degrees. Um ok. And do you know how many casts would constitute a, a standard ponseti correction? It, it, it usually depends on the degree of um deformities, the severity if it's a robotic or syndromic, um as well, it may take much more costs than uh standards, but the standards would be 5 to 6 costs before the tono and the uh final cast. Yeah. So, so ideally five casts, then the tono, then the sixth cast. And I know that sounds really pedantic. But um we, we audit how many casts we routinely use and if we're routinely using more than six casts, then we look really closely at our technique. So that sounds really panicky. But um but we hold ourselves to that standard and it's just a clue that maybe your casting uh or your technique for the because you remember it's manipulation and then you're holding it with a cast isn't quite as good as it could be. Ok. Um There are a couple of other conditions where we do maintenance. So if you've done a, if you like reverse ponseti technique for treating congenital vertical talus, we do also maintain these Children in boots and bars. So I think it would be very fair in any exam setting for you to uh say that, that this is Clubfoot until someone tells you it's not, but just have that in your mind that um the Dobbs technique of reverse ponseti for congenital vertical talus, we do then maintain them uh in a similar way, but that's very small print. OK. So what can you, we make this the final slide? Cos this looks a good one. This is the final slide. Amazing. Um So what can you see in the picture? Uh So this is a uh young child, a picture, a clinical picture of a young child trying to uh stand on his heels. And, and um I can see the full foot is turning into supination which is static test for a dynamic um uh deformity uh which is uh commonly seen in, in um patients after uh poti correction, which is a dynamic supination um de deformity. Uh And this is usually due to over finding of the tip tip. And, and uh I think according to the original paper, he mentioned that 20 to 40% will require um uh a tip and transfer to the lateral uniform. And usually we do it at the uh age of the three years. Uh so that the lateral uniform is ossified. Yes. Uh So, so I think uh so, yes, you're quite right. That would be a very standard approach. There, there is uh there was one paper I saw that suggested that actually you get better healing in cartilage even than bones. So maybe we don't need to be as paranoid about that as perhaps we have been. Um, so it's only if you're doing it before the child has finished their maintenance phase of boots and bars that usually implies that um, they've had a recurrence or a relapse, which may be because, um, they're very weak in terms of their muscles or it may be because there's been compliance issues with the boots of bars. Um, so you're right that we, we do pick up some Children that benefit from tibialis anterior tendon transfer younger than five years of age and I'm doing one tomorrow. But, um, but hopefully with compliant parents, it's this age in the year after we, we discontinue the boots and bars because they haven't got that same maintenance for 12 hours a day. That's when often you'll see this. So this is not an uncommon age. This is the second group if you like who get their to even tendon transfer the slightly older group at 5 to 6. Um, but if you're seeing Children much younger, then you have to question whether you can improve compliance with boots and bars through support in the education of your families. Ok. Very good. II think you both did very well. Yeah, well done. You. Thank you so much. Um You could see that what nil um, expertly did, which is a great exam skill that some people are better than others at. Is he offered very safe uncontroversial information that he knew was relevant to the topic. So he told me the diagnosis was club foot. And then he went on to use time usefully to describe the elements of club foot. Um And so clearly that's information you're gonna learn for this topic. And it's quite a useful skill to be able to talk, practice, talking for maybe two minutes. Um, in an intelligent way on a topic, don't take it to extremes, but it's useful if, because sometimes the examiners will just stay quiet and that can be very unnerving. Ok. Very good. Well done. Both of you. Wonderful, thanks. That's been absolutely fantastic. So, I hope you all agree that two fantastic talks and two big topics that have been covered tonight again, apologies for the beginning and technology issues. And thank you very much for bearing us. And I think regardless, I think we've achieved what we needed to achieve um over the hour and a half. So, um thank you very much. So, feedback from you probably already received. Actually, I think it automatic at half past nine and see um in order to get a certificate for tonight's event, um if you complete the feedback form, um and thank you very much for attending. So there's no more questions. We will bring it to a close. And thanks again, I think this was ras had to leave, but thank you to both speakers. Ok. Thank you.