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Hi, everyone. Uh, welcome to Meadow Education. My name is Jingjing and I'm usually on the support desk. It's really great to have you today for our talk. Joining us today is Miss Deborah Eastwood, president of the British Orthopedic Association and world renowned orthopedic surgeon at Great Ormond Street Hospital for Children, and the Royal National Orthopedic Hospital alongside Miss Dia BS, uh past chair of the World Orthopedic Concern and highly esteemed consultant in common orthopedics, university hospitals, Birmingham, Miss Eastwood, who will be teaching us about CDH and Club Foot and Miss B will be teaching us about foot and ankle trauma. If you have any questions for them, please leave them in the chat and they'll answer them as we go along or at the end of the talks. At the end of the event, there'll be a feedback form emailed to you and once you've completed that your attendance certificate will be on your Meadow account, just a couple of notes to mention about Meadow Education. Tonight's event has 42 unique countries registered to it and in a little over two months, Meadow Education has had 814 followers on Medal and this has covered 78 unique countries. We've had 40 live events which have been run with catch up content for each event. We've had 41 incredible speakers who have committed time and knowledge to us and with 4500 registrations and just shy of 2000 attendees across all these 40 events. Our catch up has received a staggering 1446 views allowing those who couldn't attend live to watch in their own time and receive an attendance certificate. That's all for me. Sorry, Maram, I saw your thunder. Um But I'll let Miss Eastwood take it away. Thank you very much. Uh And it's a pleasure to join you tonight and uh it was a bit of confusion about what I was gonna talk about. So I'm gonna start with club feet and then maybe a little bit of dislocated hips tell you a little bit about the art and science of pediatric orthopedics. Those of us in orthopedics know that the tree of Andre where there is a straight stake and a curved tree. And the principle is that if you brace a growing tree that it will grow straight and tall. And so the whole of orthopedics, which does mean the straight child is all about guiding the growth of these small people. So the toddler with his bow legs will grow straight, the embryo, which is mainly cartilage will eventually develop some bone within the cartilage of their skeleton. And so this is a very fragile period of their life. And it's a part of their life, Children or childhood where change is inevitable. And so it's the process of guiding their growth that captivated my interest and is at the heart of what we do as pediatric orthopedic surgeons as we watch and wait for our Children to grow and develop. So, one of the uncommon or maybe I put it the other way. One of the common, uncommon things is the club foot and a club foot is a old fashioned description of the shape of the foot in this condition. And we probably should call it Talipes equinovarus, but probably not just calling it Talipes. Cos Talipes just means foot and ankle. So we need to be more descriptive. So it could be congenital talipes. That means a congenital foot and ankle problem. Equi virus means that the hind foot is in equinus and the foot is in varus and it's supposed to be rather horribly described as a bit like a horse's hoof. So like everything in medicine, the diagnosis is made after the history, the examination and the investigations. But if we're talking about a brand new baby, thankfully, there isn't much history, but there is a history of the family conditions and maybe some problems during the antenatal period which may or may not influence how the child develops when we're examining the newborn baby. And we've noticed that there is a club foot deformity. We want to exclude other associated problems. So we want to exclude a syndrome and we want to make sure that nerves and muscles are working well and then we can decide to do investigations as required. And as always listen to what mum says, don't ignore her. So for example, if she says this is baby number three, but really all the time I was carrying him, he was a very quiet baby. He hardly moved at all. Now, that's not quite right for mum to say that. So maybe that child has a neuromuscular problem and was unable to kick his legs around even when he was still in utero prior to delivery. So, although the history is very short in a brand new baby do take the time to ask the relevant points. So the club foot, the congenital Talipes equina virus we tend to describe from the back of the foot forward. So the hind foot is pointing down. It's in equinus, the subtalar joint is pointing medially intervirus. The front of the foot on the back of the foot is ad ducted and that gives the appearance of there being a high arch to the foot. The cavus, which is really by definition, a pronation of the first ray. So it's equinus varus adduction and cavus. But what we really want to know is how severe that deformity is we can in countries which have the access to antenatal ultrasound screening of the baby. We can do a scan of the baby and it is quite sensitive and very specific so that in utero, we can see the limb and we can see the foot is in a club foot or a Talipes equinovarus position as we can in this scan too. We can see this deformity very early on in utero when the baby is not squashed when there is plenty of fluid around the baby. And yet the foot is still in a position of deformity. If the condition is affecting both feet, then we start wondering whether this is a syndromic presentation. So just one feature of a more generalized condition affecting the baby, there is a false positive rate. So in about 15 to 20% of cases, the radiographers will diagnose a club foot on the ultrasound, but maybe on a later ultrasound, the foot is moving normally and certainly at birth, the foot may be behaving normally. So they often also get the severity wrong. So they think it looks awful on the ultrasound scan that when the baby's born, the actual deformity is much milder. So I said that if the com of the uncommon things, it was quite common. So in 1000 live births, the incidents can vary from half to five or six per 1000. It's more common in boys and there is a family history, half of them are bilateral and as I said earlier, that makes it more likely to be a syndromic presentation in identical twins, what a 33% chance that both twins will be affected much lower in dizygotic non identical twins. So it's not just being squashed in utero. There is some genetic inheritance factor at play too and we have identified some genes but nothing that is terribly helpful at present. You've gotta keep your eyes and your ears open. These are both club feet, congenital talipes equina virus, but quite clearly, there are some differences in the foot. This one's got more skin wrinkles and this one looks smoother skinned and shiny and there's a bit of the toe missing and this child has an amniotic band syndrome and this is an idiopathic clubfoot deformity. So, idiopathic is a, a common word in pediatric orthopedics. It says that we don't know why the condition has arisen. We say it arises spontaneously. But what we really mean is that we don't know why it's arisen and I think that is an implication that we should continue to look for a cause, not give up. So what I'd like you to take away from this lecture is that whenever you see a club foot, you should keep looking for the cause. And we want to decide how bad the foot is. And the classic classification system at the moment is named after Shafiq Pirani. Uh a gentleman who was an orthopedic, is an orthopedic surgeon out in Vancouver in British Columbia in Canada and he devised a score out of six. So it's quite easy three referring to the hind foot and three to the midfoot. And there's multiple tables online which will help you us understand the scoring system. But this is a very deep medial crease and that would be this here and that would score us one and this deep crease at the back of the ankle would also score us one. So you add up all of that and the higher the score, the worse the foot is the more severe the deformity and therefore the more difficult it is to treat and the more difficult it will be to get a great result. I teach everyone that you should then classify it into the type of club foot deformity. You've got, we could say that some club feet look are only picked up later on in pregnancy and they are probably when the baby is taking up most of the uterus space and the baby's foot is being squashed and that is a postural deformity, which by definition will have cured itself by 2 to 3 months of age. Once there is space for the baby's foot to move around, there is a big group of idiopathic feet where the etiology is still largely unknown. There's a group where there is a neuromuscular cause and I give spina bifida as the classic example. And there are a group of feet where there is a syndromic cause. So the problem is widespread in the baby. And I give the example there of an arthrogrypotic er condition. So it's quite clear that there is already some overlap between the neuromuscular and the syndromic feet because spina bifida and Arvo gris both have neuromuscular components to their features. And as I'll show you later on, there will be some overlap between the idiopathic groups and the neuromuscular and syndromic feet. So I would say the primary problem is that the foot is a complex connection of bones, ligaments and joints and the talus and the calcaneum sitting on top of each other should diverge. And on the end of the talus, there is the navicular and then the first ray on the end of the calcaneus, there is the cuboid and the 4th and 5th rays. But in this pathological specimen of a brand new baby who sadly died, you can see that the talus and the Calcaneum are lying on top of each other and the navicular is not on the end of the talus. So the primary problem here is a subluxation. If not a dislocation at this joint. In the past, we used to treat feet like this conservatively. Then we went through a phase where everything was treated operatively and then we went back to being more conservative. So it used to be stretching and strapping. So you'd take this foot, you'd stretch it and you'd strap it and you'd take the position from the foot pointing down and in to something that was pointing up and out. And whilst you stretched and strapped, the idea was that you obtained and then maintained a normal range of movement. And that was done in combination between a physiotherapist and sometimes the help of a surgeon was required at some stage. The lesson here is at some stage, we thought the stretching and strapping was a little harsh and it was a bit cruel. So we went over to these very smart little white leather boots or these custom made plastic splints. And at that point, we stopped and forgot to do the stretching. We were just doing strapping. So there was lots of hiding of the foot but not much correcting of the foot and surprise, surprise that meant the feet did not correct. And therefore we ended up doing more surgical procedures and if I could do an operation and get feet that looked like these nice feet on the left of my screen, then that was great. But if I got feet that looked like those on the right side of the screen, you might think that they were quite nasty feet and that surgery hadn't worked at all and you would probably be right. But the biggest difference between these two sets of feet is really how supple the foot is. The ones that look good are actually quite stiff and uncomfortable on uneven ground. Whereas the ones that look worse are actually very flexible and very easy to put into a splint. And that child sadly has spina bifida so she can't feel her feet and hasn't got any pain in her feet. And with the splints on and the flexible feet, she is very mobile independently and very active. So, movement is life and what you see is not necessarily what you want to see. Ie you must look behind the obvious and decide which pair of feet are working better. So we went back after that brief uh e experiment. If you like with surgery, we went back to doing some stretching and some strapping, manipulating and casting. And some people even tried to use a continuous passive motion machine. So we wanted to stretch out everything on the medial side where the short tendons were, we wanted to lengthen those. And then as we lengthen those and brought the foot round these long stretched tendons on the lateral side would adaptively shorten and provide some balance to the foot again. And it was at this time that Ignacio Ponseti decide or developed his technique. He actually developed it many years ago, but no one listened to him. And then finally, in the 19 nineties, early two thousands people found his technique which had been hiding in the background and realized that it was a revolutionary technique. His principles instead of stretching and strapping were serial manipulations and serial plaster casting with a percutaneous achilles tendon release in almost all babies and a secondary later on in toddler years, uh tendon transfer to rebalance the foot and it all depended on a very precise technique. When I described the deformity of the club foot, I said the hind foot was in, in equinus, the subtalar joint was in varus. The forefoot was ad ducted and pronated giving the appearance of CVA. So when we correct it, we correct it in the opposite direction. So we start with the cus and when you're doing your stretching and your manipulating, you have your thumb on the lateral side of the foot over the tailor head and use that as the fulcrum for your manipulations. A previous technique which was not so successful, had your thumb placed over the calcaneum that's not as effective as having your thumb placed over the talus cos the primary problem is at the tailor navicular joint. So in some ways, you're wanting to push the tailor head one way and bring the forefoot the opposite way. So there's your same foot and you're going to have your thumb over the talar head over this bit just here. And then the first bit is that you correct the cavus. So you lift up with your opposite hand, thumb, you lift up the first MTP joint and stretch out the cavus of the foot. And the foot looks worse after that bit of manipulation, but it's going to look better soon. So you would do that manipulation, you'd leave the cast on for a week, then you'd bring the baby back, take the cast off, do some more manipulations. And once you've got rid of the CVA deformity, you can start abducting the forefoot around. So bringing the forefoot in line with the talus. And as you do that, the varus at the subtalar joint corrects simultaneously and you're aiming to bring the forefoot right round to abduction of about 70 degrees. It sounds an awful lot. So you're wanting that foot that was down and in to come to a position where it's certainly up and out, but it's not got a range of dorsiflexion. A brand new baby's foot should be able to get the dorsum of the foot onto the front of the tibia. So, although this foot looks a lot better than it was, it's not there yet. So if you can't dorsiflex the foot, you have to release the Achilles tendon in the clinic under a bit of local anesthetic with a sharp knife or possibly a sharp needle to thoroughly divide the achilles tendon without damaging the neurovascular bundle. And then you put them into a plaster cast and keep them in the cast for a few weeks. Whilst the achilles tendon heals and then you can put them into a brace. This is quite a fancy brace. Lots of countries manage to make their own braces for much, much less money. And I wish we could do that in the UK. But these two ft are at shoulder distance apart. So if the baby is up here, they're at shoulder distance apart and the feet are externally rotated. And the babies wear these splints, as you can see, for 23 hours a day to start off with then night time and nap time, which is most of the day until they're walking and night time only for several years. So it can be difficult to have the parents and the child stick with you on this journey. But it is important that they try and do. So. It is interesting if you're uh at all interested in growth and development that this is the growth plate, which is the heart of everything I do in pediatric orthopedics and yet everything we know, we still don't know what the link is between loading the growth plate and what that does to the cells and what the little chemical messengers do when they go from cell to cell, telling some to grow and some to stop growing some to convert to bone and some to stay as cartilage. So there's a lot about the control of growth we have no idea about, but we know that there is a Hoyer Oltmann law that helps tell us what happens. And if you pull on a growth plate, you will stimulate its growth. So if we pull on the foot gently as we manipulate it in this direction, the direction of the arrow and then as we gradually week by week, correct the shape of the foot. And as we do it, we're manipulating and stretching and distracting. We will get a really rapid change in shape of the cartilaginous bone, which is the bone of a tiny baby. So you can affect how the shape of the bone is developing by doing this Hoyer Volkmann principle of tension stimulating growth. So we have a foot that starts off in a real club foot problem. This is the first plaster cast, the second, the third, the fourth and the fifth. And you can see how the foot position is changing as you work through the process of careful precise serial manipulations and serial casting. If you don't do the manipulations, all you're doing is taking the cast on and off and the foot underneath does not change shape. Does it work? Yes, almost all babies can avoid a major surgical procedure. It usually takes five weeks, five casts. Most of the babies do need a little tono omy and there is quite a high relapse rate, but most of that is cured by just repeating the casting for a little while. We normally change the casts every week. But there is an accelerated program for uh rural areas where you can change the casts every five days or four days and uh have almost as good results. So it does work, but it can be done badly. And if you don't look after the baby's skin, it can end up looking very red and sore. So you've gotta be gentle with these babies feet. And if the foot where you take the plaster cast off is looking red or swollen or shiny, this is not a happy foot. So we should not upset it any more than it's necessary. And if it's not a happy foot, we probably need to give it a week off to get happy and then restart your casting, Sorry, your stretching, manipulating and casting. We've been talking about babies, really brand new babies who we would start casting at maybe 2 to 3 weeks of age. The older the footer is the harder it is to correct, but he can still do that even up at the age of six or eight, but it will take more casts and it will be a longer treatment period. We've also learned that some feet are particularly stiff or they're particularly, the creases are particularly deep and these are not the straightforward feet and we sometimes have to adapt our technique to deal with these odd feet. If you are adapting your technique every time you treat a foot, then it is your technique that is wrong rather than that every foot is atypical. So you'd have to go back and just try and relearn how your, er, er, relearn the a, the, the ponseti technique. Some feet do correct, but then go back again. So the stiffer or the higher pirani score when you start off the tighter the foot, the more likely it is to relapse. If the parents can't or won't wear those boots and bars, the feet will relapse. But sometimes we blame the family and say, oh, you've not been wearing your boots and bars. Therefore, the foot is bad again when really the fact of the matter is that you did not correct the foot completely. And so it never fitted well into the boot and bars. So if the foot is not corrected, doesn't fit the boots and bars, mums won't wear it because the babies will cry and that is not poor compliance. That is mum being a good mum and refusing to do something that is hurting her baby. This is something that I'm very uh well, most a lot of us are very keen on. I call it this pirani score is now out of seven because I look at how the eter the perineal muscles are working. If they're working well, that's a score of naught. But if they're not working well, when you stroke the sole of the foot, if the eter muscles don't work, then that's a score of one. And if they have a score of one and a pirani score of seven, then the outcome is less good and relapse is er higher. So we found out in 27 years ago now and we've had it recently, um confirmed from a multicenter study that if your either to muscle function here is poor, then you will have a higher recurrence, an increased need for surgery, stiffer feet and more abnormalities in terms of boots and bars not being used very regularly. Continuity of care helps if the family know you and you know the family and you treat them kindly and well and you use the same words, day in, day out and you help them when they need it and you ensure that the splint fits well and that you change from one boot to a different boot to see which ones work best, then compliance becomes much, much better. And with much better compliance, the outcome is much better. So we've identified, I suppose that not all idiopathic feet are actually the same. There are some with poor muscle function. You might say that was a sort of neuromuscular etiology. There are some feet that look a funny shape and are extremely stiff and you might think those are almost like an arthrogrypotic foot. And if they've got poor muscle function and or they're very stiff, maybe, maybe they're not truly idiopathic and maybe that's why their results aren't quite so good because Ponseti described his treatment for the idiopathic foot. So in this classification, we won't be treating the postural cos they get better on their own. The ponseti technique is excellent for the idiopathic feet. It is not so good for the neuromuscular or the syndromic foot. And so if we are identifying in the idiopathic group a few feet that are particularly stiff and particularly poor muscle function. Then it is not a surprise to me that they behave more like the neuromuscular or the syndromic feet. And the ponseti technique is still well worth doing, but you might be a little bit more likely to have to do some surgery. I do surgery on those rare occasions when I've failed to obtain or maintain a correction with the ponseti technique, there may be uh medical factors as well. That means it's difficult to really do the ponseti technique. There may be social factors but the results of operative treatment are not as good as the ponseti treatment. So really, we should try very hard to make the ponseti treatment be appropriate and work well for these families because if I do surgery, it is big surgery and we leave big wounds at the back which heal with granulation tissue and we can end up with quite a nice result. But the foot is stiff and we want a foot that is supple. So this is a foot that I operated on years ago before I knew the ponseti technique. The scars are healed up nicely, the feet look good, but they are quite stiff and he does not like walking or running on uneven ground and uneven ground is everywhere even in central London. So the art and science of pediatric orthopedics is trying to decide what to do in each case. So what I learn with club feet is that the supple foot can cope with some deformity, but the stiff foot can't. So again, in the adult, the foot that looks worse is actually very mobile and can be easily splinted in a great position. Whereas the other foot, which is a stiff flat foot is much more uncomfortable. So what the patient wants for adult life or a teenager done is a comfortable foot that is functional and that is cosmetically acceptable. I ea pretty foot. So that's what the whole of the Clubfoot management is aiming for. So I'm just gonna go on now to a little bit about the hip and then there'll be time for questions and answers because the clubfoot is a condition that is obvious when the baby is born, you see it, you cannot forget about it. Mum will point it out to you. But the trick is to also make sure that you look at everything else in the baby because the most important thing is to check whether the hip is ok or not. We have a hip condition in baby in infancy called congenital. That means you're born with it dislocation, meaning there is no contact between the femoral head and the acetabulum of the hip joint. Over time, we tend to have changed that phrase to developmental dysplasia of the hip, similar words, but a bit of a difference in meaning and there are, in fact, both conditions existing. So your examination in ba in infancy, in the neonate. When you've finished examining his uh foot, you need to examine the hip to try and decide whether there is a dislocation of the hip or a developmental dysplasia with the hip moving in and out of joint in a more subtle manner. And so again, we're talking about the basic principles. This is a baby who's been squashed up inside mum for quite some time and their hips are very flexed and they're often a little uh abducted to crossed over. And as the baby is delivered and the maternal hormones are racing round mum to relax every ligament that she possesses to allow the baby to be born. Those hormones will also have an effect on the female baby's ligaments and joints and maybe make them a little bit lax as well and make it a little bit easier for joints to be uh unstable when they're born because if we go back to the 12 week old embryo. So this is a section through a 12 week old baby. And you can see that the femoral head is deeply wrapped around by the acetabulum. And you can't really imagine that femoral head coming out of joint. But as the baby in utero grows up, this coverage of the femoral head becomes less. And it means that it is easier for the for the femoral head to be dislocated perhaps during the process of being born, particularly perhaps in the presence of the maternal hormones. So our examination is to look, move and feel. And in this baby, we get the feeling that there is maybe a shortness of the left leg compared to the right. You might think that the gap between the the black square covering the perineum and the outside side of the leg is greater on the left than on the right. And there may be some abnormal creases here as well. But the most important thing is that we want to do the Barlow and Ortolani tests. So we have a happy baby. We have gentle examining hands which are holding the baby's thighs and which are then abducting the hip. And we're looking for limited abduction of the baby hip. And if the baby hip abducts fully, then that hip has a good range of abduction and is not dislocated. So you then want to do a dynamic test, the Barlow test perhaps to see if you can dislocate the hip. And to do that, you bring the leg right up again to the ad ducted position and push backwards and see if you can encourage the femoral head to slide out of the acetabulum a bit like it might do in this baby as it was being born. So we might go into more detail on this on another session. But when I examine the baby's hip, what I want to know is, is the hip dislocated. Is there limited abduction inflection? If there is, if the hip is dislocated, can I relocate it by with my middle finger, which is on the other side just here of the baby's thigh. Can I lift the femoral head into joint? In which case, it is an auto positive hip? A dislocated hip which is reducible if it's not a dislocated hip, I bring the legs back up to the midline and I see if I can dislocate the hip. is it dislocate abo that's a Barlow positive hip. And if it's neither dislocated nor dislocatable, then I want to know is the hip clinically normal? And am I sure or do I need to investigate any further? So, in the UK, for example, it is a legal requirement to screen clinically all babies looking for the signs of a dislocated hip or the signs of instability. And we do it once or preferably twice, at least in the neonatal period in many countries. Now, we also do ultrasound screening of the baby's hips. And again, who are we screening where we either do universal screening or selective screening of babies at high risk? Again, we're looking for anatomical features of a dislocated hip or signs of instability. And again, we do it once or more in the neonatal period. And I would say that the ultrasound probe is merely an extension of my examining hand and therefore should be done together. I call it the egg and spoon race, which is a very English thing, the egg has to be in the spoon. And here we have a um pelvis and where the orange line is and around the acid tulum. So I'll line down the iliac wing and around the acid tulum. That is the picture that we get when we're doing an ultrasound scan. So there's my line down the iliac wing extended over the front of the hip joint. This is my acetabulum and this is my femoral head sitting within the hip joint in the UK. At least they often show us those pictures, show us those pictures the opposite way round which is where my spoon handle, my spoon and my egg come from. And so I have here a poor quality spoon not really looking after the egg, the femoral head, a dysplastic acetabulum, an egg that is barely a femoral head that is barely in the joint. And if I run too quickly with that, you can imagine that my egg will fall off my spoon, my hip will dislocate. Whereas if I keep these two together and allow the leg to kick and move, then gradually this egg will mold itself a better quality spoon. So this femoral head by moving in a supported manner will mold itself a better quality acetabulum and my hip joint will develop nicely. And we go back to the beginning where we say that at the beginning, when the baby is very young, everything is cartilage and only a bit of bone. So you can harness the growth potential and mold the baby to the shape that you want it to be. So those dislocated hips, we keep them in the right place in a harness. We allow the baby to kick the leg around a bit and we watch over time as the socket improves, the acetabulum improves gets deeper and a sharper edge and the femoral head is happy in the hip joint because if we don't treat it early and we then have to take x rays in the older baby, we're looking at shadows. And what we're wanting to see is where the cartilaginous femoral head is on the top of this neck. And so I therefore maybe have to put some dye into the joint to outline the cartilaginous part and to look at the problems around the acetabulum that are blocking a femoral head from going into the acetabulum. So for D DH, we talk about some blocks that stop the femoral head going into the acetabulum, there'll be tight muscles, there'll be a, a constriction of the capsule. And inside the capsule, there are several structures which are taking up space and prevent the femoral head from relocating. So, therefore, again, like the club foot, my indications of doing an operation would be a subluxed or dislocated hip that I'd failed to get in with a pelvic harness or something that presented late. And again, I have to do no harm. So, again, surgery is an art. It's open to interpretation. And what I do depends on my experience, the patient and how they present and what the family can cope with. So we've got to first do no harm and remember to treat both the foot and the hip. Very kindly. Thank you. Fantastic. So, I hope that made a little bit of sense. Thank you too. And I thank you very much for a very comprehensive uh talk. We've got some questions from the chat if that's alright. Yes, I'm just trying to look at those. So I'm starting, I suppose I'm starting uh Omar would the relapse percentage be higher in rural areas for patients and the patients who live in? Um maybe but maybe not. If you have a rural health practitioner who is a very good ponseti technician and who works well with the family, then the relapse rate will be the same as in the big cities. That's in theory, it may not, may not work quite so well in practice, but in theory, it is the skill of the practitioner that keeps the foot in a corrected position. Definitely makes sense. If anyone has any other questions for Miss Eastwood, could you pop them in the chat? Otherwise I have a a question myself. Um Actually, we've got, we've got another question. How common is Clubfoot in the UK? Is there a country where it's more prevalent? Um Yes. So it's um I would say uh one or two per 1000 babies in um 2 to 3 per 1000 babies in the UK. So um some groups are very, have a very high in instance. So for example, the Maori population in New Zealand and some of the Pacific Islanders have a very higher incidence. And so as part of their culture, they know that it's very common and they could have taught us about the ponseti technique because they tell us that it's the females of the family of the tribe who would just manipulate the baby foot for hours on end while they're chatting and whilst they're doing this, that and the other and mummy will do it and then aunty will do it and then big sister will do it. And so they learnt that manipulation helped. So yes, it's very, very different between different families. Uh Most sensitive method in diagnosing CDH less than six months. Um probably a good quality ultrasound scan. But I you ei emphasize the good quality because ultrasound scans to me look a bit like a snowstorm on a bad day. You know, you can't always see what you're looking at. So it has to be a good quality ultrasound. Um after pav post 6 to 8 weeks inhibit. Um So I, yes, you're right. I would tend to use a pelvic harness for 6 to 8 weeks. Some would do for 12 weeks once the hip is reduced. And then I think you're duty bound to follow the child up. So at six months with an X ray to check that everything's developing well, and probably at a year minimum for once a child is walking with another x-ray. There are some studies going on at the moment to decide whether you can say goodbye to the baby at one year of age or whether you need to watch the hip develop a little bit more, say up to the age of four or five. So that's a and I would say that depends on exactly what sort of hip you're treating in the first place. If it's a congenital dislocation that has popped straight back in again, maybe it's gonna be good forever. If it's one that's a little bit dysplastic, just not, doesn't seem to know how to develop, then maybe you need to watch that one a bit more carefully. Um Specific absolute contraindications, the bon set. Well, there's got to be, hasn't there. Um So if the baby was a very poorly baby on the intensive care unit, you might think that it was not the right time to be adding an extra hassle factor of doing the plastering, you could do the plastering, but you might think it wasn't. I would say also if the skin condition is poor, um you'd need to be very careful but mm very few absolute contraindications. So head of femur ossifies by six months only. Yeah. So up until six months, the ultrasound will be very useful. After six months, when the aci nucleus is getting bigger, then the ultrasound becomes less helpful, which is why you tend to have an xi tend to have an X ray from six months onwards 7 to 8 months old with an acetabular index of 30 degrees, that's probably within normal limits as long as the hip is in joint. So the bony acetabular index is really very can be very high in a brand new baby. Uh, if the child older than six years manipulation was splinting still in effect, I presume we're talking about club feet. So if the child is six and presents to you with a club foot that has previously been untreated and if the child is, er, er, has no neurological abnormality, no syndrome, ie an idiopathic clubfoot that chose to come to your clinic age six. Then yes, manipulation and splinting or casting with the ponseti technique is likely to be effective. Oh, oh, yes. Thank you. Couple. That's a horrible question. Um, so that is a syndromic condition if you've got multiple joints that are problematical. So some congenital dislocations of the knee with stretching and manipulating will go back into joint within the first few weeks of life. And once you've got the knee reduced, you can then concentrate on getting the hip reduced. So I would tend to try and get the knee reduced first and then reduce the hip if within a few weeks getting the knee into place is not working. I abandoned the knee temporarily and go back to the hip and try and get the hip in. So it's nice to get either the hip or the knee in with stretching and preferably get both back in with stretching, but sometimes not possible if it's a very stiff and syndromic condition. Thank you very much for some, oh, there's more questions, but thank you very much for the very thorough answers. So. Oh, totally arthroplasty. Age eight. Never. No. Nope. Um, uh, no, ID DH would only need a hip arthroplasty if someone had treated it and it had gone badly. And that would never be at age date. It would not, not be before growth's completed. So, not before 15 or 16. Yeah, I totally agree. Emmanuel. Um, so there are, er, programs that have come out of, er, Southern Africa and rural India, I believe, which have shown that in some areas the families move up to the center and stay for three or four weeks and they stay and have an accelerated program and they have the cast changed every 4 to 5 days and therefore the total treatment time instead of being 5 to 6 weeks becomes 2 to 3 weeks and then they can go back home with their boots and bars. But you're right. It's not, it's not ideal. Um, so we, you, there are areas where they've tried to get the, the ponseti practitioner can move from village to village and hopefully get round several villages uh, over a, a week or 10 days. But I totally agree. It's very difficult. Not impossible. If anyone has any last questions for Miss Eastwood, please pop them in the chat. I think that might be all. Thank you so much. My pleasure. 00, no. Yeah, two questions. One from MUFA and one from Ahmed. If you're happy to answer them before, I, er, never any indications for immediate immediate surgical erection of talipes in a brand new baby. Absolutely not wait until they're much closer to walking age if you have to, uh, in case of it, why do we leave hip without surgery till after one year? Um, I wouldn't, I would treat it conservatively with a pelvic harness, but if that doesn't work, then you need to pick a time when it is safe to do the surgery, which in England I would say is after the age of 6 to 7 months and the older the child is, the bigger the child is, I would say the slightly easier the surgery is. So. No, we don't definitely leave it till after one year of age, but we do it when it's safe and appropriate to do so. Thank you. Great. Thank you so much. Um, thank you very much for a wonderful talk and thank you very much for answering all our attendees questions as well. It was lovely having you. Uh, and I hope uh, you'll come back for further talks as well. Absolutely. Uh, I'd like to introduce Miss Bows, who's gonna be talking about talking about foot and ankle trauma. I'll let you take it off. Thank you so much and thank you for asking me. I much appreciate it. Ok, so, uh, I hope I'm sharing now. Ok. Wonderful. Thank you very much. So, we'll just speak a little bit about foot and ankle trauma to follow from that amazing talk. Um II learned quite a lot actually from that talk. So, thank you, Deborah. Ok. So, uh ankle injuries are um a little bit different from, uh let's say a femoral fracture. And one of the reasons for that is because the bones of the ankle are very close to the skin. And so lots of ankle injuries, whether they are sprains or fractures can be associated with quite a significant soft tissue component and that makes them special because you have to think of the soft tissues in addition to what's happening to the bones and the joints. Uh One of the uh things to notice about the bruising in an ankle injury is that it doesn't extend onto the sole because of the way that the plantar fascia is. And so unless there's an associated foot injury, as you can see in that photograph, there's quite a clear demarcation uh where the bruising is and it doesn't extend into the sole of the foot unless there is a foot injury. Uh but as you can see on the other photograph on the right hand side, uh the there can be quite significant blistering and swelling, particularly in displaced or high energy injuries. So if we start with ankle sprains, um they are a ligamentous injury and they usually result from a twisting injury. So for the so called low ankle sprains, it's usually an inversion or an aversion injury of the ankle. Whereas for the high ankle sprains, it's usually a rotational injury that damages the interosseous membrane. So you can see from the photograph on the right hand side that there are certain ligaments that are involved in lateral sprains. Uh The commonest of these is the anterior talofibular ligament. But it can also involve the calcaneofibular ligament. There is a posterior talofibular ligament, but this is less commonly involved in sprains. And you can also see that there are different gradations of sprain uh from a simple stretching all the way to a complete tear of the ligaments. Usually management of ankle sprains is non operative. So we start with what we refer to as rice, which stands for rest, ice compression and elevation and then progressive weight bearing and physiotherapy as symptoms permit. We know from the literature that physiotherapy and proprioceptive training is associated with a decreased rate of reinjury. And so surgery is rarely indicated for these injuries. We tend to reserve it for recurrent or symptomatic instability of the ankle. So, moving on to ankle fractures. So there are lots of different ways of classifying ankle fractures. And the point of a classification system really is that it helps with communication and treatment decisions. So, one of the common classifications that we use when we are describing ankle fractures is the Weber classification. And that classifies the injury according to the level of the fibular fracture in relation to the syndesmosis. So you can see on the uh x-ray that a type, a vabra fracture is below the level of the syndesmosis. So when I say syndesmosis, I'm referring to the inferior tibiofibular joint aba B fractures at the level of the syndesmosis. Whereas Ava C fracture is above the level of the syndesmosis where A and B fractures are usually stable injuries and can be managed non operatively. But some B and almost all C fractures involve the syndesmosis and the interosseous ligament and therefore, are inherently unstable. And so these are usually managed surgically. Now, I'll talk a little bit about another classification system which we commonly use, which is called the Lager Hansen classification. And although it's not quite as straightforward as the Weber classification, it has certain advantages because it's very descriptive of the type of force that was required to cause the fracture. And that in turn helps us with understanding how to reduce the fracture. So the Lager Hansen classification usually uses two words to describe the fracture. The first word describes the position of the foot at the time of the injury, the second word describes the direction of displacement. So again, you can see on these illustrations on the left hand side, this is called a super abduction injury. So that means that the foot at the time of injury was sated and then the force of the injury was an auction force. And so this tends to take off the lower ligaments on the lateral side and then it takes off the medial malleolus in a vertical fracture pattern. On the right hand, the illustration is showing a super nation external rotation injury. And this is where again, the foot is supernate at the time of injury, but the force now is an external rotation force. So you can see that the structures that are likely to be damaged are the lateral malleolus and the medial malleolus and it goes up in severity. So it starts at the lateral side and then gradually moves around to the medial side resulting in a break in the medial malleolus as well. So what about what happens when the foot is pronated? So when the foot is pronated, the force can either be an abduction force or an external rotation force. So the illustration on the left shows you what happens when the foot is pronated and is subjected to an abduction force. And you can see that these tend to be uh short of bleak or transverse fractures of the distal fibula together with the medial malleolar fracture. On the other hand, the illustration on the right shows what happens when you have an external rotation force that is applied to a pronated foot. And again, the injury here will start on the medial side and then we'll work usually across the joint, up the interosseous membrane and out through the fibula. So these tend to be quite high fibular fractures. And if you were using your Weber classification, they would be a Weber c. So it's just a different way of classifying, but it's a little bit more helpful when we think about how to reduce the fracture because it tells us which forces we need to reverse in order to get a reduction. So these are x-ray representations of what I've just shown you. Uh So you can see if you start from the left side. Uh That's a ation auction injury where the foot has been supernate and then an auction injury has been applied to it and it takes off the fibula at a low level, but then passes up through the media malleolus in a vertical fracture pattern. The next one along is supination external rotation where uh you get a medial malleolar fracture and again, a distal fibular fracture. But this is an oblique fracture of the distal fibula. The pronation abduction is the next one. And again, here you can see that the force travels along that pattern of abduction so that you end up with a fibular fracture, which is either transverse or short of leak. And then the last one shows you pronation exon rotation where you end up with a very high fibular fracture. And usually this means that the line of the force has traveled from the medial side across the joint and up the interosseous membrane. So this is quite an unstable fracture pattern. So how do we know that we have uh displacement? And the reason we want to know if we've got displacement when the fracture is reduced is because we need to understand whether this is an injury that requires surgery or not. So, after you've reduced your ankle fracture, then you need to look at certain radiographic parameters to understand whether the fracture is still displaced enough to need surgery. So if you look at this X ray, it shows you a normal ankle and there are certain things that we look at. So if you start with the X ray on the far right, this shows you an ankle, that is what we call a mortus view, that means that the leg is about 15 degrees internally rotated. And when you take an X ray in that position, you can see that there is a clear space between the talus and the tibia all the way around and that clear space is equal, all the way round and the normal is about four or five millimeters. So that's one thing that you're looking for. Another thing that you're looking for is the overlap between the tibia and the fibula. And you can see that on a mortar view, the overlap is about five millimeters. If you look at the X ray in the center, this is a straight AP view and because it's a straight ap view, the overlap is slightly greater. So it's about 10 millimeters. So these are the parameters that you're looking at on an X ray. Now, the treatment of ankle fractures really depends on the type of fracture and the type of reduction you get and really on the patient as well. Because if you have a very unwell patient, then you may choose non operative management. So, indications for fixation are usually if you get an unstable fracture, open fractures, we do operate on uh talar displacement as seen on x rays using the parameters I've just described or widening of the syndesmosis, bimalleolar and trimalleolar fractures tend to be intrinsically unstable. So you need to uh look at those quite carefully to decide if they need surgery. There is now evidence in the literature to show that you can use closed contact casting. So that's applying a plaster cast uh that is closely applied to the leg. Uh without of course, uh the risk of creating plaster sores. So the bony provenances still need to be padded, but a close contact cast for older patients uh with poor skin is probably preferable to surgical treatment. Uh However, the precondition of that is that you have to have gained a closed reduction. So if you can't reduce the fracture closed, then you would have to open it and fix it. I'll speak about what we call the posterior malleolar fracture. So, on an X ray, this is actually the posterior articular part of the distal tibia and they're commonly referred to as posterior malleola fractures. Now, previous teaching used to say that if the size of the posterior malleolar fragment was less than 25% of the articular surface, then those didn't require fixation. However, new thinking tells us that the fragment is usually attached to the posterior inferior tibiofibular ligament and this is an integral part of the syndesmosis. So, actually reducing and fixing the fracture, restores the integrity of the syndesmosis. So now when we consider posterior malleolar fractures, we use this classification here which is the uh Molloy classification, Mason and Mollo classification. So if you look at the uh the first image on the top of that picture, you can see that this is just a small sliver of cortex. And although it is attached to the P I TFL, uh we tend to treat these without fixation providing uh the fibula is out to length. If you look at the type two fractures, two A is a big posterolateral fragment and two B is a combination of poster medial and a posterolateral fragments. Those usually require fixation. And then a type three is a much bigger fragment and that does require fixation. So that is the current thinking of the posterior malleolus pelon fractures. On the other hand, are fractures of the tibial pla fond. So that's when I say tibial pla fond, what I mean is the articular surface of the distal tibia. Now, these are a slightly different beast, they tend to be higher energy than a simple ankle fracture. And the management is therefore much more complex. They usually also associated just like ankle fractures with a significant soft tissue component and the zone of injury tends to be a lot wider. So if you look at the clinical photograph on the right of the screen, you can see that the zone of injury stretches for almost from the heel all the way up to the mid part of the calf. So a very wide zone of injury, the management is more complex than the simple ankle fractures. And it's really essential to get CT scans in order to understand the fracture pattern and to know uh how you're going to fix it. So there is a classification which I mentioned briefly, which is the O TAA O classification. And broadly speaking, there are three types, there are extra articular fractures which don't involve the uh articular surface. There are partial articular fractures where most of the articular surface remains intact, but a large part is taken off by the fracture. And then there are complete articular fractures where it involves most of the tibial pla font and those again are subdivided according to whether the articular component and the metaphyseal component are simple or complex. So it just helps in describing the fracture and then sometimes it also helps in uh guiding us as to how we would uh fix these fractures. So Pones can be treated in a variety of ways. They can be managed non operatively if they are relatively undisplaced or if you have a patient with a lot of comorbidities, they can be treated by internal fixation or external fixation and sometimes with a very bad fracture where the articular surface is completely destroyed, they can also be treated by primary ankle fusion. So the what what you do will depend on the configuration of the fracture, the condition of the soft tissues and the patient's condition. So the x rays there show you two examples. The one on the right is of internal fixation and the one on the left is of management in a circular frame fractures and dislocations of the talus are a significant injury. Now, the talus has no muscular attachment. It has only ligamentous attachments and that makes it prone to dislocation in high energy injuries. Now, the problem with fractures and dislocations of the talus is that the blood supply to the talus is a little bit special and the blood supply to the body of the talus comes from the deltoid branch of the artery of the tarsal canal. So that's a branch of the posterior tibial artery. And when you have a fracture of the tail and neck or a dislocation of the talus, that tends to disrupt the blood supply to the body of the talus. And that can lead to avascular necrosis. So, in dislocations and displaced fractures, the risk of avascular necrosis and posttraumatic arthritis in the subtalar joint is very high. So in these injuries, they need urgent reduction and usually require surgical stabilization. Now, I'd like to draw your attention to the X ray on the left on the top which shows Hawkins sign. So I've mentioned that displaced and dislocated fractures are at a high risk of developing avascular arthrosis, which is where the body of the talus dies. And so what we uh observe postoperatively is we look very carefully at the X rays to make sure that we can see Hawkins sign. The Hawkins sign if you look at where the arrows are pointing to is a line of uh lucency just underneath the cartilage of the talus. So it's a subchondral lucency. And the reason that's important is because it shows that the bone is still alive because that lucency appears when you have an intact blood supply, which can take away the mineralization of the bone. If you didn't see that lucency, and if you saw sclerosis instead, then you would be very concerned for avascular necrosis. Avascular necrosis is a very difficult condition to treat because ultimately, it leads to fragmentation and collapse of the bone. And in these cases, you may need to perform a subtalar or an ankle fusion as a salvage procedure. There are nowadays, talar replacements, but this is quite a new technique. And uh I think that uh they're probably only suitable in certain very select cases. So, Calcaneal fractures again, uh usually a high energy injury after a fall from a height or a road traffic collision. The majority of Calcaneal fractures are intraarticular, which means that they involve the subtalar joint and they usually again have a soft tissue component because the Calcaneum is very close to the skin. If you have an associated injury to the heel pad, such as crush or loss of the heel pad or even dislocation of the heel pad, then that can be a limb threatening injury because that means that most of the blood supply to the calcaneum has been disrupted. And if you lose your heel pad, there is very little you can do to replace it. So if you were to lose skin in other parts of the body, it can be replaced by uh plastic surgery using flaps. But if you lose your heel pad, you can't really replace that with a flap. And so this is a limb threatening injury. If that happens, the X rays on the right hand side show you certain angles that we use to measure, which tell us whether uh the Calcaneum has been fractured and has lost height or shape. So bolar's angle is the angle that you can get if you draw a line from the highest point of the Calcaneal tuberosity to the highest point of the subtalar joint. And another line from the highest point of the subtalar joint to the highest point of the anterior process of the calcaneum that gives you your Bolar angle, which is about 20 to 40 degrees. Normally, the other angle that we draw is the critical angle of the gane. And uh oh I'm sorry, uh let me just uh move back. So the other angle that you can draw is the critical angle of the GSE. And that's from the highest point of the subtalar joint to the sulcus and the highest point of the anterior process to the sulcus. And that angle is usually 100 and 20 to 100 and 40 degrees normally. So when you're looking at x rays, those are the things that you're looking for for subtle fractures, obviously more obvious fractures, uh you'll be able to see without having to draw those lines. And the CT scan is usually very helpful in that it delineates the fracture pattern. So at the bottom, you can see x rays of two types of calcaneal fractures that are fairly common. One is the tongue type where the attachment of the achilles tendon has pulled the superior part of the calcaneal tuberosity upwards and the other is the joint depression type where the subtalar joint has collapsed. So, treatment of calcaneal fractures again, uh depends on many different factors. Uh the patient as well as the injury, usually we advocate surgical fixation for whether the tuberosity is displaced and has been pulled upwards by the achilles tendon or if the heel has changed shape in any way. So if it becomes shortened or widened or it's in a varus angulation and it's going to impinge on the distal fibula. Those are cases where you want to restore the height and the shape of the heel. Uh if the subtalar joint is damaged and that's that, that damage is already done and you may not be able to influence what happens after that. But if you correct the shape of the heel, then you can make sure that healing happens in a good anatomical position and that then gives you a good foundation for fusion. Later on soft tissue breakdown and infection are significant risks of surgery to the calcaneum. And so nowadays, we we are moving towards percutaneous fixation and fresh fractures. So the images at the uh bottom right of the screen uh show you some examples of percutaneous fixation. The achilles tendon is the largest tendon in the body and it is formed from the confluence of the gastrocnemius and soleus tendons. If you have a plantar foot, plantar flexed foot that is suddenly or forcibly dorsiflexed, then you can get an achilles tendon rupture and it commonly occurs during sports, the patient usually reports that they feel a pop or they feel as though someone has hit them at the back of the heel. And when you examine them clinically, you can see in that clinical picture, what you have to do is turn the patient prone and then squeeze the calf muscles. And if the achilles tendon is intact, then you will see the foot moving into plantar flexion. So that's known as the simmons test or the Thompson test. If you squeeze the calf and the foot doesn't move, then that usually indicates an injury to the achilles tendon. And you can use ultrasound or MRI to show you whether it's a complete or a partial rupture. So again, uh you can use operative or non operative methods of treating achilous tendon ruptures. Uh previous literature had suggested that surgical repair has a lower rate of rupture. But more recent evidence shows that actually there is no difference between non operative and operative management. Providing you use functional rehabilitation together with physiotherapy. So what we do nowadays is functional casting or bracing. So you start off with the foot and full equinus and then you gradually reduce that degree of equine surgery surgery. We tend to reserve for uh re ruptures or delayed diagnoses and that can be done open or percutaneous list. Frank injuries are injuries to the midfoot. So they're injuries to the tarsal metatarsal joints and they usually occur when you have axial loading on a plantar flex foot. So a fall from a height or road traffic collision, occasionally in sports like in all foot and ankle injuries, you may have a significant soft tissue component. And in these injuries, you will get plantar bruising. Unlike with pure ankle injuries, the lis frank ligament is a ligament that connects the base of the second metatarsal to the medial canae form. So you can see on those images there that it shows you the lisfranc ligament connecting the medial canae form to the base of the second metatarsal. Uh the lisfranc er ligaments there are dorsal and plantar as well as interosseous ligaments. And the key here is that if you look at the er image, you will see that the second metatarsal is a little bit longer than the others and it's recessed into its joint with the er intermediate knee form. So that recess means that if you look at a cross section of the metatarsal, you will see that they form an arch. So that is the transverse arch of the foot. And because they are arranged in this particular pattern, they form the second metatarsal forms what is called the keystone. So it is that uh that part of the arch which is at the maximum point of the curve. And so the second metatarsal is the keystone of the transverse arch. And the reason that is important is is if you injure the tarsometatarsal joints and the second tarsometatarsal joint loses its integrity, the arch will collapse. So you need x rays and scans to delineate the full nature of a less frank injury. As I've said, it may be ligamentous or bony. And I find that weight bearing x rays are very useful. If you're trying to pick up a subtle injury. If it's displaced, then it needs urgent reduction, particularly if the skin is at risk, those usually require fixation if they are displaced. And we can use uh open reduction and internal fixation with plates for the middle and the medial columns. So that is the first to the third tarsal metatarsal joints, the fourth and the fifth tarsometarsal joints are more mobile and we therefore tend to fix them with K wires which can be removed later on to uh restore that normal mobility very occasionally. If there is a lot of damage, then you need to do a primary fusion of the tarsometatarsal joint. And we also do primary fusions for posttraumatic arthritis. A very common injury of the foot is 1/5 metatarsal base fracture. Um and this happens commonly after inversion of the foot. So you will see that, that illustration shows you that there are three zones of injury at the base of the metatarsal. So right at the base, you have that purple zone which is where you have avulsion fractures taking place because that's the attachment of the peroneous brevis tendon. And so if you have a sudden contracture of that tendon during an inversion, it will pull off the base and that's an avulsion injury a little bit, uh, more distal, you have the metaphyseal junction and a fracture in that region is called the Jones fracture. And the reason that's important is because they have a risk of nonunion, which can be quite high. Um, but we still manage them non operatively and we only progress to surgery if they go on to a nonunion, the only time that you would fix them acutely is if you have an elite athlete and then a little bit more distal is the zone of stress fractures, which is the one in blue. And this happens from repeated microtrauma. Usually in athletes, they're slower to heal because they are cortical bone, they're not cancellous bone. And if they take a long time to heal and they go on to a non union, they, they can cause a varus deformity of the foot and that needs operative management. So I've mentioned throughout that foot and ankle injuries are usually associated with a significant soft tissue injury. And if you have a lot of swelling in the foot, you can get compartment syndrome of the foot. So compartment syndrome is where you have uh a very rigid space such as you find in the foot where there is uh soft tissue spaces that are bound by bones or by ligaments which are rigid structures that don't expand. So if you have swelling from fractures or bleeding into the foot. Then what happens is that swelling has nowhere to expand because of the rigid nature of the walls of the compartments. And that will cause ischemia in the foot because it reduces the perfusion in the foot. And so it causes ischemia just as you would have compartment syndrome in a leg or in a forearm. Now, there are allegedly nine compartments in the foot. This is a little bit controversial. Uh but you have your medial and lateral compartments, you have the plantar compartments, there are two or three and then you have the dorsal interosseous compartments. So there are many compartments in the foot. And if you do get compartment syndrome, then that's usually an indication for an intervention. Now, previously, we used to do a lot of open decompressions. So if you look at the illustration on the top, right, you will see that that's an illustration of how to do an open fasciotomy of the foot. Normally performed through three incisions, a medial incision and two dorsal incisions, which allows you access to all the different compartments. However, we know now that doing open fasciotomies is not without morbidity and you can end up with uh a deformity of the foot if you do open fasciotomies uh because you can get uh contractures. And so we've moved away from open fasciotomies now and we tend to do what's called pie crusting. And so that's a very um descriptive term for people who bake. If you look at the er clinical photograph on the bottom right hand side, you can see that that is pie crusting and that literally means just making multiple stab incisions into the compartments to allow the edema to settle. And you can combine that with topical negative pressure dressings, which will also help with reducing the edema. And then last but not least, I'll mention charco arthropathy. So, a charco arthropathy is uh destruction of joints that you get in patients who have peripheral neuropathy for some reason. Uh diabetes in our country is a common reason for peripheral neuropathy. But you can get a Charcot joint with any kind of peripheral neuropathy. What happens there is that there is no uh protective sensation and there's a lack of app proprioception. So the patient is unable to judge the pressure going through the foot. And so that tends to lead to a lot of destruction of joints usually associated with lots of medical comorbidities like poor diabetic control, uh renal failure. And in these injuries, if you carry out surgery, there is an increased risk of infection and failure of fixation. Uh So you can see here, uh this is a diabetic patient who was treated with an attempted rigid fixation. So the X ray in the middle will show you the POSTOP fixation. And that was you can see that there are screws passing from the fibula into the tibia in a an attempt to make it a very rigid construct. But sadly, the fixation failed, as you can see in the final x-ray where uh there was uh breakage of the plate and loss of reduction of the fracture. And so in these patients, you need absolute rigidity to counteract that lack of protective sensation. We often therefore end up using multiple devices. What what are called superstruct and fusion of the joints is usually necessary because that provides more reliable stability compared to just fracture fixation. Thank you very much. And I'm happy to take any questions. Thank you very much, MS Bs for a really excellent talk. We've got one question in the chat from Margaret. Uh Can you fracture an ankle and a foot without resulting injury to tendons, ligaments, et cetera? Uh Yes. So you can get fractures without uh resulting injury to tendons. Um However, a lot of ankle fractures and foot fractures are also associated with soft tissue injuries. It does make sense and I think she's got another question. Oh, it's the same question. I think she's, yeah. If anyone has any more questions for uh Miss Bose, please pop them in the chat. I give them a few seconds. Uh So they can type away those ballet feet look painful. Yes. Yes, they do. And um I because I actually love ballet. So uh that, that sort of resonated with me. Um Yeah, I was, I was shocked when I learned how many ballet dancers have really bad foot injuries, but they keep dancing with them. So um there's, there's some questions there considered temporary external fixation. Um Yes, that's right. So if you have a fracture that's unstable and you need to fix it, but there's a lot of soft tissue swelling, then you would use a temporary external fixator to hold it in position. Uh Whilst you're waiting for the soft tissues to settle down. Yes. Good question. Conservative management for Lisfranc injuries. Um Yes. So if they're minimally displaced or if when you take a weight bearing X ray, you find that they're not displacing, then those can be managed non operatively better way to remember. Ankle. That's a very good question. I mean, the, the, the classification can be quite confusing, especially the Lager Hansen classification. Um I actually find it, as I've said, a bit more useful than the Weber classification because it tells you the direction of the displacement. Um I don't know if there's an easy way. You just have to think about the position of the foot and the direction of the displacement uh pie crusting. Um I don't know if it's superior but it's, it's not inferior. So it has the same effect as an open fasciotomy, but without the risks of an open fasciotomy. OK. How to decide between temporary ex fix? And, yeah. So um I don't believe there is any randomized evidence. V It's a really good question. Um We tend to make individualized decisions depending on the injury and on the patient. So for example, if I have a patient where they have AAA pelon fracture, that is amenable to internal fixation, but they're very swollen, then I would do a temporary external fixator, wait for the swelling to come down and then do internal fixation. On the other hand, if you've got a patient where they've got significant soft tissue injury and you know that you're not going to be able to do internal fixation. Those are the ones that I would treat definitively with a ring fixator. Um, or sometimes you've got a patient where the soft tissues are closed but quite badly damaged or you have open fractures where you're able to close it. But still, you know that you, if you need to fix the peel on with two or three plates, then the soft tissues will not withstand that. Um Those are the fractures where, where I would go for a ring fixator. So it's a very individual decision, young and burgess. Um Yes, as I've said, there are many different classifications. Um Yes, how, how you remember them? I II haven't got an easy answer for that one, I'm afraid. Um, so far we didn't have level one evidence. Um I think there are some evidence. You, you're right. I mean, we probably don't have a lot of uh long term evidence, but the papers coming out now are showing that uh if you fix the posterior malleolus, you uh greatly increase the contact area with the talus and that does protect against delayed arthritis, posttraumatic arthritis. So there is some evidence of that um coming out and time will tell, I guess uh the rationale behind the fame trial. So the rationale behind the fame trial. So for those of you who don't know, um I mentioned that uh there was some evidence to show that close contact casting for uh older patients if you can reduce the fracture has just as good results as fixation. Now, the same trial looks at the same thing in younger patients. Um and whether you could do a close contact casting for displaced fractures in young patients. Um And so that was the rationale behind the fame trial, whether you could apply the same uh uh reasoning to a younger patient. Um The measures that are accepted, as I said, you have to be able to have a close reduction uh in order to do a close contact cost. Is it routine to operate on achilles tendon ruptures? Uh No, as I've said, uh we've moved away from that now and uh we, we see that the newer evidence shows us that if you do a functional bracing, uh you have just as good results as uh surgical management. So we've moved away from surgical management. Now, information about Tarsal Coalition, I think that is Professor Eastwood's territory more than mine. Um in case of a tailor extrusion. Would you attempt to hunt overnight? No, I wouldn't, I wouldn't leave it until the morning. Uh, if you have a tailor extrusion, I would manage that as an emergency overnight. Um, II definitely wouldn't leave it until the morning. Strong evidence for fixation of purely ligamentous. Um, I don't know if there is strong evidence, as I've said, if, if we have minimally displaced less fractures. Um, and if you have a weight bearing X ray that shows you a good position, then we do tend to treat those non operatively. Um But a purely ligamentous fracture is probably more reason for fixation because if you have fractures that aren't purely ligamentous, then we know that bones heal better than soft tissues apart from the plantar bruise, any other signs or symptoms. Yes. Uh Swelling and displacement. What determines your fixation for a trimalleolar? I presume you mean what determines my fixation for a posterior malleolar fragment? Is that right? Um If that's the case, then uh I tend to use the classification system that I talked about. So if it's anything larger than a type one, so type two or three, then I would tend to fix it. Um Simply because as I've said, reduction and fixation makes sure that you've stabilized the syndesmosis. It means you don't have to put a syndesmotic screw in which leads to all those questions about how long do you leave a syndesmosis screw in? When do you take it out. So if you fix the posterior Maness, you don't have all those questions. And as I've said, you greatly increase the contact, the surface area of contact between the tip pla and the talus isn't young and Burgess for Pelvis. Uh So I thought that too. Um II suddenly thought, oh my goodness, is there a young and Burgess for the ankle that I'm not aware of? Um But yes, II do think that young and Burgess is for the pelvis. Yes. Um In diabetic neuropathy, what is the pathological pathway? Um As I've mentioned, the problem with the diabetic neuropathy or any other peripheral neuropathy is that there's a lack of protective sensation and because there's a lack of protective sensation, the patient isn't aware of the amount of pressure that they're putting on the ankle and that does lead to destruction of the joint. Um No, I don't believe there's a preference woman. It all depends on how destroyed the joint is. I guess if you have a joint that's very destroyed, then you would go for fusion. Um But I don't think there's a preference. It's very individual depending on the injury. Thank you very much MS BS for an incredibly comprehensive the um answers. That was a lot of questions from the audience. Um If the audience have any other questions, please pop them in the chat to perhaps wrap up maybe early. Um If we don't have any more questions, but thank you. So so much uh for giving a wonderful, wonderful talk. Uh, the audience are clearly very, very appreciative of it and I learned a lot as well myself. Um, I don't think we've got anything in the chart yet. Good and we hope to see yourself and Miss Eastwood back with me, education to give more informative and educational talks. Absolutely. Thank you. That'd be wonderful. I don't think we've got any more questions. Just lots of thank you. Yeah. Always good to have. Absolutely. Absolutely. Yes. It's very, uh, very kind of you all. Thank you. Great. I will end the live um, so we can stop our recording, but you'll still be able to.