Computer generated transcript

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

Out different approaches to rotational abnormalities. Obviously, most of you know, my background is in pediatrics. But actually, if you know how to understand where these abnormalities come from, we can then apply it to adults. And then we'll go through a couple of surgical techniques of how I manage um these. So, you know, the aims Jack. So obviously, we're going to talk mainly about the clinical assessment. We're gonna go through some cases and then we'll go through the different techniques that we use, which can either be done over a plate or using an intramedullary nail. So, obviously, tort issues, there are normal variants as we see in sort of Children. Uh And we need to know how to clinically assess them. Obviously, we know that Children when they're young, they have quite amount of femoral anteversion. So I tell all parents that babies cannot come out a mum. If they do not have femoral anteversion, they can't pelvis cannot come out through unless their hips rotated forwards. And obviously, that means when the child, if a baby was to literally walk out of the womb, they would probably have quite a significant in toing a pigeon toing because of that. But we know that that improves over time to a point where by, by the age of nine or 10, it should be a normal uh torsion, which in an adult is around 20 to 25 degrees pointing forwards. But you can see how high it is in this earlier age group, which is why if you ever see a toddler in clinic, you'll see that a lot of them are in towing. And if you ever done pediatrics, you'll see how many uh patients are referred with this. So, you know, clinic examination for these pa er patients is really important. The first thing you've just gotta do is watch the way they walk and look where their, where their foot is going, but also pay attention to where their knee is pointing the actual patella as well, which is very difficult to do in chubby, chubby er toddler, but much easier to do as they get a bit older. And that will almost certainly give you straight away where the rotacea abnormality lies. Obviously, we do express, er, expect a degree of out toeing again as you can see, should sort of be lining up with a slight degree of out towing, you know, not, not significantly er, toing at any stage. How do we examine them? Obviously, the best way is to examine them, er, supine, but also prone and in the prone position. Er, really what we do is we have a look. Firstly at, for me is to look at their foot. First of all, this is on the right hand side, you draw ble line, which is a line that goes through the middle of the heel and it should pass between the 2nd and 3rd toe and we'll explain what happens if that's not the case. The next thing I look at is the thigh foot angle. So that's the angle between the thigh from er, in a prone position and the foot. And that's telling me very much about tibial torsion. And then finally, I rotate the hips both internally, which is actually putting the hip outwards and externally. Now, obviously, they end up hitting each other if you do it externally. So I do the internal one first, I drop one leg and then I check the external rotation. But more than that is this really useful test. This is rider test. This is basically what you do is you put your foot uh oh sorry, it's a, it's a PDF, isn't it? So what you do is you um put your finger on the greater tranter and you roll the leg out, you roll the foot outwards into internal rotation until you find that the GT is most prominent. OK, till it's actually sticking out the most. And what this will show you is you can see at this position of the leg at 35 degrees that GT was at its most prominent as rotated here. And that then tells you what the femoral neck version is. You can do this in your hip hip arthroplasty patients. You can do this young adult hip patients. But if you have a good view of what your version is, this is a really easy way without getting a CT scan of knowing what your femoral anteversion is. OK. Or retroversion, if there is no internal rotation but lots of external rotation, it will also give you a very good example of that. So something that you should all be doing and assessing in these patients. So we're gonna go to er case one again, unfortunately, because this is a PDF, it's not done by animations. Um but this is a girl who presented. Now when you look at her legs, the first thing you'll see is that her feet are relatively pointing forward, but a slight more inwards, but look at her kneecaps, those kneecaps are called squinting patellae. They look like they want to kiss each other. That's how I explain it to the kids. And then when you get them in the prone position, you can see that there is no external rotation but lots of internal rotation about 80 degrees or so. When you look, then at an X ray, what you will find in your femoral anteversion cases is apparent Coxa valga, the neck angle will be higher and sometimes that may even look like your hips are subluxing a bit depending on their age. So in some, some of these cases, if it's quite severe, uh let's say you don't have CT available to you. You can then do a feet inverted position where you get them to turn their feet inwards. And it should normalize your shen's line. As you can see here, Shen's lines are broken, but up here, Shen's lines have been restored and you can also normalize your neck angle. That is now a normal neck angle with what looks like a normal grade tranter hypophysis. It's not overriding the tranter because it's not sitting. You watch my hands here, it's not pointing forwards. My GT is here. If it's pointing forwards, you won't see your GT, it will sort of be poking over the front. But as you turn it, normally, you'll then start seeing your GT normally, which you can see in the second picture here. And obviously, in this case, what we did was we did bilateral osteotomies. And you can now see that there's significantly more external rotation reduction in internal rotation and they had a normal foot progression angle. When they walked on the other hand, you can get completely the opposite. So in this one, you can see that the neck angle looks pretty darn good. Yeah, you can see when he's lying, that his foot is completely out, turned on that left hand side compared to the right hand side. And um interestingly in this patient, if you look at the ap long leg that I did. You have an AP of the hip but almost a lateral of the knee showing that there's quite a substantial amount of rotational abnormality. Um When you look at these X rays and I'm sure you discussed this last week when you were reviewing your um sort of how to look at this imaging. You can look for things like the ischial spine sign, which is this little sign here that tells you about acetable retroversion. You can see the crossover sign. If you look at the anterior and posterior walls, you can see there's a crossover as well and then the posterior wall sign as well. So all of these three things suggest there's a degree of acetable of retroversion which would then match if you have a femoral retroversion. So here's a CT scan I've taken slices at the hip cranially and the middle of the neck and the foot. Now, let's look specifically at this left foot. If I showed you this middle image only can you, can you see the arrow? Yeah, when I point to it, unfortunately, we can't see the annotation that doesn't help. Uh Is there any way that I can create an arrow on here? So I'm pointing at so many different things, but um I don't think there is, I'm not quite sure how. Oh, sorry. So all the things I'm pointing to, if you haven't understood it, please just tell me and I'll I'll talk through it if it's slower. Um If you look at the middle CT image, so third image is on the right, the middle ct image. If I was to draw an angle up that femoral neck and across the back of the is your spines, you would say that's only around 20 degrees antiverted, right? There's not, it's not like it's pointing backwards as you would expect it to. But when you then look at the slices at the knee, you can then see how outwardly rotated that uh, the, the distal femoral condyles are. And therefore, if you were to, if you now watch my fingers, if you were to rotate that knee, that hip socket from 20 degrees forward is now gonna point backwards and that's gonna give you your true femoral retroversion which would explain to and in this case, what you'd find is, uh, you can do, uh, again a derotation osteotomy. In this case, it was done over a nail again, I'll show you, er, what can be done later. Um, we'll go through the surgical tips, uh, just to, uh, I promise, but if you are looking to annotate, if you were to share um, your whole screen rather than a window, then we'll be able to see your cursor. Ok. So if I so sorry, give me one second. Let me just see. I did. It was a PDF. You see, cos last week? He said there was a PDF. So let me just open it up rotational techniques, which means I can't see any view, but that's.