Pediatric Lower Limb Deformities: Principles and Techniques of Management

Dedication
Foreword
Preface
Acknowledgements
Contents
Contributors
Part I: General Principles and Techniques
	1: Etiology of Lower Limb Deformity
		Introduction
		Underlying Generalized Conditions
			Metabolic Disorders
				Rickets
				Renal Osteodystrophy
			Genetic Disorders
				Osteogenesis Imperfecta
				Neurofibromatosis
			Neuromuscular Disorders
				Cerebral Palsy
				Charcot-Marie-Tooth Disease
			Arthrogryposis Multiplex Congenita
			Skeletal Dysplasias
			Benign and Malignant Tumors
			Inflammatory Disorders
			Vascular Malformations
		Congenital
			Hemihypertrophy and Hemiatrophy
				Idiopathic Hemihyperplasia
				Beckwith–Wiedemann Syndrome
			Congenital Deficiency of the Long Bones
				Longitudinal Tibial Deficiency
				Congenital Fibular Deficiency
				Congenital Femoral Deficiency
			Congenital Dislocation of the Knee
			Congenital Coxa Vara
			Congenital Bowing of the Tibia
				Anterolateral Bowing of the Tibia
					“Congenital” Tibial Dysplasia
				Congenital Posteromedial Bowing of the Tibia
				Anteromedial Bowing of the Tibia
		Developmental Conditions
			Genu Varum
				Physiologic Genu Varum
				Tibia Vara/Blount’s Disease
			Genu Valgum
		Acquired Sequelae and Complications
			Residual Hip Deformities
			Physeal Fractures
			Non-physeal Fractures
			Musculoskeletal Infections
			Iatrogenic Causes
		References
	2: Clinical Evaluation Including Imaging
		Introduction
		History
		Physical Examination
			Vital Signs
			Upper Extremity
			Spine and Trunk
			Neurologic
			Gait
				Foot Progression Angle
				Short Leg Gait
				Equinus
				Trendelenburg Sign
			Lower Extremities
				Supine Exam
				Prone Exam
					Femoral Version and Antetorsion
					Tibial Torsion
					Axial Foot Deformities
		Diagnostic Imaging
			Assessment of Limb Length
			Version Diagnostic Imaging
				Acetabular Version
				Femoral Version
				Tibial Torsion
			Coronal Plane Angulation
			Quantitative Deformity Analysis
				Mechanical Axis and Anatomic Axis
				Joint Orientation Angles
				Oblique Plane Deformities
		Laboratory Studies
		References
	3: Decision Making in Lower Extremity Deformity Correction
		Introduction
		Clinical Evaluation
		The Problem List
		Surgical Indications: General
		Surgical Indications: The Knee
		Surgical Indications: The Ankle
		Relative Contraindications
		Surgical Options
			Soft-Tissue Modification
			Physeal Modulation or Ablation
			Acute Correction with Osteotomy
			Gradual Correction with Osteotomy
		Summary
		References
	4: Growth Modulation for Angular and Length Correction
		Introduction
		Deformities of the Lower Extremities
			General
		Angular: Frontal
			Physiologic
			Pathologic
		Treatment
			Timing/Angular
			Technique/Angular
			Follow-Up
		Angular: Sagittal/Oblique
			Knee
			Ankle/Frontal
			Ankle/Sagittal
		Complications of Guided Growth
			Management
		Length: Anisomelia
			Physiologic
			Pathologic
		Treatment: Length
			Timing: Over vs. Under the Chronologic Age of 10
			Treatment/Length
			Complications/Length
		Summary
		References
	5: Physeal Bar Excision
		Introduction
		Etiology and Prognosis
			Trauma
			Infection
			Neoplasm and Tumorlike Conditions
			Vascular Insult
			Other Causes of Physeal Injury
		Assessment of the Abnormal Physis
			Timely Identification
			Partial Versus Complete Physeal Arrest
			Location of Physeal Arrest
			Extent of Physeal Arrest
				Plain Radiographs
				Computed Tomography
				Magnetic Resonance Imaging
			Growth Remaining
		Surgical Indications
		Surgical Technique and Pitfalls
			Role of Osteotomy
			Surgical Approaches (Tips and Tricks)
			Interposition Material
			Radiographic Markers
			Clinical Outcome
		Summary
		References
	6: Acute Deformity Correction Using an Osteotomy
		Principles of Acute Deformity Correction
			General Considerations
			Age Considerations
			Principles Pertaining to Correction of Lower Limb Alignment
			Influence of Level of Osteotomy
			Adjuvant Fibular Osteotomy: When and Where?
			Principles Pertaining to Specific Osteotomies
				Opening Wedge Osteotomy
				Closing Wedge Osteotomy
				Dome Osteotomy
				Angular Correction and Translation
				Oblique Osteotomy
				Lengthening/Shortening Osteotomy
			Special Considerations
				Deformity Secondary to Physeal Injury
				Mango Slice Effect
				The Deformity Memory Effect
				Cozen’s Phenomenon
		Indications
			Site-Specific Osteotomies
				Metaphysis
				Epiphyseal
				Juxta-Apophyseal
				Diaphysis
			Certain Considerations Based on Location of the Deformity
				Proximal Femur
				Osteotomies Around the Knee
				Acute Correction of Length Discrepancy
				Reorientation Osteotomy of Acetabulum
			Osteotomy with Adjuvant Procedures
			Disease-Specific Indications
		Planning
			Rules Governing Osteotomy Planning
			Planning for Tibial Deformity Correction
				Step 1: Finding the CORA
				Step 2: Finding the Axis of Correction for Two CORAs
			Planning for Femoral Deformity Correction Other than Coxa Vara
				Step 1: Plotting Mechanical Axis for Distal Femur
				Step 2: Plotting Proximal Femoral Mechanical Axis
			Planning for Multiple Bony Deformities in the Same Limb
		Hardware Considerations
			Kirschner Wires
			Screws
			Dynamic Compression Plate
			Tension Band Wiring
			Blade Plate
			Locked Plates (LCP)
			Intramedullary Devices (Such as Rush Rods and Fassier-Duval Telescoping Rods)
			External Fixation and Limb Reconstruction Systems
			Bone Void Fillers
			Adapted Fixation Techniques
				Fixator-Assisted Plating
					Technique
				Supracutaneous Locked Plating
			Complications
			Acute Complications
				Neurological
				Compartment Syndrome
				Vascular
				Skin and Wound Problems
				Iatrogenic Fractures
				Physeal Injury
			Late Complications
				Joint Stiffness
				Vascular
				Recurrent Deformity
				Non-union and Delayed Union
				Hardware-Related Complications
				Cast-Related Complications
				Muscle Weakness
		Acute Versus Gradual Correction
		References
	7: Gradual Deformity Correction
		Introduction
		History
		Biology
		Clinical Uses
		Analysis of Deformity
		Planning the Osteotomy
		Devices
		Postoperative Care
		Potential Complications
		Summary
		References
	8: Hybrid Techniques for Limb Length and Deformity Correction
		Introduction
		Lengthening Over Nail (LON)
		Plate-Assisted Lengthening (PAL)
		Lengthening and Then Plating (LAP)
		Bone Transport with a Plate
		Lengthening and Then Nailing (LATN)
		Lengthening and Then Screw Fixation
		Summary
		References
	9: Motorized Intramedullary Lengthening, an Emerging Technology for Limb Length and Deformity Correction
		Introduction
		Indications
		History
		A Brief History of Internal Limb Lengtheners
		General Guidelines for Motorized Intramedullary Limb Lengthening
			The Reverse Planning Method
				Step 0
				Step 1
				Step 2
				Step 3
				Step 4
				Step 5
		Visual Aids
		Venting the Canal
		Shanz Pins
		Entry Points
		Reaming Techniques
			Conventional Reaming
			Rigid Reaming
		Blocking Screws
		Antegrade Femoral Lengthening
			Patient Indications
			Planning for Antegrade Femoral Lengthening
				Antegrade Femoral Technique
		Retrograde Femoral Lengthening
			Patient Indications
			Planning
			Retrograde Femoral Surgical Technique
		Tibial Lengthening
			Patient Indications
			Planning
			Tibial Surgical Technique
		Intraoperative Nail Testing for All Limb Lengthening Techniques
			Post-operative Management
		Complications of Motorized Intramedullary Lengthening
		Outcomes
		Summary
		References
Part II: Related Concepts and Management Options
	10: Biomechanically Based Clinical Decision Making in Pediatric Foot and Ankle Surgery
		Introduction
		Ankle and Foot Function During Normal Gait
		Segmental Malalignment Patterns of the Ankle and Foot
		Surgical Interventions
		Assessment Tools and Indications
		References
	11: Pediatric Joint Contractures
		Introduction
		Equinus Contracture
			Pathoanatomy
			Clinical Evaluation
			Imaging
			Management Strategy and Decision Making
				Nonoperative
				Operative
					Lengthening of Muscles and Tendons
					External Fixation
					Types of External Fixation Constructs
		Knee Flexion Contracture
			Etiology
			Biomechanics
			Clinical Evaluation
			Imaging
			Decision Making and Management Strategy
				Decision Making
				Nonoperative
				Operative
					Soft Tissue Releases
					Bony Correction Options
					External Fixation with Gradual Soft Tissue Correction
		Knee Extension Contractures
			Etiology
			Clinical Evaluation
			Imaging
			Decision Making and Management Strategy
				Nonoperative
				Operative
		Summary
		References
	12: Physical Therapy During Limb Lengthening and Deformity Correction: Principles and Techniques
		Introduction
		Rehabilitation During Distraction Osteogenesis
			Inpatient Phase
			Lengthening or Correction Phase
			Consolidation Phase
			Post Frame Removal
		Role of Physical Therapy in Management of Complications
			Muscle Contractures
			Joint Stiffness
			Muscle Weakness
			Joint Subluxation
			Nerve Injury
			Weight-Bearing Considerations
		Specific Musculoskeletal Disorders
			Legg-Calve Perthes Disease
			Congenital Femoral Deficiency
			Fibular Hemimelia
			Achondroplasia
			Internal Lengthening Devices
			Gait Considerations
		Summary
		References
	13: Amputation and Prosthetic Management: Amputation as a Reconstructive Option
		Treatment Concepts
		Patient and Family Management
		Specific Conditions
			Congenital Femoral Deficiency
				Treatment in Gillespie Type A
				Gillespie Types B and C
			Congenital Fibular Deficiency
			Congenital Tibial Deficiency
			Congenital Pseudarthrosis of the Tibia
		Tumor Reconstruction
		Volume Changes with Oncology
		Amputation After Trauma
		Prosthetic Considerations
			First Prosthesis
			Prosthetic Replacement for Children
			Length of the Residual Limb
			Residual Limb Overgrowth
			End Weight-Bearing
		The Future of Prosthetics
		References
	14: Working in Resource-Challenged Environments
		Introduction
		International Collaboration
			Volunteering and Hosting
			Commit to a Program
			Common Mistakes Made by Volunteers
			Common Mistakes Made by Hosts
			Understanding Repercussions of Good Work
			Keep Your Motives Pure
			Credentialing and Liability
		Operative Challenges: Improvise Don’t Compromise
			Indications
			Perioperative and Anesthetic Considerations
			Sterility
			Cidex®
			Ethylene Oxide
			Operating Room Set Up
			Surgical Modus Operandi in Resource-­Challenged Environments
			Internal vs. External Fixation in Resource-­Challenged Environment
			Reuse of Implants and External Fixation Components
			Cordless Power
			Postoperative Care
			Other Aspects of Orthopedics in the “Wild”
		Specific Techniques
			Clubfoot
			SIGN Nail
			Spica Cast
		Educational Resources
		Summary
		References
Part III: Underlying Conditions
	15: Metabolic Disorders
		General
		Pathophysiology
		Nutritional Rickets
			General
			Treatment
		Rickets of Prematurity
		Drug-Induced Rickets
		Vitamin D-Resistant Rickets (Familial Hypophosphatemic Rickets)
			General
			Treatment
				Medical Treatment
				Orthopedic Treatment
				Author’s Preferred Method, Tips and Tricks
					Surgical Technique
					Follow-Up
		Tumor-Related Hypophosphatemic Rickets (Oncogenic Hypophosphatemic Osteomalacia)
		Renal Osteodystrophy
			General
			Treatment
				Medical Treatment
				Orthopedic Treatment
					Angular Deformity
					Slipped Capital Femoral Epiphysis
					Avascular Necrosis
		Hypophosphatasia
			General
			Treatment
				Example Cases
		References
	16: Osteogenesis Imperfecta
		Introduction
		The Problems
			Bone Deformity(ies)
			Soft Tissue Problems
		Before Surgery
		Surgical Correction
			Why?
			When?
			How?
				Different Types of Rods Can Be Used in OI Bones
				Open or Percutaneous Osteotomy?
					Osteotomy
				Technique for Femoral Rodding (see Box 16.1)
				Technique for Tibial Rodding (see Box 16.2)
			Surgical Tips
				Positioning of the Patient
			Coxa Vara Correction (see Box 16.5)
		Postoperative Rehabilitation
			Stretching of Tight Muscles
			Use of Braces
		Results
		References
	17: Lower Limb Deformity in Neuromuscular Disorders: Pathophysiology, Assessment, Goals, and Principles of Management
		Cerebral Palsy
			Classification of Cerebral Palsy
			Pathophysiology of Musculoskeletal Deformity in Cerebral Palsy
			Specific Deformities of the Lower Extremity
				Pelvis and Hip
				Knee and Lower Leg Segment
				Ankle and Foot
			Lower Limb Assessment in the Ambulant Child (GMFCS Levels I–III)
				Observation of Gait
				Abnormal Gait Patterns in Cerebral Palsy
				On-Table Physical Examination
					Assessment of Muscle Tone and Length
					Assessment of Bone Alignment
					Assessment of Muscle Strength and Selective Control
			Lower Limb Assessment in the Non-ambulant Child (GMFCS Levels IV–V)
			Goals of Treatment in Cerebral Palsy by GMFCS Level
			Management of Lower Extremity Problems: Principles of Treatment and Techniques
			Orthopedic Procedures at the Hip
				Iliopsoas Lengthening
				Adductor Releases
				Femoral Derotation and Varus Derotational Osteotomy
				Periacetabular Pelvic Osteotomy
				Femoral Head Resection and Related Procedures
			Orthopedic Procedures at the Knee and Lower Leg Segment (Tibia)
				Hamstring Lengthening
				Distal Femoral Extension Osteotomy
				Patellar Tendon Shortening or Advancement
				Anterior Hemiepiphysiodesis of Distal Femoral Physis
				Rectus Femoris Transfer
				Distal Tibial (Supramalleolar) Derotational Osteotomies (Fig. 17.25)
			Orthopedic Procedures at the Ankle and Foot
				Gastrocnemius and Soleus Lengthening
				Tibialis Posterior Tendon Lengthening or Split Tibialis Posterior Tendon Transfer (SPOTT)
				Split Tibialis Anterior Tendon Transfer
				Foot Osteotomies
			Summary
		Myelomeningocele (Spina Bifida)
			Hip Dysplasia
			Knee Flexion Deformity and Tibial Torsion
			Ankle and Foot Deformities
		Poliomyelitis
		Hereditary Motor Sensory Neuropathy
			Foot Deformities (Fig. 17.26)
			Hip Deformities
		Muscular Dystrophies
		Summary
		References
	18: Arthrogryposis
		Prevalence
		Etiology
		Classification
			Group 1: Disorders Affecting Mainly the Four Limbs
			Group 2: Disorders Affecting the Limbs with Involvement of Other Parts of the Body
			Group 3: Disorders Affecting the Limbs with Involvement of the Central Nervous System
		Genetic Aspects of Arthrogryposis
		Intellectual Skills
		Workup of a Child with Arthrogryposis
		Clinical Picture
		Prognosis
			General Management
				Lower Limb
					Foot
					Knee
					Hip
				Upper Limb
				Scoliosis
				Orthopedic Management of Specific Conditions
					Popliteal Pterygium Syndrome
					Larsen Syndrome
		Timing for the Management of Lower Limb Deformities
		Ambulation in Children with Amyoplasia
		Rehabilitation
		Summary
		References
	19: Limb Lengthening and Deformity Correction in Patients with Skeletal Dysplasias
		Introduction
		Lower Extremity Deformity in Skeletal Dysplasia
		Surgical Considerations
			Preoperative Evaluation
			Imaging
			Anesthesia
			Positioning
			Implant Size and Design
		Methods of Deformity Correction
			Acute Correction
			Gradual Correction with Guided Growth
			Gradual Correction with External Fixation
		Controversies in Lengthening for Stature
		Postoperative Considerations
		Planning for the Future
		Specific Skeletal Dysplasias and Their Associated Deformities
			Achondroplasia
			Spondyloepiphyseal Dysplasia Congenita (SEDC)
			Multiple Epiphyseal Dysplasia (MED)
			Diastrophic Dysplasia
			Morquio Syndrome
			Metaphyseal Chondrodysplasia
			Ellis-van Creveld Syndrome (EvC) or Chondro-
		Summary
		References
	20: Lower Extremity Benign Bone Lesions and Related Conditions
		Introduction
		Nonossifying Fibroma
		Fibrous Dysplasia
		Osteofibrous Dysplasia
		Enchondromatosis
		Solitary Osteochondromas and Multiple Hereditary Exostoses
		Dysplasia Epiphysealis Hemimelica (Trevor’s Disease)
		References
	21: Management of Juxtaphyseal Malignant Bone Tumors Around the Knee Joint: New Concepts in Limb-­Sparing Surgery
		Introduction
		Indication
		Surgical Techniques
			Type I: DO Method (Fig. 21.2)
			Type I: LN Method (Fig. 21.3)
			Type II: DO Method (Fig. 21.4)
			Type II: LN Method (Fig. 21.5)
			Type III: DO Method (Fig. 21.6)
			Type III: LN Method (Fig. 21.7)
			Type IV: DO Method (Fig. 21.8)
			Type IV: LN Method (Fig. 21.9)
			Type V: LN Method (Fig. 21.10)
			Type VI: LN Method (Fig. 21.11)
		Case Examples
			Case 1 (Type I: DO Method) (Fig. 21.12)
			Case 2 (Type IV: LN Method) (Fig. 21.13)
		References
Part IV: Congenital and Developmental Disorders
	22: Congenital Femoral Deficiency Reconstruction and Lengthening Surgery
		Introduction
			Demographics
			Embryology
			Pathophysiology and Genetics
			Deformity and Pathoanatomy
				Osseous Deformities
				Ligamentous Structures
				Muscle Pathoanatomy
				Vascular Pathoanatomy
		Evaluating the Child with Unilateral CFD
			History
			Physical Exam
			Imaging
				Radiographic Examination
				Magnetic Resonance Imaging
				Computerized Tomography (CT)
		Classification Systems
			Aitken, 1959
			Pappas, 1983
			Gillespie and Torode, 1983
			Hamanishi, 1980
			Kalamachi, 1985
			Paley, 1998
		Treatment Options for Congenital Femoral Deficiency
			Rotationplasty
			Syme Amputation
			Limb Lengthening
			Recommended Surgical Reconstructive Strategy for Paley Type 1 CFD
				Outlining a “Life Plan” for the Family
					Step 1: Preparatory Surgery for the Hip and Knee
					Step 2: Serial Lengthenings of the Femur and/or Tibia
					Step 3: Hemiepiphysiodesis and Epiphysiodesis
			The Superhip Procedure
			Superhip Surgical Technique (Figs. 22.7, 22.8, 22.9, 22.10, and 22.11)
			Postoperative Course
		Pelvic Osteotomies
			Paley Modification of Dega Osteotomy (Paley-­Dega Osteotomy) (See Fig. 22.8)
			Paley Modification of Periacetabular Triple Osteotomy (Paley PATO) (Fig. 22.12)
			Ganz Periacetabular Osteotomy (PAO) (See Fig. 22.11)
			Knee Considerations in CFD
			Indications for Preparatory Surgery of the Knee Prior to Limb Lengthening
			Superknee Surgical Technique (Ligamentous Reconstruction Only) (Figs. 22.9 and 22.13)
			Superknee Procedure with Patellar Realignment for Dislocated/Dislocating Patella (Figs. 22.11 and 22.14)
				Langenskiöld Patellar Realignment
			Superknee Procedure with Knee Flexion Deformity (Figs. 22.10 and 22.15)
				Knee Flexion Contracture Release
			Peroneal Nerve Decompression (Fig. 22.16)
			Femoral Lengthening for Paley Type I CFD
				Choice of Osteotomy Level
				Soft Tissue Releases for Limb Lengthening
				Botulinum Toxin Injection
				Knee Instability
		Surgical Technique
			Distal Femoral Lengthening: Ilizarov™ Fixator Technique (See Fig. 22.17)
				Knee Hinges
			Distal Femoral Lengthening: Orthofix™ Fixator Technique (See Fig. 22.17)
			Distal Femoral Lengthening: Modular Rail System (Smith & Nephew, Memphis) Technique (Figs. 22.9, 22.10, and 22.20)
			Modification for Valgus ± Flexion Deformity of the Distal Femur
			Rehabilitation and Follow-Up During Lengthening
			Fixator Removal and Rodding of Femur (See Figs. 22.9 and 22.10)
			Surgical Technique for Prophylactic Rodding of Femur at Time of External Fixator Removal
			Specific Complications and Their Treatment for Congenital Femoral Deficiency Lengthening
				Nerve Injury
				Poor or Failed Bone Formation
				Incomplete Osteotomy and Premature Consolidation
				Hip Subluxation/Dislocation
				Knee Subluxation/Dislocation
				Limb Malalignment
				Fractures
				Joint Stiffness and Contracture
			Difference in Treatment of Types 1a and 1b
			Treatment of Paley CFD Type 2 (Fig. 22.26)
			Superhip 1.5 Procedure for Treatment of a Mobile Proximal Femoral Pseudoarthrosis with a Mobile Femoral Head with Cartilaginous Remnants of the Femoral Neck Present (Fig. 22.27)
			Superhip 2 Procedure for Treatment of a Mobile Proximal Femoral Pseudoarthrosis with or Without Partial Fusion of the Femoral Head (Figs. 22.28 and 22.29)
			Pelvic Support Osteotomy
			Treatment of CFD Type 3
			Limb Reconstructive Surgery for Type 3
			Prosthetic Reconstructive Surgery for Type 3
		Summary
		References
	23: Fibular Hemimelia: Principles and Techniques of Management
		Introduction
		Classification
		Clinical Assessment of a Child with FH
		Radiographic Assessment of a Child with FH
		Principles of Treatment
		Surgical Techniques for FH
			Lengthening for Paley Type 1
			Lengthening Plus Ankle Realignment for Paley Type 2
			Lengthening Plus Super-Ankle Reconstruction for Paley Type 3
				Surgical Technique for Type 3a (Figs. 23.24 and 23.25)
					Positioning
					Surgical Approach
					Osteotomy
					Frame Application
				Surgical Technique for Type 3b (Figs. 23.26 and 23.27)
					Positioning and Surgical Approach
					Osteotomy
				Surgical Technique for Type 3c (Fig. 23.28)
					Positioning and Surgical Approach
					Osteotomy
				Surgical Technique for Type 3d (Fig. 23.29)
					Diagnosing Type 3d
					Positioning and Surgical Approach
					Osteotomy
				Surgical Technique for Type 4
					Initial Nonsurgical Treatment
			Additional Procedures
		Post-surgical Care
		Outcomes
		References
	24: Tibial Hemimelia
		Introduction
		Genetics
		Pathoanatomy
		Classification
		History of Treatment
			Early Treatments
			Brown Procedure (Fibular Centralization)
			Amputation
			Tibiofibular Synostosis
			Distal Tibia and Ankle Stabilization
			Limb Lengthening
			Weber Patelloplasty
			New Horizons and Strategies for Reconstruction in Tibial Hemimelia
			Paley Classification with Subtypes and Description of Common Features
		Limb Reconstruction Surgery
			Paley Type 1 (Fig. 24.4)
			Paley Type 2 (Fig. 24.5, 24.6)
			Paley Type 3
			Paley Type 3a (Fig. 24.7)
			Paley Type 3b (Fig. 24.8)
			Paley Type 4
			Paley Type 4a (Fig. 24.9)
			Paley Type 4b (Fig. 24.10)
			Paley Type 4c (Fig. 24.11)
			Paley Type 5
			Paley Type 5a (Fig. 24.12)
			Weber Patellar Arthroplasty (Fig. 24.13)
			Type 5bi (Fig. 24.14)
			Type 5bii (Fig. 24.15)
			Paley Centralization of the Fibula on the Femur (Fig. 24.16)
		Summary
		References
	25: Congenital Pseudarthrosis of the Tibia
		Anatomy and Pathology
		Associations
		Classification Systems
		Imaging
		Prognostic Factors
		Non-operative Management
		Operative Management
		Modified McFarland Bypass Graft
		Intramedullary Nailing
		Free Vascularized Fibula
		Ilizarov External Fixation
		Periosteal Grafting
		Masquelet’s Procedure
		Amputation
		Medical Management
		Bone Morphogenetic Protein
		Bisphosphonates
		Electrical Stimulation
		Bone Marrow Grafting
		Combined Approach
		Summary
		References
	26: Congenital Posteromedial Bowing of the Tibia
		Introduction
		Incidence
		Demographic Features
		Etiology
		Deformities
			The Tibia
			The Fibula
			The Ankle and Foot
		The Natural History
			Rate and Pattern of Spontaneous Remodeling
			Residual Deformities, Shortening, and Functional Problems
		Evaluation
		Treatment
			Indications
			Aims of Treatment
			Treatment Options
				Correction of the Calcaneo-Valgus Foot Deformity
				Correction of Sagittal, Coronal, or Torsional Deformities of the Tibia and Fibula
				Correction of the Valgus Ankle
				Correction of Limb Length Inequality
				Correction of Muscle Imbalance Across the Ankle
			Decision Making
			Pitfalls in Diagnosis and Treatment
		References
	27: Controversies in Blount’s Disease
		Introduction
		Terminology
		Classification
		Differential Diagnosis
		Natural History
		Treatment
			Controversies in the Treatment of Infantile Blount’s Disease
				Does Bracing Work?
				Growth Modulation
				Risks of High Tibial Osteotomy and Acute Deformity Correction
				Effectiveness of Physeal Arrest Resection
				Utility of Physeal Arrest Resection Surgery in the Absence of a Bony Physeal Arrest
				What to Do with the “Failed” Case?
				Is There a Role of “Hemi-Plateau Elevation”?
		Adolescent Blount’s Disease
		Treatment Considerations in Adolescent Blount’s Disease
			Role of Obesity and Impact of Treatment on Obesity
			Associated Deformities
			Growth Modulation
			Acute Correction with Internal Fixation
			Correction with External Fixation (Acute or Gradual) (with 6-Strut Fixators/Others)
		Adolescent Blount’s Disease Summary
		Does Juvenile Blount’s Disease Exist?
		Summary
		References
Part V: Sequelae and Complications
	28: Methods to Enhance Bone Formation in Distraction Osteogenesis
		Introduction
		Monitoring of Regenerate Bone
		Physical Stimulation
			Mechanical Stimulation
			Low-Intensity Pulsed Ultrasound
			Pulsed Electromagnetic Field
		Biologic Stimulation
			Local Application-Bone Morphogenetic Protein
			Bone Marrow Cells/Platelet-Rich Plasma
			Stem Cells
				Stem Cells
				Growth Factors
				Scaffolds
				Other Uses of Stem Cells
				Osteogenic Progenitor Stem Cell Culture Technique
				Injection Technique (Fig. 28.4)
			Other Experimental Local Stimuli
				TP508
				ED-71
				FGF-2
			Optimal Timing of Biologic Stimulants
		Biological Stimulation: Systemic Application
			Parathyroid Hormone
			Growth Hormone
			Other Experimental Systemic Stimuli
		Anticatabolic Therapy: Systemic Application
			Bisphosphonate
			Other Experimental Anticatabolic Therapies
		Summary
		References
	29: Residual Deformities of the Hip
		Introduction
		Residual Deformities of the Hip Joint Secondary to Developmental Dysplasia
			Treatment of Residual Hip Dysplasia for Patients <6 Months of Age
			Treatment of Residual Hip Dysplasia for Patients >6 Months to 2 Years
			Treatment of Residual Hip Dysplasia for Patients >2 Years Until Closure of the Triradiate Growth Plate
			Treatment of Residual Hip Dysplasia for Patients After Closure of the Triradiate Growth Plate
		Periacetabular Triple Osteotomy of the Pelvis: Operative Technique
			Positioning and Exposure
			Osteotomies
			Deformity Correction and Fixation
			Postoperative Care
		Residual Deformities of the Hip Joint Secondary to Slipped Capital Femoral Epiphysis
		The Modified Dunn Procedure for Residual Deformities of the Proximal Femur Secondary to SCFE: Operative Technique
			Positioning and Exposure
			Surgical Hip Dislocation
			Deformity Correction and Fixation
			Postoperative Care
		The Modified Southwick Osteotomy for Residual Deformities of the Proximal Femur Secondary to SCFE: Operative Technique
			Positioning and Exposure
			Deformity Correction and Fixation
			Femoral Neck Osteoplasty
			Postoperative Care
			Alternative Technique: Percutaneous Osteotomy and External Fixation
		Residual Deformities of the Hip Joint Secondary to Legg–Calvé–Perthes Disease
		Coxa Breva
		The Morscher Osteotomy for Coxa Breva Secondary to Perthes Disease: Operative Technique
			Positioning and Exposure
			Deformity Correction and Fixation
			Postoperative Care
		Coxa Magna
		The Femoral Head Reduction Osteotomy for Coxa Magna Secondary to Perthes Disease: Operative Technique
			Positioning and Exposure
			Deformity Correction and Fixation
			Postoperative Care
		Residual Femoral Head Subluxation
		Hip Distraction Treatment for Residual Femoral Head Subluxation Secondary to Perthes Disease: Operative Technique
			Patient Positioning
			Core Decompression
			Stem Cell Injection
			Soft Tissue Releases
			Hip Distractor Application
			Postoperative Care
		Summary
		References
	30: Posttraumatic Lower Limb Deformities in Children
		Introduction
		Causation and Etiological Factors
		Classification
		Clinical Manifestations
		Investigations
		Remodeling of Bony Deformities
			Case Study (Fig. 30.2)
				Clinical Summary
				Philosophy of Treatment
			Case Study (Fig. 30.3)
				Clinical Summary
				Philosophy of Management
				Management
		Important Posttraumatic Deformities: Lower Limb
			Posttraumatic Chondrolysis of the Hip and Avascular Necrosis
				Case Study (Fig. 30.4)
					Clinical Summary
					Philosophy of Treatment
				Posttraumatic Coxa Vara
				Case Study (Fig. 30.5)
					Clinical Summary
					Philosophy of Treatment
			Malunited Shaft Femur or Pseudarthrosis with Deformity
				Case Study (Fig. 30.6)
					Clinical Summary
				Philosophy of Treatment
			Distal Femoral Deformity Following Iatrogenic Physeal Injury
				Case Study (Fig. 30.7)
					Clinical Summary
					Philosophy of Treatment
			Physeal Injury of the Distal Femur with Angular Deformity
				Case Study (Fig. 30.8)
					Clinical Summary
					Philosophy of Management
			Malunited Intra-articular Fractures
				Case Study (Fig. 30.9)
			Physeal Injury to Proximal Tibia
				Case Study (Fig. 30.10)
					Clinical Summary
					Philosophy of Treatment
				Case Study (Fig. 30.11)
					Clinical Summary
					Philosophy of Treatment
				Case Study (Fig. 30.12)
					Clinical Summary
					Philosophy of Treatment
			Posttraumatic Tibia Valga
				Case Study (Fig. 30.13)
			Physeal Injury Ankle with Malunion
				Case Study (Fig. 30.14)
					Clinical Summary
					Philosophy of Treatment
				Case Study (Fig. 30.15)
					Clinical Summary
					Philosophy of Treatment
			Soft-Tissue Loss with Skeletal Injury
				Case Study (Fig. 30.16)
					Clinical Summary
					Philosophy of Treatment
		Summary
		Acceptability Criteria for Reduction in Lower Limb Fractures
			Fracture Neck Femur
			Fracture Shaft Femur
			Fracture: Separation of Distal Physis of Femur
				In Salter–Harris Types 1 and 2
				In Salter–Harris Types 3 and 4
			Fracture Tibial Tuberosity
			Fracture Patella
			Fracture of Tibia and Fibula
				Proximal Metaphysis
				Diaphysis
				Distal Tibial Fractures
					Salter–Harris Types 1 and 2
					Salter–Harris Types 3 and 4
		References
	31: Postinfectious Deformities of the Lower Limb
		Introduction
		Late Sequelae of Infantile Septic Arthritis of the Hip
		Radiographic Classifications of Late Sequelae of Infantile Septic Arthritis of the Hip
		Late Operative Treatment Modalities for Residual Deformities of Septic Arthritis of the Hip
		Choi Type II and III Hips Causing Femoroacetabular Impingement and Secondary Hip Dysplasia
		Late Treatment Options for Choi Type IV Deformity
			Greater Trochanteric Arthroplasty Versus Pelvic Support Osteotomy (Ilizarov Hip Reconstruction)
		Late Sequelae After Septic Arthritis and Osteomyelitis Around the Knee and Ankle Joints
			Postinfectious Articular Deformity Causing Knee and Ankle Joint Incongruity
		References
	32: Iatrogenic Deformities
		Introduction
		What Is Acceptable Alignment?
		What Are the Consequences of Malalignment?
		What Are the Legal Implications of Iatrogenic Deformities?
		Common Iatrogenic Deformities
			Tibia Malunion
				Case 1
				Case 2
			Fibular Malunion
				Case 3
			Transphyseal ACL Reconstruction Causes Premature Physeal Closure
				Case 4
			Femur Malunion and Growth Disturbance
				Case 5
				Case 6
			Vascularized Fibula Graft Nonunion and Valgus Ankle Deformity from the Fibular Donor Site
				Case 7
			Deformity from Tibial Lengthening
				Case 8
			Translational Deformity
				Case 9
		Summary
		References
ERRATUM TO Hybrid Techniques for Limb Length
and Deformity Correction
ERRATUM TO
Biomechanically Based Clinical Decision Making in Pediatric Foot and Ankle Surgery
ERRATUM TO Fibular Hemimelia: Principles and Techniques
of Management
ERRATUM TO Tibial Hemimelia
ERRATUM TO Posttraumatic Lower Limb Deformities in Children
Index