Pediatric Lower Limb Deformities: Principles and Techniques of Management

Preface
Acknowledgments
Contents
Contributors and Commentators
Contributors
Commentators
Part I: General Principles and Techniques
	1: Etiology of Lower Limb Deformity
		Underlying Medical Conditions
			Metabolic Disorders
			Rickets
				Renal Osteodystrophy
			Genetic Disorders
				Osteogenesis Imperfecta
				Neurofibromatosis
			Neuromuscular Conditions
				Cerebral Palsy
				Charcot Marie Tooth
				Arthrogryposis and Related Syndromes
				Skeletal Dysplasia
			Bone Tumors
			Inflammatory Conditions
		Congenital Etiology
			Hemihypertrophy and Hemiatrophy
			Congenital Femoral Deficiency
				Congenital Fibular Deficiency
				Congenital Tibia Deficiency
				Congenital Knee Dislocation
				Congenital Patella Dislocation
				Coxa Vara
				Congenital Bowing of the Tibia
			Developmental
				Physiologic Genu Varum
				Blount’s Disease
				Proximal Focal Fibrocartilaginous Dysplasia
				Genu Valgum
			Acquired
				Residual Hip Deformity
				Physeal Fractures
				Nonphyseal Fractures
				Post-Infectious
				Iatrogenic
		Summary
		Commentary
		References
	2: Clinical Evaluation Including Imaging
		Introduction
		History
		Physical Examination
		Body Mass Index
		Upper Extremity
		Spine and Trunk
			Neurologic
			Gait
			Foot Progression Angle
			Short Leg Gait
			Equinus
			Trendelenburg Sign
			Knee Thrust
		Lower Extremities
			Supine Exam
			Standing Exam
			Prone Exam
		Femoral Version
		Tibial Torsion
		Axial Foot Deformities
		Limb Length Discrepancy
		Physical Exam Summary
		Diagnostic Imaging
		Assessment of Limb Length
		Version Diagnostic Imaging
		Acetabular Version
		Femoral Version
		Tibial Torsion
		Quantitative Deformity Analysis
		Oblique Plane Deformities
		Conclusions
		Commentary
		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
		Combined Acute and Gradual Correction
		Summary
		Commentary 1
		Commentary 2
		References
	4: Outcome Measures in Limb Lengthening and Deformity Correction
		Introduction
		Outcome Assessment in Lower Limb Deformities
		PROMS in Children
		How to Choose an Appropriate PROM?
		How Are PROMs Developed?
		Integrating into Clinical Practice/Implementation Science
		Future Directions
		Commentary
		References
	5: Keys to Building a Successful Pediatric Limb Reconstruction Program
		Introduction
		Resource Available Model
			Surgeon
		Develop a Limb Reconstruction Team
		Limb Reconstruction Clinic Setting
		Operating Room (OR) Setting
		Patient Volume
		Practice Habits
		Working with Industry
		Hospital Commitment
		Managing Expectations
		Resource Challenged Environment
		Appendix: Reading List
			Books
			Reference Articles
		Commentary
		References
	6: Growth Modulation for Angular and Length Correction
		Background
		Deformities of the Lower Extremities
		Angular: Frontal
		Treatment
		Angular: Sagittal/Oblique
		Complications of Guided Growth
		Length: Anisomelia
		Treatment: Length
			Timing: Adolescent:
			Timing: < age 10 years
			Treatment/Length
			Complications/Length
		Rotational Guided Growth?
		Summary
		Commentary
		References
	7: Physeal Bar Excision
		Introduction
		Etiology
			Trauma
			Infection
			Neoplasm and Tumor-Like 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
		Commentary
		References
	8: 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
			Bifocal Procedures
			Special Considerations
				Deformity Secondary to Physeal Injury
			Mango Slice Effect
			Deformity Memory Effect
			Cozen’s Phenomenon
		Indications
			Site-Specific Osteotomies
				Metaphysis
				Epiphyseal
				Juxta-Apophyseal
				Diaphysis
			Specific 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
			Planning for Femoral Deformity Correction Other than Coxa Vara
			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)
			Angle Stable Devices for Metaphyseal Deformity Correction
			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
				Nonunion and Delayed Union
				Hardware-Related Complications
				Cast-Related Complications
				Muscle Weakness
				Acute Versus Gradual Correction
		Commentary
		References
	9: Gradual Deformity Correction in Children and Adolescents
		Introduction
		Gradual Correction Using External Fixation
		Basic Principles of Gradual Correction Using External Fixation
		Gradual Correction of Femoral Deformities Using External Fixation
		Gradual Correction of Tibial Deformities Using External Fixation
			Tibial Osteotomy
			Osteotomy Technique
		Gradual Correction of Foot Deformities
		Gradual Correction of Upper Limb Deformities
		Acute Correction of Deformities Using Internal Lengthening Nail
		Commentary
		References
	10: Pin Site Care
		Introduction
		Preoperative Preparation
		Intra-Operative Considerations
			Fixator Stability Principles
			Skin Prep and Decolonization
			Revision of Frame: How to Clean the Frame
			Fixation Elements: Wire and Pin Design
			Half Pin/Wire Coating
			Insertion Technique: Soft Tissue Considerations
			Insertion Technique: Bone Considerations
			Intra-Operative Pin Site Dressing
		Postoperative Pin Site Care
			Recovery
			On the Ward
			Prophylactic Antibiotics
			Timing of the First Dressing Change
			Pin Site Care
			Patient and Caregiver Education
		Pin Site Infection
			Bacteriology and Antibiogram Properties
			Treatment Principles
			Surgical Management of Pin Site Infections
		End of Treatment Considerations
			Wire Removal
			Half Pin Removal
		Conclusion
		Commentary
		References
	11: Fixator Assisted Nailing and Plating
		Introduction
		Preoperative Planning
		Fixator-Assisted Nailing (FAN)
		Fixator-Assisted Plating (FAP)
		Postoperative Management
		Complications
			Acute Complications
				Neurological Complication
				Compartment Syndrome
				Vascular Injury
				Soft tissue problems
			Late Complications
				Delayed Union and Nonunion
				Recurrence of Deformity
				Peri-implant Complications
		Summary
		Commentary
		References
	12: Hybrid Techniques for Limb Length and Deformity Correction
		Introduction
		Lengthening Over Nail (LON)
		Lengthening and Then Nailing (LATN)
		Plate-Assisted Lengthening (PAL)
		Lengthening and Then Plating (LAP)
		Bone Transport with a Plate or Nail Assist
		Lengthening and Then Screw Fixation
		Summary
		Commentary
			Commentary on Hybrid Fixation for Lengthening and Deformity Correction
		References
	13: Motorized Intramedullary Lengthening of the Femur: Antegrade and Retrograde
		Evolution
		Indications
		Preoperative Evaluation
			History and Physical Examination
				Gait/Alignment/Muscles/Shortening/Rotation
			Joint Stability
				Hip Joint
				Knee Joint
				Ankle Joint
				Mental Health Examination
				Social Examination
				Bone Health Examination
		Femoral Lengthening Along the Long Axis of the Lengthening Nail
		Antegrade Versus Retrograde
		Preoperative Radiographs
		Preoperative Planning
			Simple Antegrade Lengthening Without Deformity Correction
		Intraoperative Pearls (Figs. 13.12, 13.13, 13.14, 13.15, 13.16, 13.17, 13.18, 13.19, and 13.20)
			Reverse Planning Method
		Blocking Screws
		Deformity Correction
			Electric Versus Magnetic Nail: Pros and Cons
			Post-operative Period
				Postoperative Course
			Lengthening Protocols
		Postoperative Follow-Up
			Clinical Examination
			Radiographs
			When Has Desired Limb Length Been Achieved?
				Weight-Bearing Protocols
				Physical Therapy
				Nail Removal
				Complications
			Dealing with Complications
		Special Indications
			Extramedullary Bone Lengthening with Motorized Lengthening Nail
			Bone Transport for Treatment of Segmental Femoral Defects
			Stump Lengthening
		Future
		Commentary
			Motorized Internal Femoral Lengthening Commentary
			Review of Ilizarov’s Six Elements for Successful Distraction Osteogenesis
			Modifying Ilizarov’s Six Elements of Distraction Osteogenesis for Motorized Internal Lengthening
			Mentoring the Neophyte Lengthening Surgeon
			New and Future Possibilities with Motorized Internal Limb Lengthening
		References
			Further Reading
	14: Motorized Intramedullary Lengthening of the Tibia
		Introduction
		Indications
		Technique
			Pre Operative Planning
			Intra Operative Execution
		Reaming and Nail Insertion
		Magnet
		Post Op Recommendations
		Outcomes
		Pearls and Pitfalls
		Conclusion
		Commentary
			Motorized Intramedullary Lengthening of the Tibia
				Introduction
				Indication
				Technique
				Reaming and Nail Insertion
				Post-Op Recommendations
				Outcomes
				Pearls and Pitfalls
		References
Part II: Related Concepts and Management Options
	15: 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
		Commentary
			Biomechanically Based Clinical Decision Making in Pediatric Foot and Ankle Surgery: Commentary
		References
	16: Congenital Foot Deformities
		Introduction
		Systemic and Local Bone Growth Factors
		Normal Development
		Foot Conditions and Developmental Limb Deformities
			Curly Toe/Digital Flexion Contractures
				Treatment
			Polydactyly
				Polydactyly Surgical Pearls
			Syndactyly
			Macrodactyly
			Varus Fifth Toe
			Longitudinal Epiphyseal Bracket
			Subungual Exostosis
				Subungual Exostosis Pearls
			Metatarsus Adductus
				Metatarsus Adductus Pearls
				Metatarsus Adductus Pitfalls
			Brachymetatarsia
				Brachymetatarsia Surgery Pearls
				Brachymetatarsia Pitfalls
			Vertical Talus
			Etiology
			Vertical Talus Clinical Features
			Vertical Talus Imaging
			The Dobbs Method
				The Dobbs Methods: Manipulation and Casting
				The Surgical Portion of The Dobbs Method
			Calcaneovalgus
			Oblique Talus
			Tarsal Coalitions and Flatfoot Deformities
				Physical Exam
				Imaging and Diagnostic Studies
				Authors Preferred Treatment
				Surgical Technique
					Talocalcaneal Coalition Resection:
					Calcaneonavicular Coalition Resection:
			Clubfoot
				Pathogenesis
				Physical Exam
				Treatment
				The Ponseti Method
				Casting Pearls
			Complex Clubfoot
				Complex Clubfoot Pearls
			Atypical Clubfoot
				Atypical Clubfoot Pearls
				Bracing Period
				Surgical Management of Clubfoot
			Achilles Tenotomy
			Anterior Tibialis Tendon Transfer
				Anterior Tibialis Tendon Transfer Pearls
				Posterior Medial Release
				Complications
			Skewfoot
		References
	17: Management of Pediatric Foot and Ankle Deformities: Gradual Correction
		Introduction
		Update on Technology
		Soft Tissue Contracture
		Clubfoot
		Equinuocavusvarus Deformity
		Arthrogryposis
		Osteotomy
		Tibial Lengthening
		Acute Trauma
		Metatarsal Lengthening
		Summary
		References
			Further Reading
	18: Pediatric Joint Contractures
		Introduction
		History/Examination
		Imaging
		Principles of Treatment
		Non-operative Treatment
		Joint-Specific Operative Treatment
			Hip
			Knee
			Ankle
		Conclusion
		Commentary
		References
	19: 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
		Commentary
			Fracture Risk Management
		References
	20: Amputation and Prosthetic Management: Amputation as a Reconstructive Option
		Treatment Concepts
		Patient and Family Management
		Decisions That Have to Be Made
		Human Costs
		Result
		Short/Long Term
		Making the Decision
			The Doctor’s Role
		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
			Osseointegration
		Commentary
		References
	21: Working in Resource-Challenged Environments
		Introduction
		Initial Steps: Selecting a Partnership
			Commit to a Program
			Great Ways Volunteers Can Make a Positive Impact
			Host Responsibilities
			Understand Potential Repercussions of Good Work
			Keep Your Motives Pure
			Credentialing and Liability
		Operative Challenges: Improvise, Don’t Compromise
			Indications
			Perioperative and Anesthetic Considerations
			Sterility
			Operating Room Set Up
			Performing Operations in Resource-Challenged Environments
			Internal vs. External Fixation in Resource-Challenged Environments
			Re-use of Implants and External Fixation Components
			Cordless Power
			Post-operative Care
			Other Aspects of Orthopedics in the “Wild”
		Specific Techniques
			Clubfoot
			SIGN Nail
			Spica Cast
		Educational Resources
		Summary
		Commentary
		References
Part III: Underlying Conditions
	22: Metabolic Disorders
		General
		Pathophysiology
		Rickets
			General
		Nutritional Rickets
			Treatment
		Hereditary Hypophosphatemic Rickets
		X-Linked Hereditary Hypophosphatemic Rickets (XLH)
		Treatment
		Medical Treatment
		Non-pharmacological Treatment and Rehabilitation
		Orthopedic Treatment
		Author’s Preferred Method, Tips, and Tricks
		Surgical Technique
		Follow-Up
		Renal Osteodystrophy
			General
		Treatment
			Medical Treatment
			Orthopedic Treatment
			Angular Deformity
			Slipped Capital Femoral Epiphysis
			Avascular Necrosis
		Hypophosphatasia
			General
			Treatment
			Idiopathic Genu Valgum
		Commentary
		References
	23: Osteogenesis Imperfecta
		Introduction
		Diagnosis
		Differential Diagnosis
		Classification
		Pathogenesis
		Clinical and Radiological Features
		Management of OI
		Medical Treatment
		Rehabilitation
			Presurgery
			Immediate Postsurgery
			Orthotics/Bracing
		Surgical Treatment
		Perioperative Considerations
			Soft-Tissue Problems
			General and Anesthesia-Related Considerations
			Preoperative Planning
		Surgery
			Why?
			When?
			How?
			Types of Rods
			Patient Positioning
			Osteotomy
			Technique for Femoral FD Rodding (See Box 23.2)
			Technique for Tibial FD Rodding (See Box 23.3)
			Technique for Coxa Vara Correction
		Results and Complications
		Commentary
		References
	24: Lower Limb Deformity in Neuromuscular Disorders: Pathophysiology, Assessment, Goals, and Principles of Management
		Cerebral Palsy
		Classification of CP
		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)
			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 Nonambulant 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
		Orthopedic Procedures at the Knee and Lower Leg Segment (Tibia)
		Orthopedic Procedures at the Ankle and Foot
		Split Tibialis Anterior Tendon Transfer (SPLATT)
		Summary
		Myelomeningocele (Spina Bifida)
		Hip Dysplasia
		Knee Flexion Deformity and Tibial Torsion
		Ankle and Foot Deformities
		Poliomyelitis
		Hereditary Motor Sensory Neuropathy (HSMN)
		Foot Deformities (Fig. 24.26)
		Hip Deformities
		Muscular Dystrophies
		Conclusion
		Commentary
		References
	25: 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
		Commentary
		References
	26: Limb Lengthening and Deformity Correction in Patients with Skeletal Dysplasias
		Introduction
		Lower Extremity Deformity in Skeletal Dysplasia
		Surgical Considerations
			Pre-operative Evaluation
			Imaging
			Anesthesia
			Positioning and Neuromonitoring
			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
		Post-operative 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-ectodermal Dysplasia
		Summary
		Commentary
		References
	27: Lower Extremity Benign Bone Lesions and Related Conditions
		Introduction
		Nonossifying Fibroma
		Fibrous Dysplasia, McCune Albright Syndrome
		Osteofibrous Dysplasia
		Enchondromatosis
		Solitary Osteochondromas and Multiple Hereditary Exostoses
		Dysplasia Epiphysealis Hemimelica (Trevor’s Disease)
		Commentary
			Nonossifying Fibroma
			Fibrous Dysplasia, McCune Albright Syndrome
			Osteofibrous Dysplasia
			Enchondromatosis
			Solitary Osteochondromas and Multiple Hereditary Exostoses
			Dysplasia Epiphysealis Hemimelica (Trevor’s Disease)
		References
	28: 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. 28.2)
			Type I: LN Method (Fig. 28.3)
			Type II: DO Method (Fig. 28.4)
			Type II: LN Method (Fig. 28.5)
			Type III: DO Method (Fig. 28.6)
			Type III: LN Method (Fig. 28.7)
			Type IV: DO Method (Fig. 28.8)
			Type IV: LN Method (Fig. 28.9)
			Type V: LN Method (Fig. 28.10)
			Type VI: LN Method (Fig. 28.11)
		Case Examples
			Case 1 (Type I: DO Method) (Fig. 28.12)
			Case 2 (Type IV: LN Method) (Fig. 28.13) (Video 28.1)
		Commentary
		References
Part IV: Congenital and Developmental Disorders
	29: Congenital Femoral Deficiency Reconstruction and Lengthening Surgery
		Introduction
			Epidemiology
			Embryology
			Pathophysiology and Genetics
		Deformity and Pathoanatomy
			Osseous Deformities
			Ligamentous Structures
			Muscle Pathoanatomy
			Vascular Pathoanatomy
		Evaluating the Child with CFD
			History
			Physical Exam
		Imaging
			Radiographic Examination
			Magnetic Resonance Imaging
			Computerized Tomography (CT)
		Classification Systems
		Treatment Options
			Outlining a “Life Plan” for the Family
			Nonoperative Management
			Treatment Options for CFD
			Lengthening Reconstruction Surgery
		Preparatory Surgery
			Treatment for Paley Type 1 CFD
				Preparatory Surgery of the Hip
				SUPERhip 1 Surgical Technique
				SUPERhip 1 Surgical Technique (Figs. 29.9, 29.10, and 29.11)
					Case Examples (Figs. 29.12 and 29.13)
				SUPERhip 1 for Paley Type 1b Subtrochanteric-Type Surgical Technique [58, 65]
				Preparatory Surgery of the Knee
				SUPERknee Surgical Technique (Figs. 29.14 and 29.15)
				Patellar Realignment Surgical Techniques (Fig. 29.16)
				Posterior Capsule Release of Knee Surgical Technique (Fig. 29.18)
			Treatment for Paley Type 2 CFD
				Femoral Sling Surgical Technique (Fig. 29.21)
				SUPERhip 2 Surgical Technique (Figs. 29.23 and 29.24)
				Pelvic Support Osteotomy Surgical Technique (Fig. 29.25)
			Treatment for Type 3 CFD
				Lengthening Reconstruction Surgery for Type 3
				Limb Lengthening Surgery
				Monolateral External Fixator Technique (Fig. 29.28a–i)
				Extramedullary Implantable Limb Lengthening Technique [58, 82] (Fig. 29.29a–f)
				Intramedullary Implantable Limb (IMIL) Lengthening Technique (Fig. 29.30)
				Rehabilitation and Follow-Up During Lengthening [54, 85]
				Fixator Removal and Rodding of Femur
				Surgical Technique for Prophylactic Rodding of Femur at Time of External Fixator Removal (Fig. 29.31)
				Epiphysiodesis and Hemi-epiphysiodesis
		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
		Prosthetic Reconstruction Surgery for CFD
			Rotationplasty
			Rotationplasty Surgical Technique
			Paley-Brown Rotationplasty
			Paley Rotationplasty
			Muscle Transfers and Closure for Both Paley and Paley-Brown
			Supramalleolar Osteotomy or SHORDT for Rotationplasty
			Postoperative Management
			Summary
		Commentary
		References
	30: Fibular Hemimelia in the Pediatric Patient
		Introduction
		Classification
		Clinical Assessment
		Radiographic Assessment
		Prediction of Height and Limb Length Discrepancy at Maturity
		Principles of Treatment
		Surgical Techniques
			Lengthening for Paley Type 1
			Lengthening Plus Ankle Realignment for Paley Type 2
			Lengthening Plus SUPERankle Reconstruction for Paley Type 3
			Surgical Technique for Paley Type 3a (Figs. 30.27 and 30.28)
				Positioning
				Surgical Approach
				Osteotomy
				Frame Application
			Surgical Technique for Paley Type 3b (Figs. 30.29 and 30.30)
				Positioning and Surgical Approach
				Osteotomy
			Surgical Technique for Paley Type 3c (Fig. 30.31)
				Positioning and Surgical Approach
				Osteotomy
			Surgical Technique for Paley Type 3d (Fig. 30.32)
				Diagnosing Type 3d
				Positioning and Surgical Approach
				Osteotomy
			Surgical Technique for Paley Type 4 (Clubfoot Type)
				Initial Nonsurgical Treatment
		Additional Procedures
		Post-surgical Care
		Outcomes
		Commentary
		References
	31: 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 Patellar Arthroplasty (Patelloplasty)
		Limb Reconstruction Surgery (Senior Author’s Preferred Techniques)
		Paley Type 1 (Fig. 31.9)
		Paley Type 2
		Paley Type 2a (Figs. 31.10 and 31.11)
		Paley Type 2b (Figs. 31.12 and 31.13)
		Paley Type 2c (Figs. 31.14 and 31.15)
		Paley Type 3a (Figs. 31.16 and 31.17)
		Paley Type 3b (Figs. 31.18 and 31.19)
		Paley Type 4
		Type 4a (Figs. 31.20 and 31.21)
		Type 4b (Figs. 31.21 and 31.22)
		Paley Type 5
		Paley Type 5a (Figs. 31.23, 31.24, 31.25, and 31.26)
		Paley-Weber Patellar Arthroplasty
		Olecranization of Patella (Fig. 31.26)
		Type 5b (Fig. 31.27)
		Type 5c (Figs. 31.28 and 31.29)
		Summary
		Commentary
		References
	32: Treatment of Congenital Pseudarthrosis of the Tibia
		Introduction
		Classification of CPT
			Paley Classification of Congenital Pseudarthrosis of the Tibia (Fig. 32.1)
		Pathobiology and Pathomechanics
		Primary vs. Secondary Changes in CPT
		Treatment Methods
			Ilizarov External Fixation
			Intramedullary Rodding
			Vascularized Fibular Grafting
			Adjunct Treatment
			Amputation
		Treatment Results
		Evolution of the Paley Cross-Union Protocol
		Prior Treatment Lessons [5]
			Paley Cross-Union Protocol Surgical Technique [47, 48] (Figs. 32.7, 32.8, 32.9, 32.10, 32.11, 32.12, 32.13, 32.14, 32.15, and 32.16)
		Cross-Union Results
			Postoperative Considerations
				FD Rod Pull Out
				FD Rod Exchange
				Hemiepiphysiodesis
				Leg Length Discrepancy
			Calcaneo-Valgus Foot Deformity
		Pre-CPT (Paley Type 1 and 2)
		Conclusions
		Commentary
		References
	33: 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
		Commentary
		References
	34: 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
		Commentary
			Controversies in Blount’s Disease
			Bracing/Orthoses
			Guided Growth
			Acute Deformity Correction
			Is There a Role For Hemi-Plateau Medial Elevation
			Adolescent Blount’s Disease
			Summary
		References
Part V: Sequelae and Complications
	35: 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
			Growth Factors
			Scaffolds
			Other Uses of Stem Cells
			Osteogenic Progenitor Stem Cell Culture Technique
			Injection Technique (Fig. 35.4)
		Other Experimental Local Stimuli
			TP508
			ED-71
			FGF-2
			CO2
		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
		Commentary
			Methods to Enhance Bone Formation in Distraction Osteogenesis
		References
	36: Residual Deformities of the Hip
		Introduction: Defining Hip Deformity
		Residual Hip Deformities Secondary to Developmental Dysplasia
		Treatment of Residual Hip Dysplasia in the Skeletally Immature Child
		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
			Two-Incision Tönnis Triple Technique
			Technique
			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
		Commentary
			Commentary on Residual Hip Deformity Chapter
			Summary
		References
	37: Posttraumatic Lower Limb Deformities in Children
		Introduction
		Causation and Etiological Factors
			Classification
			Clinical Manifestations
		Radiographic Imaging
		Remodeling of Bony Deformities
			Case Study (Fig. 37.2)
			Clinical Summary
			Philosophy of Treatment
			Case Study (Fig. 37.3)
			Clinical Summary
			Philosophy of Management
			Management
		Important Posttraumatic Deformities: Lower Limb
			Posttraumatic Chondrolysis of the Hip and Avascular Necrosis
				Case Study (Fig. 37.4)
				Clinical Summary
				Philosophy of Treatment
			Posttraumatic Coxa Vara
				Case Study (Fig. 37.5)
				Clinical Summary
				Philosophy of Treatment
			Malunited Shaft Femur or Pseudarthrosis with Deformity
				Case Study (Fig. 37.6)
				Clinical Summary
				Philosophy of Treatment
				Case Study (Fig. 37.7)
				Clinical Summary
				Philosophy of Treatment
				Case Study (Fig. 37.8)
				Clinical Summary
				Treatment Philosophy
			Distal Femoral Deformity Following Iatrogenic Physeal Injury
				Case Study (Fig. 37.9)
				Clinical Summary
				Philosophy of Treatment
			Physeal Injury of the Distal Femur with Angular Deformity
				Case Study (Fig. 37.10)
				Clinical Summary
				Philosophy of Management
			Malunited Intra-Articular Fractures
				Case Study (Fig. 37.11)
			Physeal Injury to Proximal Tibia
				Case Study (Fig. 37.12)
				Clinical Summary
				Philosophy of Treatment
				Case Study (Fig. 37.13)
				Clinical Summary
				Philosophy of Treatment
				Case Study (Fig. 37.14)
				Clinical Summary
				Philosophy of Treatment
			Post-Traumatic Tibia Valga
				Case Study (Fig. 37.15)
			Physeal Injury Ankle with Malunion
				Case Study (Fig. 37.16)
				Clinical Summary
				Philosophy of Treatment
				Case Study (Fig. 37.17)
				Clinical Summary
		Philosophy of Treatment
			Soft Tissue Loss with Skeletal Injury
				Case Study (Fig. 37.18)
				Clinical Summary
				Philosophy of Treatment
			Valgus Deformity at the End of Long Bone Plate
				Case Study (Fig. 37.19)
				Clinical Summary
				Philosophy of Management
		Summary
		Acceptability Criteria for Reduction in Lower Limb Fractures
			Fracture Neck Femur
			Fracture: Separation of Distal Physis of Femur
			Fracture Tibial Tuberosity
			Fracture of Tibia and Fibula
				Proximal Metaphysis
				Diaphysis
				Distal Tibial Fractures
		Commentary
			Commentary to Posttraumatic Deformities in Children
			Posttraumatic Femoral Deformities
			Posttraumatic Tibial Deformities
			Posttraumatic Upper Extremities Deformities
		References
	38: 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
		Postinfectious Segmental Long Bone Defects
		Commentary
		References
	39: Bone Defects
		Definition of Bone Defects
		Etiology and Classification
		Evaluation Specific to Bone Defects
			Clinical Evaluation
			Radiographic Evaluation
		Treatment of Bone Defects
			Goals
			Spontaneous Regeneration
		Considerations for Successful Bone Defect Reconstruction
		Techniques
			Bone Grafting
			Induced-Membrane Technique (IMT)
			Acute Shortening and re-Lengthening (ASRL)
			Bone Transport
			Ipsilateral Fibula Transposition
			Vascularized Autograft
			Osteochondral Reconstruction
		Commentary
			Commentary from Stephen Quinnan
		References
	40: 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
			Fibular Malunion
			Transphyseal ACL Reconstruction Causes Premature Physeal Closure
			Femur Malunion and Growth Disturbance
			Vascularized Fibula Graft Nonunion and Valgus Ankle Deformity from the Fibular Donor Site
			Deformity from Tibial Lengthening
			Translational Deformity
		Summary
		Commentary
		References
Index