Adult-acquired flatfoot deformity is caused by posterior tibial tendon dysfunction and results in collapse of the medial longitudinal arch. It is classified into stages based on deformity severity and joint involvement.
Conservative management is recommended for stages 1 and 2, involving rest, orthotics, physical therapy and bracing to correct deformities. Surgery is considered if conservative measures fail for over 4-6 months. Joint-sparing procedures are preferred, such as posterior tibial tendon repair/transfer and medializing calcaneal osteotomy. For more severe stage 2 cases, lateral column lengthening procedures like calcaneocuboid fusion or Evan's osteotomy may be used. Stages 3 and
Patella dislocation is a common problem in the young. Recurrence of dislocation can be significant problem causing pain and discomfort. The assessment and guidelines towards non-surgical and surgical treatment options are discussed here.
Patella dislocation is a common problem in the young. Recurrence of dislocation can be significant problem causing pain and discomfort. The assessment and guidelines towards non-surgical and surgical treatment options are discussed here.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Basics of patellofemoral instability for postgraduates. Gives brief introduction about patellofemoral joint anatomy, causes, examintaion and treatment for patellofemoral instability
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Basics of patellofemoral instability for postgraduates. Gives brief introduction about patellofemoral joint anatomy, causes, examintaion and treatment for patellofemoral instability
Collapse of medial longitudinal arch, with the entire sole of the foot coming into complete or near-complete contact with the ground.
Books Refered :
Text Book Of ANATOMY - Vishram Singh
Joint Structure And Function – Cynthia Norkin
Therapeutic Exrercise – Carolyn Kisner
Orthopaedic Physical Assessment – Magee
Orthopaedic Medicine – L. Ombregt
Campbell’s Operative Orthopaedics
Brief discussion regarding management of physiotherapy, pharmacotherapy, orthosis, principles of orthopedic surgical managements, addressing problems at hip, knee and ankle, soft tissue release procedures, osteotomies, timing of surgery, complications, prognosis, hip at risk signs, birthday syndrome, role of botulinum toxin, upper extremity involvement, contracture release.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
2. INTRODUCTION
• Adult-acquired flatfoot deformity is a complex deformity associated
with the collapse of the medial longitudinal arch.
• Posterior tibial tendon dysfunction remains the most common
etiology.
5. Pathophysiology
‘Posterior tibial tendon is crucial for effective gait’
as its contraction facilitates hindfoot inversion, in turn
locking the transverse tarsal joints and creating a rigid platform for
push off.
6. Posterior tibial tendon is supplemented by
• Foot’s osseous architecture
• Spring ligament (plantar calcaneonavicular ligament)
• Deltoid ligament
• Plantar fascia and
• Talonavicular capsule.
7. Insufficiency of the posterior tibial tendon
• Collapse of the medial arch and excessive valgus deviation of the
hindfoot.
• The midfoot becomes abducted at the transverse tarsal joint, with
uncovering of the talar head.
• The vector of pull of the Achilles tendon subsequently becomes
lateral to the axis of the subtalar joint and accentuates eversion.
• Progressive stretching of the medial soft-tissue structures further
accentuates the hind foot valgus deformity, and equinus deformity
may ensue because of an Achilles contracture.
12. SYMPTOMS
• Medial ankle/foot pain
• Weakness
• Progressive loss of arch
• Lateral ankle pain due to sub
fibular impingement is a late
symptom[advanced]
13. • Range of motion single-limb heel rise
Unable to perform in stages II,III,IV.
• Posterior tibial power reduced
• Flexible or fixed flexible deformities are passively correctable to a
plantigrade foot[stage II]
• Rigid deformities are not correctable [stages III and IV]
14. Diagnosis of AAFD 5 KEYS
• Symptoms and deformity
• Single limb heel raise test
• Too many toes sign
• Mobility of talonavicular and calcaneocuboid joints
• Weight bearing x-ray
15. 1.Symptoms and deformity
• Medial pain =AAFD stage 1 and 2a
• Lateral pain =AAFD stage 2 b
No/mild correctible deformity –stage 1
Forefoot abduction and hinfoot valgus –stage 2 and stage 3
Ankle deformity –stage 4
20. 4]mobility at talonavicular and
calcaneocuboid joint
Mobile joints =AAFD stage 2
Immobile joints=AAFD stage 3 / stage 4[stiff/arthritic]
21. 5]weight bearing x-rays :2 views
On ankle lateral view=flattening of arch =severity of deformity
Watch for talo-first-metatarsal angle.
Normal-0 degree
Moderate- 15-30 degree
Severe->30 degree
22. talo-first-
metatarsal angle
• The lateral talus-first
metatarsal Meary
angle, which is the
angle between the
longitudinal axes of
the talus and first
metatarsal
• measure 0 +/- 10
degrees and is
elevated in flatfoot
deformity (often >20
degrees, apex
directed plantarly)
24. Calcaneal pitch, which
is the angle between
a line drawn along the
most inferior part of
the calcaneus and the
supporting surface or
the transverse plane
(normal, 10° to 20°).
25. Weight bearing AP view
• Talar head uncoverage =forefoot abduction
• Talar uncoverage expressed by the percentage of the talus that is not
in contact with the navicular medially
27. Weight bearing
anteroposterior radiograph
Talonavicular uncoverage percentage,
measured as the percentage of the talar
head articular surface not covered by the
navicular (dashed line) over the entire
extent of the talar head articular surface
29. Other xray parameters:by studies
Standing ankle radiographs- lateral talar tilt and ankle arthritis, which
can occur in the later stages of flatfoot deformity.
30. Other xray parameters:by studies
Arch height :
Distance between the medial cuneiform and the base of the fifth
metatarsal may be more clinically useful to differentiate between
normal feet (17 mm) and flatfeet (6 mm).
31. Operative parameter: Hindfoot alignment
x-ray
• Saltzman views
• Hindfoot moment arm: is measured by the shortest distance between
the midtibial axis and the most inferior portion of the calcaneus
(normal, –3 mm [varus]; flatfoot, >+10 mm [valgus]).
• Hindfoot alignment angle: is formed by the intersection of the
longitudinal axis of the tibial shaft and the axis of the calcaneal
tuberosity (normal, 5 degrees; flatfoot, 22 degrees)
33. MRI Evaluation
• MRI is not routinely needed
• However, it can be used to :
1. Evaluate the spring ligament and the degree of damage to the
posterior tibial tendon
2. To identify sites of intraosseous edema, which may be associated
with impingement
3. A preoperative diagnosis of a spring ligament rupture in patients
with severe abduction deformity.
35. Tendoscopic
Evaluation • Tendoscopy is a minimally invasive modality that can be utilized to evaluate
tendon pathology, particularly in patients with suggestive symptoms.
43. TENOSYNOVECTOMY OF TIBIALIS POSTERIOR
• To perform an open synovectomy completely removing the inflamed
synovium,
• Requiring a large 6-cm medial ankle incision.
• Postoperative management included plaster cast immobilization for 3
weeks, followed by a boot with controlled ankle movement for
another 3 weeks
• Now the standard is beginning to shift to Posterior tibialis tendon by
endoscopy, which has proved to be an efficient way to treat
tenosynovitis occurring in stage I and II AAFD.
46. Stage 2a vs stage 2b
Stage 2a
• Less than 30% medial talar head uncoverage [or no lateral
incongruence]
• No clinical forefoot abduction
Stage 2b
• More than 30% medial talar head uncoverage or lateral incongruence
• Significant clinical forefoot abduction.
48. Management of stage 2
‘essentially conservative!’
• Goals:
Deformity correction
Tendon protection
Conservative management first line: try for at least 4 -6 months
Young patients and cases with severe deformity –less likely to respond
49. Stage 2:conservative
Rest to tendon to reduce inflammation
• NSAIDS
• Systemic disease :treat accordingly
• Physical therapy-strengthening ,theraband,cryotherapy,iontophoresis.
• Orthotics –semi rigid, medial heel wedge ,medial column post
• UCBL,Foot mould ,pop cast or AFO.
BUT NO LOCAL STEROIDS
52. STAGE 2:MANAGEMENT
• When to do surgery?
Only after failure of 4 to 6 months of conservative care
• What surgery ?
Joint sparing procedures are the procedure of choice
In very late cases of AAFD stage 2 with subtalar arthritis joint sacrificing procedures are
done
53. Joint sparing surgery
• Tenodesis of tendon of tibialis posterior with tendon of flexor
digitorum longus.
• Transfer of flexor digitorum longus tendon
54. Joint sparing surgery
Medializing sliding calcaneal osteotomy[MCO]
‘Done in all cases of hindfoot valgus’
• Shifts weight bearing axis of tendoachilles
• Addresses hindfoot valgus
• Preserves hindfoot motion
• Usually combined with:
Posterior tibial tendon augmentation [FDL]
58. 3]LATERAL COLUMN LENGTHENING: When!!!
• Forefoot abduction greater than 15 degree talo-first metatarsal angle
on lateral xray.
• More than 25% of talar head uncovering on AP X-RAY
• Overweight patients
What are the procedures?
1. Calcaneocuboid distraction arthrodesis
2. Evan’s procedure
59. Calcaneocuboid
distraction arthrodesis
when??
• Powerful correction is needed
• Adult and long standing cases
• How?
in anterior part of calcaneum
osteotomy is done ,and graft is
taken and placed ,so that
lenghthening is achieved.
60. Evan’s osteotomy.
When??
• Younger age agroup
• To save calcaneocuboid joint
• How?
osteotomy at the body of
calcaneus between the anterior and
middle facet of the subtalar joint
61. 4]Cotton osteotomy
Plantar flexion open wedge medial cuneiform osteotomy
When it is done?
Collapse through talonavicular joint on x-ray of weight bearing axis.
65. Triple
arthrodesis
• If pes planovalgus deformity is
fixed with arthritis in all three
joints .
• Rare conditions:
arthritis of 1 st tarsometatarsal
joint =1st metatarsocuneiform
arthrodesis is done
66. Stage IV:MANAGEMENT
• Deltoid ligament is insufficient, leading to lateral talar tilt and
tibiotalar valgus deformity.
• STAGE IVA:Tibiotalar involvement with a flexible flatfoot.
• STAGE IVB:rigid foot deformity in the setting of ankle joint
involvement
• Radiology:
• Lateral talar tilt +/- ankle arthritis
68. Deltoid ligament
reconstruction
• Supplement to other
reconstructive procedures.
• Improved clinical outcomes as well
as correction of valgus talar tilt by
5 degrees.
• Deltoid ligament reconstruction
techniques using peroneus longus
autograft and anterior tibial
tendon graft is done
69. Gastrocnemius recession or Achilles tendon
lengthening
• Supplemented with all reconstructive procedures where Equinus
contracture is present.
Gastrocnemius recession -for isolated gastrocnemius tightness.
Achilles lengthening -for gastrocnemius-soleus tightness.
These are both adjunct procedures for AAFD and are not done in
isolation
Origin: Posterior surface of tibia, posterior surface of fibula and interosseous membrane
Insertion: Tuberosity of navicular bone, all cuneiform bones, cuboid bone, bases of metatarsal bones 2-4
BY SEQUENCE
The cut is made perpendicular to the axis of the tuberosity at a 60° angle with respect to the sole of the foot. Upward translation is avoided. Once the calcaneus is held in the appropriate position, which is ∼10–12 mm of medial shift, it is fixed with one 7.3-mm cannulated screw introduced from inferolateral to anteromedial to enter the sustentacular bone.
repair of the tendon was done after the osteotomy WITH FDL TENDON
Posterior slap in inversion was applied for 2 weeks and then short leg cast for 4 weeks. Weight bearing is permitted after 4 weeks of the procedure as tolerated by the patient.Osteotomy healed approximately within 6 weeks, and then medial arch support was applied for 6 months after cast removal. Impact activities were avoided until 12 weeks postoperatively