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The foot progression angle. But now also look at where the kneecaps are pointing. So this child who's obviously a lot heavier as you can see, kneecaps are pointing forwards, feet are pointing inwards. And in the pro position, there's symmetrical internal external rotation. So we would think that using this, there is no evidence of femoral version abnormality. But when you look at the 5 ft angle, you can see that there is an internal uh tibial torsion. OK. So this is a child who has an abnormal twist internal of their tibia, such as they're almost tripping up over their feet. And you know, this is relatively uncommon. Um You know, we only have for about, you know, 10% of patients that come and see me with Toing. But in this case, you can then do a distal tibial derotation, osteotomy. I use a locking plate, I let them weight bear immediately in a cast and get them going. And you can see how the before and after clinical pictures show you what can be achieved, they quite a minimal incision. The next case is obviously the opposite. It's, you know, significant kneecaps pointing forwards, significant out towing again, when you look at the other clinical pictures from behind and from the front, you can see there's significant out toing, but knees are pointing forwards. This is an external tibial er torsion correction and that required a sort of staged bilateral derotation osteotomy. And you can see an improvement of one side postoperatively on the right hand side compared to the contralateral side for this for sort of young adult stuff. I'm not gonna cover this as much because tibial derotation isn't much as part of it. Although uh Tony and from B reading has spoken about doing this in some of his young adult patients. Finally, the, the misnomer and the, and the real difficult ones, the ones that end up getting missed for ages and ages and ages are these patients where their feet point forwards and everyone thinks they're normal, but they present to you with patellar apprehension, patellar dislocations, knee pain, groin pain, something just doesn't sit right. But when a GP or doctor has a look at them in clinic, they say, well, your knees are pointing forwards, you've got no problems. This is when the importance is of looking at those kneecaps. So when you see this, you can see that the kneecaps are kissing just as you was expecting a flan version and the feet are pointing forwards. So then I took pictures from above and you can see with the kneecap pointing inwards as it is on the top second row picture with the dot You see the feet are definitely pointing forwards, but when you correct it, so the kneecap is actually pointing forwards, the feet are pointing outwards and this is known as miserable malalignment syndrome. It is excessive femoral anteversion with compensatory external tibial torsion. And I see more and more young girls with this every single week to a subtle degree. So I think make it a good habit of looking at your patient's foot progression angle and where their knees are. Cos it will help account for a lot of those young adults. You see, not only with hip, hip pain, but also with knee pain or chondromalacia, patellae or posto chondral defects or, you know, patella maltracking. Um And so the best way of obviously imaging this is to sort of get a a full CT lower limb scan and you'll be able to then look at the version individually. You may find that the patella is tracking or there's some impingement lesion of the patella. Unfortunately, these do require quite major reconstruction uh as we did in this girl and you can see how her feet are pointing forwards and knees are pointing forwards, but she had to have quite dramatic surgery. That's for osteotomies. So I really put my patients off having this done unless they really, really need it doing. We know that fever improves as kids get older, usually around to the age of 10. So if I meet someone young, I'm holding fire with this. Then they're coming to me at 30 14. I would consider doing one side, femur and tibia on the same sitting and then go to the contralateral side. I've only had to do one bilateral case in the last five years and I probably only do one newly lateral case every six months. So it's not a very common procedure but just look out for this. Cos I think once you understand, version it will then help your approach with all of this. So finally, and this is really for babies that black line I was telling you about which is the line passing through the middle of the heel should go between your 2nd and 3rd toe. If you see er this clinical image on the left, you can see that's certainly not the case. It's probably going between the 3rd and 4th toe. And that's when we start calling metatarsus, the ductus. So metatarsal the ductus is basically a ducts of the actual metatarsals, er very little bony surgery that needs to be done. You can sort of classify according to blech with these middle pictures and actually cos they tend to be young babies, you can cast them a bit like ponseti, but just stretching out that medial crease and then I treat them in boots and bars. Um and I hold them in that position for a period of time. Again, this is not something you tend to see in sort of the older population, it tends to be more babies in older populations. Yes, you can do lengthening osteotomies. Muscle releases all sorts but no real evidence that any of it helps. But this is not really, this is more of a foot and ankle problem than a young adult hip problem. So, in summary, there's the sort of torsion issues can either be physiological or pathological into or out toing and it can come from the femur tibia or feet. And I think it's just a easy way to sort of break that down. But moving on to it's uh sort of applications in adult hip practice. Obviously, we talked last week about a number of different um er pediatric pathologies that can lead to obviously problems with the hips. We can see the sufi up here had a collapse of V neck and we did a valgus sliding derotation osteotomy. You have a post Perthes patient, which is number two below that, we did a valgus osteotomy and a pa ao to over uh over cover that head. You may have significant dysplasia with abnormal rotation. The number three below that again, had a femoral derotation osteotomy and uh apa o over that. And then finally, this was a patient with a, a sort of late presenting slip that had never been treated. And we did a flexion traer osteotomy to help normalize that if you look at the um the sort of lateral that top right hand corner to where it looks now it's sitting much better in the joint. So femoral osteotomy is a really, really helpful and versatile procedure and just like I've spoken to you about version in uh the femur that II look after in kids very often. Just look at the portion of um abnormalities between the femur and acetable that we see in adults. Only a third of adults actually have normal femoral and normal acetable aversion, only one third. And you can see here how many have excessive femoral anteversion. That's 6% that's almost 30% of patients have increased femoral version. And then 22% of people have almost decreased femoral version which causes the out toeing. So you cannot really get into hip preservation without understanding that there's two sides to a joint and it's not your ap radiograph. It's also your sort of coronal and axial, sorry, your axial sort of assessment of the bone because you're not gonna get a stable joint unless you make those match. And when you're doing hip arthroplasty, it's so important, not only your inclination angle of your cup, but the amount of weight if it's too open or two close, but also what position it is in and then it matters on what your rotation is on your femur. So if any of you have had a dislocated hemi disc hip, this is where your understanding must lie that everyone is built differently. And the more you plan for this and the more you appreciate this in your older adult practice, it's easier to apply to these sort of young adult cases. So, really important to understand this. So first thing we'll go over is femoral osteotomy over a proximal femoral plate. So my preference is actually to use a blade plate. Um And so I'll tell you what I do with that. So this is a, a patient. We did a femoro osteotomy and APA O in this. Hence why they're sort of got both legs uh prepped as they do, but essentially supine with a rolled bump underneath the hip. We make our skin incision, you feel for the degrade tranter and then you make your incision usually about 8 to 10 centimeters at the maximum going down, you get, you split your fat and your fascia. Um I use local anesthetic with adrenaline and as soon as I split my fascia and see the vastus, I stick my local anesthetic and adrenaline through the vastus onto bone and I inject and I inflate and that it has two things that it does. Firstly, it lifts that muscle up away from the bone, so you can find your interval much easier. Secondly, the adrenaline vaso constricts, all those really annoying perforators that you have on the bone. So if you've done a DHS or if you see there's a perforator, try it even in your DHS approach, you will notice that it dramatically reduces the bleeding and also makes your uh uh anatomy a bit easier to find. Once, once you uh see your vastus, you then wanna find uh a particular tendon that can tell you where you are. Can I ask anyone what you know that is no one? OK. Fine. It's a glu max tendon. So, Glu glu max tendon is really what you should be seeing around where the Homan is in that top picture. Uh You should be able to identify that that is really important cos that protects your sciatic nerve. OK. So you wanna stay anterior to your Glu max tendon and go between your gluma tendon and the subvastus. Er And so the vastus lateralis. So I use my dia I create a little window. There's usually the fluid that drips out, which is my local anesthetic I put in and then I can use my Periosteal elevator to go over the front of the femur and then put a home in such that I get a really good exposure like the bottom left hand picture here. So it's completely skeletonized periosteum lifted um exposure to the proximal femur. So when it comes to doing your osteotomy, you need to have decided, are you doing a va varus osteotomy? Are you doing a valgus osteotomy? Are you doing a flexion or extension osteotomy or are you doing a pure derotation osteotomy? In this case, I'm gonna only be talking about a derotation osteotomy because that's what pertains to the torque. So in this, there are plates and the plate we'll be using is 100 and 30 degree plate. Cos that really matches your normal neck angle. You insert your wire.