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Prior investigators had pioneered a technique of closed femoral shortening with an intramedullary saw set which allows the procedure to be performed entirely within the medullary cavity and without direct approach to the shaft of the femur (166, 167). This technique is easier, does not require a skilled assistant, and has a fairly high success rate. This is a very difficult prosthesis to align and fit, although it gives excellent function (177, 194). The medial clavicle is approached through a transverse incision extending from the middle thirdέedial third junction of the clavicle to just past the midpoint of the sternal notch. This completes a superficial plantar-medial release for a cavovarus foot deformity with flexible hindfoot varus. Specific strengthening of the rotator cuff and scapular stabilizers is employed and also an examination of the throwing mechanics of these athletes. This negates any changes caused by growth, and realignment to compensate for gait changes is virtually impossible. These clicks are usually transmitted from the trochanteric region or the knee and have no diagnostic significance (102). Because of the physical characteristics of the liner, the greater the distracting forces placed on the prosthesis, the tighter the liner grips the residual limb. Radiographically as well, the foot looks like an idiopathic flatfoot with plantar flexion of the talus, sag at the talonavicular joint, dorsolateral positioning of the navicular on the head of the talus, and exaggerated angular deviation between the talus and calcaneus. For instance, the complication rates in limb lengthening for congenital disorders is greater than limblength discrepancy from shortening due to growth plate injury (infection, trauma, or neoplasia). The bony surfaces can be sealed with bone wax to lessen the bleeding that might tend to displace the fat graft. It is possible to perform stapling in such a way that normal growth resumes when the staples are removed (146ͱ48). A valgus osteotomy converts the shear forces across the physis into compressive forces, and this appears to improve ossification in the femoral neck. The age range of 18 months to 3 years is considered a "gray zone"; some surgeons advocate preliminary traction before open reduction, but an increasing number of surgeons prefer to perform concomitant femoral shortening (354ͳ56). Triangular metaphyseal fragment in inferior femoral neck with associated inverted Y appearance 4. Other findings include proximal dislocation of the fibula into the distal lateral thigh segment, which gives its common appearance on physical exam. Care should be taken to maintain a pick-up or clamp on the tendon to prevent proximal retraction after release. It is generally considered when amputees require maximum late-stance stability because of weak knee extensors, knee-flexion contractures, or poor midto late-stance balance (227). Fortunately for most children, remodeling or reversal of the overgrowth occurs spontaneously, obviating the need for guided growth techniques or osteotomies to correct the overgrowth. B deformity and shortening can be expected in infants and young children, with up to 65 degrees of angulation remodeling documented in infants (31). The varus derotation osteotomy is used alone in such cases by surgeons who think that redirection of the femoral head toward the center of the acetabulum stimulates normal acetabular development (156, 184, 208, 393ʹ02). Tibial osteotomy for varus gonarthrosis: indication, planning, and operative technique. In the adult population, ankle sprains comprise 25% of athletic injuries (241Ͳ43). The tibia is exposed subperiosteally and curved retractors placed around the tibia. The more immature the patient at the time of entering the reossification stage, the greater the potential for remodeling. A meniscotome is used to extend the two parallel incisions proximally in line with the fibers of the tendon. It curves over the tip of the trochanter, staying slightly posterior, and ends far enough distally to permit the insertion of the pins at the proper angle into the neck.

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Subtrochanteric fracture after fixation of slipped capital femoral epiphysis: a complication of unused drill holes. At times a portion of the fibula will be resected to facilitate manipulation of the tibial for drilling the medullary canal and provide contact between the reduced tibial fragments. In addition, no data are presented on the interobserver or intraobserver reliability of the outcome criteria. The authors have not seen any patients as described in the literature with complete tibial absence yet the presence of adequate active knee extension, but would recommend knee disarticulation and prosthetic fitting for these patients as well because of its high functional result compared to the poor functional results reported for the Brown procedure. If a malignancy is suspected, however, urgent biopsy of the lesion may be necessary to confirm the diagnosis and to expeditiously guide treatment. Each year, above the age of 17, the risk for stress fractures was noted to have been reduced by 28% (367). A: After excision of the pseudarthrosis, the Williams rod is inserted, antegrade, through the distal tibia, talus, and calcaneus and exits through the heel pad. Most sports injuries in the skeletally immature are amenable to nonoperative management. Their construct of thin wires and circumferential rings provides rigidity against bending in the sagittal and coronal planes but is not so rigid in the axial direction, allowing slight axial movement in response to applied loads. In these young patients, an attempt at excision may be preferred to the difficult treatment of limb lengthening. To minimize the risk of disease transmission, a screening processes is performed which can leave a window of 3 or 4 weeks for graft implantation. Ballistic stretching can cause activation of the stretch reflex and cause muscleδendinous strain and is not recommended after acute injuries. Because most patients regain flexion in the first year after lengthening (198), it appears that maintaining knee extension is more important. The pin (B) is inserted into the fracture site, and the fragment is levered upward to bring the fracture surfaces closer to a more parallel plane. Closed treatment is typically utilized for type 1 fractures and for type 2 or 3 fractures that are able to be successfully reduced closed. Congenital pseudarthrosis of the tibiatreatment by transfer of the ipsilateral fibular with vascular pedicle. This cut must proceed between the medial wall of the ilium and the medial wall of the acetabulum. Intertrochanteric corrective osteotomy for moderate and severe chronic slipped capital femoral epiphysis. This lateral trochanter entry site is necessary to avoid injury to the medial portion of the trochanteric growth plate and injury to the terminal branches of the medial circumflex artery in the trochanteric fossa. Patients should be advised that the wait for return to competitive athletics may be prolonged. Coxa vara infantum, hip growth disturbances, etiopathogenesis, and long-term results of treatment. A sharp rake is used to pull up the belly of the vastus lateralis muscle, exposing its posterior attachment into the femur at the linea aspera. The Hip: Proceedings of the Thirteenth Open Scientific Meeting of the Hip Society. In the case of leg lengthening, the parents and the patients must understand why the child may wear an external device for many months even after the length is gained. Bulb or syringe irrigation is safest for cleansing of wounds, eliminating the risk of high-pressure extravasation of saline into fixed tissue compartments and the risk of forcing debris deeper into the wound. Although modern prosthetics have made amputation a somewhat more acceptable alternative, the improved ability to lengthen limbs has also made limb salvage a more feasible option. In addition, Smillie (200) has suggested that the juvenile form may be caused by a disturbance in the ossification of the epiphysis itself, resulting in the separation of small islands of bone from the main bony epiphysis. Typically, the proximal transverse incision is made first completely cutting through approximately 60% of the medial triceps surae tendon (only) from medial to lateral. This has the added advantage of providing more mobility to the fragments, which tend to be held together by the thick periosteum and the surrounding ligaments. We further advise the anesthesia team of the risk so that they can adequately hydrate the patient and keep the PaO2 high during the reaming process. D: Fifty-one years after reduction, when the patient was 53 years of age, the hip is subluxed and shows severe degenerative changes (Iowa Hip Rating, 48 of 100 points). Although not all fractures and childhood injuries can be prevented, there are many ways in which the rate and severity of injuries can be decreased.

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For a 3-cm discrepancy, epiphysiodesis of the femur alone is recommended at the onset of puberty. Exercises are begun immediately after birth to stretch the tight plantar-medial structures, including the posterior tibial tendon and plantar soft tissues. The pathology of acute necrosis of cartilage in slipping of the capital femoral epiphysis. The involvement in competitive sports is usually a good benchmark to initiate fitting adolescents with the highestperformance dynamic-response feet. Physeal closure occurs in the operated hip first in most cases, and simultaneous closure occurs in fewer than 10% of cases (116, 164, 204, 227Ͳ29). With a second infarction, however, they were able to show a more characteristic histologic picture of Legg-Calv鮐erthes syndrome. In general, nonsurgical treatments including bed rest, traction, and hip immobilization in a spica cast have not altered the natural course of the disease (24, 29, 43). Locking screws or similar mechanisms are needed proximal and distal to the osteotomy because the osteotomy has no intrinsic stability. A variation of a Wiltse osteotomy may obviate that problem, as described below (83). He also stated that, despite his definitions, there is a large overlap between the two conditions. Because these patients are often obese or morbidly obese, a thorough evaluation of their cardiopulmonary system is essential prior to any consideration of operative treatment. For physeal injuries, suture or sternal wire fixation from the metaphysis to the epiphysis (medial clavicular head) is adequate. The menisci are carefully evaluated as there should be a low threshold for meniscal repair in this patient population. The surgical treatment of patients with osteosarcoma who sustain a pathologic fracture. In most cases, the fragment is smaller than 2 cm in diameter and should be excised. An oblique incision is made in the skin lines, 1 to 2 cm distal to the anterosuperior iliac spine. The assessment of contact stress in the hip joint after operative treatment for severe slipped capital femoral epiphysis. Central bars are approached either through a metaphyseal window or through the osteotomy site for those cases requiring angular correction in addition to bar excision. Louis Shriners Hospital for Children, half of the patients required a posterior ankle and subtalar release to achieve satisfactory dorsiflexion. Despite differences in the patterns of muscle imbalance that create cavovarus, the pattern of deformity development is fairly constant (47ʹ9). The approach to casting after reduction is the same as that described earlier for closed reduction. The Trendelenburg test in patients with Legg-Calv鮐erthes syndrome is often positive. A second-look arthroscopy is scheduled to see if the fixation is raised before the resumption of weight bearing. In-toeing may be caused by residual foot deformity from metatarsus adductus, clubfoot, or skewfoot (1, 4, 5). Insert another one from dorsal-to-plantar at the level of this transverse pin perpendicular to the desired longitudinal axis of the hindfoot. C: One year after resection of the coalition, no reformation of the bar has occurred. As the cut is made across the calcaneus, it should remain in the transverse plane. Diaphyseal fracture patterns are directly related to their mechanisms of injury: torsional force results in spiral fractures (A), perpendicular moment force results in transverse fractures (B), compressive force, also known as axial loading, results in oblique fractures (C), and compression and moment forces result in "butterfly" fracture patterns (D). The external contour of the foot should be inspected to ascertain that the desired threedimensional alignment of the foot has been achieved.

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Fixation can be accomplished with a small cannulated screw, which allows early range of motion to minimize the risk of elbow stiffness. Although equinovalgus foot deformity is usual, occasionally equinovarus can be seen, especially in these cases (78, 79). The classification system was found to have poor interobserver and intraobserver reliability by Cook et al. Prosthetic devices for children with bilateral upper limb deficiencies: when and if, pros and cons. Southwick osteotomy for severe chronic slipped capital femoral epiphysis: results and complications. Historically, the term "chondromalacia patellae" has been used to describe this entity (330). This external tibial torsion deformity becomes more obvious once the heel cord has been lengthened. Three-dimensional imaging of the bridge facilitates its excision in the operating room (190). Epiphysiodesis is an excellent way to treat mild-to-moderate discrepancy in length; as a requirement, appropriate candidates must have enough growth remaining to recoup differences in length. In some cases, the degree of valgus is more severe than can be explained by the smaller lateral femoral condyle alone, and its recurrence after correction speaks of a more dynamic cause. The fibular epiphysiodesis can be performed through the same skin incision as the lateral aspect of the tibia, but the surgeon must approach the fibula from the anterior aspect to avoid the peroneal nerve. Although the efficacy of these transfers has not been scientifically proven, the split transfer adds little time and no morbidity, and it makes theoretic sense. However, there is no particular pattern of fracture that is diagnostic of child abuse. Napiontek (297) reported overcorrection of the valgus deformity in half of his patients who underwent peritalar reduction combined with subtalar arthrodesis. Finally, an osteotomy is created that will allow the femoral shaft to be brought back into the median plane of the body and secured with the plate (C). When a child presents with hip, groin, thigh, or knee pain, care must be taken to evaluate both hips. Treatment of moderate to severe slipped capital femoral epiphysis with extracapsular base-of-neck osteotomy. It must be also remembered that underlying the articular cartilage is a small area of endochondral ossification that contributes to the growth of the cartilage of the articular surface. If the patella cannot be relocated with the patient supine, reduction can be facilitated by placing the patient prone. The neck of the talus is short and deviated plantar-medially on the body of the talus (102, 153, 157ͱ60). The cavovarus foot, therefore, has two major rotational deformities in opposite directions from each other: pronation of the forefoot and supination (varus and inversion are other descriptive terms) of the hindfoot. Strengthening is an important part of the rehabilitation program and includes isometric, isotonic, isokinetic, concentric and eccentric, closed kinetic chain, and functional exercises. Delay results in the development or persistence of abnormalities in the shapes of the bones and joints that makes reconstruction more difficult. Following corrective osteotomy, the pathologic changes in the proximal medial tibia must be carefully monitored. At the time of presentation, approximately 80% of the boys are reported to be between 12 and 15 years and 80% of the girls between 10 and 13 years (17). From the few reports in the literature, patients of both sexes are affected equally (68, 69, 76, 78). Methods for measuring maturity based on the appearance of various ossification centers in various populations of "normal" pediatric patients have been published. Congenital hip dysplasia: problems in the diagnosis and management in the first year of life. For the child, the plate will either have to be custom made or have to be made by bending an available device. Surgical treatment performed at about 1 year of age is indicated to improve shoe tolerance. The pathoanatomy is one of variable degrees of failure of formation with occasional duplication and malorientation of bones.

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He found a 50% incidence of radiographic changes including coxa magna, widening of the femoral neck, and changes consistent with degenerative arthritis of the hip. With the knee in 90 degrees of flexion, tension is applied to the graft, and the proximal aspect of the graft is sutured to the periosteum of lateral femoral condyle. Caution must be exercised to avoid injury to the lateral digital neurovascular structures of the great toe, because the medial digital neurovascular structures of the hallux will at least be stretched if not inadvertently damaged by the medial release. These methods were based on the premise that weight relief would prevent the mechanical deformation of the head and early degenerative joint disease (89, 317ͳ19). The residual limb-length inequality is usually mild and can be addressed in most cases with a shoe lift. Ultrasound and congenital dislocation of the hip: the importance of dynamic assessment. In addition, as there may be an increased risk of stiffness and scarring following an open reduction, range-of-motion exercises should be stressed, with use of formal therapy if needed. The justification for any classification system should be to direct differential treatment and to assign prognosis, based upon the natural history of the condition and the proven efficacy of treatment. The patient and family must be cooperative; a visiting nurse is often helpful in instituting this program. B: Ten months after operative open reduction, femoral shortening, and Pemberton osteotomy. Prospective longitudinal studies documenting the outcomes of minor anatomic abnormalities found in ultrasonographic examinations need to be completed (164, 165). Slipped capital femoral epiphysis: rationale for the technique of percutaneous in situ fixation. When the bone is in place, it should be relatively secure; however, it is reasonable to secure it with a Kirschner wire that is passed retrograde along the medial column of the midfoot through the base of the first metatarsal, the anterior fragment, the graft, and the posterior fragment. Muscle testing and sensory examination should be part of the initial examination in all patients, as clubfoot has been found to be associated with absent anterior compartment muscles and lesions involving the innervation to the anterior and lateral compartment muscles. Recent advances have used computer-based systems to score the x-rays and determine the skeletal age (90͹2). This determines the amount of anteversion of the femoral neck, which is important for the correct insertion of the blade. Walking may become awkward because of the knees rubbing or hitting together as the child tries to narrow the base of support. Pros and cons exist at every stage of the process; some advocate delaying limb lengthening until patients are older children (10 to 12 years) so that they can comprehend the task ahead; others suggest that lengthening at an earlier age (5 to 7 years) may allow for more normal growth postlengthening and perhaps less ultimate discrepancy. The dynamic-response foot has found its way into competitive-level sports as well as day-to-day activities. Physiologic bowing and Blount disease are two points within the same spectrum, with Blount disease being the pathologic result of unresolved infantile bowing (51, 54). Interosseous ligament injuries are universally seen in conjunction with a deltoid ligament injury. While no one technique is fail safe, the authors would recommend always utilizing at least two techniques when determining treatment. The severity of changes in bone morphology and the degree of osteomalacia is variable. In these cases, the arthritis is more insidious in onset and will persist beyond the 2 weeks that are typical for transient synovitis. However, shortening of the first metatarsal from a nonunion or physeal injury, a devastating complication, has been reported in 5% to 30% of patients (459, 461, 462). Recent advances in silicone and urethane technology have increased comfort, flexibility, and cosmesis of the sleeve suspension systems. At the completion of this step, any muscle advancements or other steps to augment the realignment are completed, and the wound is closed over a suction drain. Groups of cartilage cells have been noted between metaphyseal trabeculae (155, 157, 159).

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They noted that, of the children of index patients with the syndrome, only 2% had Legg-Calv鮐erthes syndrome. If so, the resected joint surfaces are held together with staples, screws, wires, or combinations of these internal fixation devices. Such levering can damage the anterosuperior acetabular cartilage and/or cause posterolateral labral injuries (145ͱ48). Insert a third pin parallel with, and immediately proximal to , Lisfranc joints through the three cuneiforms and the cuboid. Dunn reported chondrolysis in 18% of his cases (13 of 73), with a rate of 17% in 24 in acute-on-chronic cases and 18% in 49 in chronic cases (297). Most feet underwent one or more repeat surgical soft-tissue releases, and these feet were characterized by pain, stiffness, and arthritis. The length of the keel controls the toe lever arm and thus the hyperextension moment at the knee, and the compression of the elastomer heel absorbs and deflects the forces at heel strike. These fractures typically have an intact longitudinal band of periosteum that provides enough stability such that cast immobilization is successful in maintaining reduction in most cases (52). The correct size of steel rods is estimated by holding a rod next to the humerus and viewing both with the image intensifier. The patient is encouraged to undertake full weight bearing as early as possible, and physical therapy is instituted to maintain mobility and joint range of motion. Many children will use the prosthesis for specific tasks (riding a bike) while preferring to remove it for others (swimming). The natural history of complete dislocation depends on the presence or absence of two factors: a well-developed false acetabulum and bilaterality (27, 58, 67, 117, 204, 205). A: Anteroposterior radiograph of the pelvis of a girl, 12 years and 4 months of age, with idiopathic chondrolysis of the right hip. A sterile tourniquet is applied and inflated to 250 mm of Hg of pressure prior to incision. Muscle imbalance from both static and progressive neuromuscular disorders leads to progressive increase in the severity and stiffness of cavus foot deformities, though the rate of progression varies considerably. The findings of multiple healing rib fractures (including posterior) and the acute skull fracture clearly indicate child abuse. Once independent gait is established in the infant, refinement to gait can be achieved through further prosthetic alignment. One series reported a higher incidence of chondrolysis in those of Hawaiian descent (357). Lateral hip rotation is greater than medial rotation in infants; it averages 65 degrees (range, 45 to 90 degrees), compared to children over the age of 10 years who average 40 degrees (range, 20 to 55 degrees) (1ͳ, 5, 9, 10). However, like the child with bilateral amelia, these children will function in most activities by substituting foot function for what they cannot do with their upper extremities. As expected, most patients with Perthes disease in both series were doing well clinically, as do most patients over the short term regardless of the extent of the deformity. In the children where this was true, patients at the time of knee fusion underwent excision of both distal femoral and proximal tibial epiphyses and physes, and no residual limb was too short to successfully fit with an above-knee prosthesis. Therefore, the best approach is probably to differentiate congenital oblique and vertical talus deformities from the flexible flatfoot with a short Achilles tendon, based on the definition of the latter by Harris and Beath (279). The choice depends on the radiographically determined site(s) of deformity and the age of the child. Based on our past clinical experience, an acute traction or impingement injury to the peroneal nerve may also occur (38). No capsule is present (D); therefore, it is sufficient to stay slightly anterior to the sciatic notch. Isotonic exercise involves the contraction of muscle against fixed resistance while the joint moves through its arc of motion. Likewise, an enlarged, partially duplicated and unsegmented metatarsal head can be safely reduced in size by performing a transphyseal longitudinal osteotomy (467). The multiaxis foot allows passive dorsi- and plantar flexion, inversion, and eversion.

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The angular deformities seen in Blount disease and the anterolateral bowing seen in congenital pseudoarthrosis of the tibia, both cause an apparent discrepancy due to the deformity and a true discrepancy in that the affected bones are shorter than their normal counterparts. The tripod effect (48) accounts for the varus position that the hindfoot must assume during weight bearing due to the fixed pronation of the forefoot. Prosthetic hips arc on a single axis and are mounted on the outside anterior distal aspect of the affected side. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. If cartilage regeneration via mesenchymal cell stimulation is selected, then the authors prefer drilling and pick treatment over abrasion because the former do not flatten the convex surface of the femur and therefore do not increase the force per unit area at the edges of the lesion. Anatomic dysplasia refers to inadequate development of the acetabulum, the femoral head, or both (49). Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years. When performing a valgus-producing osteotomy, it is often desirable to lateralize the distal fragment. Although the presence of excessive hip external rotation may augment posterior shear loads, an increased incidence of slipped epiphysis has not been found in patients with femoral retroversion without other contributory factors being present (17). This disorder is characterized by major criteria (macroglossia, overgrowth abnormalities, and anterior chest wall defects) and minor criteria (ear creases, flame-shaped facial nevi, kidney enlargement, hypoglycemia, and hemihypertrophy) (58). Painful callus that developed under the head of the talus in a skewfoot with contracted Achilles tendon. B: Alignment at 18 years of age following tibial internal rotation osteotomy to correct excessive external tibial rotation. With these implants, we can perform an osteotomy at the junction of the intertrochantericγubtrochanteric level. As the tip of the rod crosses the ankle joint, the potential for disruption of articular cartilage exists. Power lifting and Olympic-style weight lifting are not recommended for the skeletally immature (14). In one study with pin penetrations reported in 28 cases, chondrolysis resulted in only 3 of these 28 hips (11%) (204). There have been no additional wound healing problems or radiographic evidence of avascular necrosis of the medial tibial plateau. Moderate-to-severe contusions take from 4 to 6 weeks, on an average, to heal before return to sports participation (236Ͳ38). Wedge-shaped distal tibial epiphysis in the pathogenesis of equinovalgus deformity of the foot and ankle in tibial lengthening for fibular hemimelia. After opening the skin, the peroneus brevis is identified, freed from its sheath, and retracted plantarward. The nonconventional or extension prosthesis allows the child to "stand" on the prosthesis, extending his limb to the floor and accommodating the deformity. The acetabular index is increased, the medial floor of the acetabulum is widened, and the acetabular teardrop figure is absent. Treatment of traumatic shoulder dislocation in children and adolescents is nonsurgical, with gentle closed reduction. It is safer than ballistic stretching in which sudden bounces or joint motions are permitted. The clamp is then spread in line with the fibers of the tendon to start the posterior split in the tendon. Flexion-type fractures account for about 2% of supracondylar fractures, and most often arise from a fall directly on the elbow. The Salter innominate osteotomy provides about 15 degrees of lateral coverage and 25 degrees of anterior coverage, although many clinicians believe that more lateral coverage can be obtained. A cartilaginous coalition has the appearance of an articulation with somewhat undulating subchondral bone surfaces. Mesenchymal ingrowth allows formation of the anterior part of the pelvis and the abdominal wall muscles. Does skeletal maturity predict sequential contralateral involvement after fixation of slipped capital femoral epiphysis? The knee is evaluated through a full range of motion to ensure rigid fixation without fracture displacement and to ensure that there is no impingement of the screw heads in extension. This is additional evidence of the longstanding nature of the condition before detection (1͵, 274, 286).

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The eclectic surgeon recognizes the value of this procedure in the treatment of the subluxating or dislocated hip with an acetabulum that is relatively large in relation to the femoral head, such as the subluxating hip or in some of the neurogenic dislocating hips. Endocrinologic and metabolic factors in atypical presentations of slipped capital femoral epiphysis. When the tip of the guide pin is in the desired location (the center of the femoral head and 5 mm from the subchondral bone), its length can be measured. The elbow is best pinned at slightly <90 degrees of flexion because it is technically difficult to pin the elbow in extension. Normal menisci are never discoid during development and hence discoid menisci likely represent a congenital variant (64, 84). A hemostat or suture can be placed on the fibrofatty tissue to retract it and the extensor brevis muscle out of the way without damaging the muscle. In patients in the active stage of the disease regardless of their age with a noncontainable hip or patients with a painful hip after healing who demonstrate hinge abduction, abduction osteotomy should be considered. However, the disease process appears to have two distinct stages in most patients. The risks of arthroplasty involve the affected hip itself, and can be marked and repetitive because of wear, loosening, and dislocation. The latter is a cup-like structure made up of the navicular, the spring ligament, and the anterior end of the calcaneus and its facets. The correction obtained by manipulation is maintained by immobilizing the foot in a thinly padded well-molded toe to groin cast. This medialization results in reduction of the lever arm in order to reduce joint loading. The hemostat is again passed along the same tract to the point where the tibialis anterior meets the ankle retinaculum, turned at an acute right angle, and passed out the proximal extent of the dorsomedial foot wound. The distal fragment is posterior and often deeper than expected; easy to palpate but difficult to visualize. Most of these injuries are minor sprains and contusions and are associated with athletic activities; fractures infrequently occur at school (9). A small group of athletes taking part in sports with a high demand for throwing will complain of pain and decreased ability to throw. Spontaneous resolution of the cyst, however, is uncommon, and therefore further treatment may be needed to treat the cyst (106) with bone grafting. Amputation (Syme or Boyd procedures) and prosthetic fitting is chosen if the discrepancy is anticipated to become >15 to 20 cm and especially if the patient has a functionally useless foot (14). As the deformity of hallux valgus progresses, the flexor tendons and sesamoids sublux laterally; the adductor of the great toe inserting on the proximal phalanx increases the deformity, and finally, once the hallux valgus deformity is present, the abductor hallucis with its medial insertion on the proximal phalanx has no ability to adduct the great toe. Two proximal and two distal external fixator pins are placed in a manner that fixes the bone but does not bind to the nail. The soft tissues are elevated from the undersurface of the isthmus of the calcaneus using a Joker elevator or Crego retractor. The absence of degenerative changes in the talonavicular joint and calcaneocuboid joint should be ensured. First, in children with severe congenital deficiency of the lower extremity, the foot is often in severe equinus, with the heel pad proximal to the end of the tibia. A,B: the nonconventional or extension prosthesis without a knee joint, which is usual. Occasionally, a patient will have a shortened limb that will also require correction of a deformity; the surgeon has the choice of choosing acute deformity correction followed by gradual lengthening or gradual correction of both problems. Amputation in children: a follow-up of 74 children whose lower extremities were amputated. X and Y: extent of metatarsal articular surface; X and Y: extent of proximal phalanx articular surface. The most common mechanism of tibial eminence fracture in children has been a fall from a bicycle, but with increased participation in youth sports at earlier ages and higher competitive levels, fractures resulting from sporting activities are being seen with increased frequency.