Video Introductions

Maneesh Bhatia

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Pilar M de Albornoz

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Manuel Monteagudo

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Venu Kavarthapu

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Nilesh sMakwana

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Chapter 1 - Foot and ankle examination

A general foot and ankle examination consists of seven components inspection, gait analysis, palpation, joint range of movement, neurovascular status, key muscle strength and special tests. During Coleman block test with a flexible hindfoot, the heel will correct to a neutral or valgus position. Performing Coleman block test is essential in any case of hindfoot varus, as a flexible deformity can be addressed by correcting the first ray in isolation, whilst a fixed deformity requires surgery to both the hindfoot and forefoot. The CFL is an extra-articular ligament that resists internal rotation and inversion in a plantigrade or dorsiflexed foot. It is assessed using the anterior drawer test and inversion stress test with the ankle in a plantigrade position. Coleman block test must be performed and accurately interpreted for any hindfoot varus.

Bilateral neglected Achilles rupture examination

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Cavovarus examination

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Eqinovarus examination (neurological cause)

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Diabetic Foot Presentation

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Chapter 2 - Applied anatomy and surgical approaches

An appropriate selection and execution of a surgical approach is essential for the success of any surgical procedure done for foot and ankle injuries and ailments. It divides into medial and intermediate dorsal cutaneous nerves of the dorsum of the foot at different levels, and these branches supply dorsal areas of the foot and toes except for the web space between the great and second toe and the lateral side of the little toe. The anterior approach to the ankle is commonly used for arthrodesis and arthroplasty of the ankle and for fixation of Pilon fractures. The anterolateral approach provides excellent visualisation of distal tibia up to the medial shoulder and distal fibula, and is useful for fixation of intra-articular fractures of the distal tibia or osteochondral fracture of talus. The posterolateral approach can be performed with patient in either the lateral or prone or recovery (sloppy lateral) position.

Applied anatomy and surgical approaches

Chapter 7 - The rheumatoid foot

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterised by synovitis and periarticular bone loss. This chapter aims to provide a guide on how to assess a patient with RA, including commonly encountered anti-arthritic medications, conservative measures and surgical options available. Laboratory investigations that should be performed in patients with suspected RA include erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-cyclic citrullinated peptide antibodies. Radiographic evaluation should include weight-bearing views of the foot and ankle. Prescription footwear is an important adjunct therapy in RA patients because they have lost the fatty protective plantar tissue, have hypersensitive and inflamed skin and unstable joints. The orthotics function to: redistribute weight-bearing forces, decrease vertical and shear pressure and also horizontal movement within the foot. In the ankle and hindfoot, fluoroscopic guided injections have been shown to be superior to blind injections for diagnostic purposes and temporary relief of synovitis or arthritis.

Ankle Replacement

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Chapter 8 - Pes plano valgus

Pes Plano Valgus (PPV) is one of the commonest conditions referred to an outpatient foot and ankle clinic. Physical examination is the key to diagnose PPV, but imaging studies are necessary to exclude arthritis as this finding may influence the choice of treatment. Lateral pain due to fibular impingement may be present in severe deformities. Clinical examination should start with a visual gait analysis with the patient barefoot and both knees and ankles visible. It is very important to rule out proximal deformities because PPV may be secondary to compensation of a varus knee. Raikin et al. developed a new classification considering the deformity of the different segments rearfoot, ankle and midfoot. Clinical examination and imaging studies allow the reader to know whether the deformity is flexible (think of osteotomies) or rigid (think of arthrodesis). The goal of surgery for a flexible but painful PPV is deformity correction to achieve a plantigrade foot.

Pes Planus Calc Osteotomy

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Pes Planus Evans Osteotomy And Implant Trial

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Pes Planus Cotton Osteotomy And Plantarflexion Effect

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Audio Resources

Figure 7

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Figure 8

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Figure 9

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Chapter 9 - The rheumatoid foot

It is a complex three-dimensional structure held in shape by the delicate balance of the intrinsic and extrinsic muscles. In a forefoot driven cavovarus foot, early clinical problems can be from overloading of the first metatarsal head area, resulting in a plantar callosity, sesamoid disease or early hallux rigidus. For balancing purposes, the authors would recommend using equal height blocks under both feet simultaneously. A wide range of potential operations are described in literature which can be daunting. Clawing of the great toe can be rebalanced by the Jones procedure, which involves transfer of EHL to the first metatarsal neck and stabilisation of the interphalangeal joint by fusion in a straight position. Most patients with a pes cavus have a foot drop and a weak tibialis anterior muscle.

Tibialis Posterior Reconstruction

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Chapter 11 - Ankle arthritis

It is a complex three-dimensional structure held in shape by the delicate balance of the intrinsic and extrinsic muscles. In a forefoot driven cavovarus foot, early clinical problems can be from overloading of the first metatarsal head area, resulting in a plantar callosity, sesamoid disease or early hallux rigidus. For balancing purposes, the authors would recommend using equal height blocks under both feet simultaneously. A wide range of potential operations are described in literature which can be daunting. Clawing of the great toe can be rebalanced by the Jones procedure, which involves transfer of EHL to the first metatarsal neck and stabilisation of the interphalangeal joint by fusion in a straight position. Most patients with a pes cavus have a foot drop and a weak tibialis anterior muscle.

Ankle replacement

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Arthroscopic Ankle Fusion & Percutaneous Achilles Tenotomy

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Chapter 12 - Ankle instability

It is a complex three-dimensional structure held in shape by the delicate balance of the intrinsic and extrinsic muscles. In a forefoot driven cavovarus foot, early clinical problems can be from overloading of the first metatarsal head area, resulting in a plantar callosity, sesamoid disease or early hallux rigidus. For balancing purposes, the authors would recommend using equal height blocks under both feet simultaneously. A wide range of potential operations are described in literature which can be daunting. Clawing of the great toe can be rebalanced by the Jones procedure, which involves transfer of EHL to the first metatarsal neck and stabilisation of the interphalangeal joint by fusion in a straight position. Most patients with a pes cavus have a foot drop and a weak tibialis anterior muscle.

Ankle arthroscopy & microfracture

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Ankle Instability

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Ankle ligament reconstruction

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Chapter 13 - Achilles disorders

Achilles tendinopathy is a common cause of heel pain and disability and is categorised into two types based on its location insertional Achilles tendinopathy or non-insertional Achilles tendinopathy. In contrast corticosteroid injections may be considered to treat retrocalcaneal bursitis where they appear to result in significant improvements in pain. Unfortunately a small number of AT ruptures have been reported following retrocalcaneal bursal injections, which may be explained by small anatomic connections between the retrocalcaneal bursa and AT. To reduce the risk of soft tissue break down, the retrocalcaneal bursa and Haglund's deformity can be excised endoscopically. Unfortunately, endoscopic surgery does not allow for the debridement and repair of a degenerate AT thereby limiting its use in the management of IAT. MRI and US are the two most useful radiological modalities for NIAT, and have similar diagnostic sensitivities.

Achilles Reconstruction

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Chapter 14 - Achilles Tendon Rupture

Achilles tendinopathy is a common cause of heel pain and disability and is categorised into two types based on its location insertional Achilles tendinopathy or non-insertional Achilles tendinopathy. In contrast corticosteroid injections may be considered to treat retrocalcaneal bursitis where they appear to result in significant improvements in pain. Unfortunately a small number of AT ruptures have been reported following retrocalcaneal bursal injections, which may be explained by small anatomic connections between the retrocalcaneal bursa and AT. To reduce the risk of soft tissue break down, the retrocalcaneal bursa and Haglund's deformity can be excised endoscopically. Unfortunately, endoscopic surgery does not allow for the debridement and repair of a degenerate AT thereby limiting its use in the management of IAT. MRI and US are the two most useful radiological modalities for NIAT, and have similar diagnostic sensitivities.

Acute Ta Rupture Suture Passing Mis

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Acute Ta Rupture Subcutaneous Release Mis

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Acute Ta Rupture Suture Testing Before Closure

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Chronic Ta Rupture Gastrocsoleus Release

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Chronic Ta Rupture Estimation Of Final Gap

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Chronic Ta Rupture Suture Testing

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Bilateral Neglected Achilles Rupture Examination

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Figure 1

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Figure 2

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Figure 3

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Figure 5

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Figure 6

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Chapter 18 - Calcaneal fractures

Fractures of the calcaneum have a reported yearly incidence of around 12 per 100,000 population, with fractures occurring 2–3 times more often in males and at a younger average age compared to their female counterparts. Tuberosity fractures account for 1-2% of all calcaneal fractures and represent a type of avulsion fracture that defunctions all or part of the Achilles tendon. Patients with calcaneal fractures will present with pain and swelling around the hindfoot with difficulty or complete inability to bear weight through the affected limb. MRI is rarely required in the acute setting of calcaneal fractures as most injuries will be found with the other imaging modalities. The initial management of calcaneal fractures should focus on the assessment and protection of the overlying soft tissues. In 2014, the UK Heel Fracture Trial reported similar 2-year results in calcaneal fractures treated with either operative or non-operative management. Calcaneal fractures may result in post-traumatic arthritis of the subtalar or calcaneocuboid joints.

Calcaneal fracture fixation

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BOFAS

Common Foot & Ankle Tumours - BOFAS Lecture of Distinction