PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA’s Resident REVIEW Cutting Edge Orthopaedic Information Enhancing Resident Education August 2010 From the Editor, Challenging Cases: What Would You Do? Kenneth Noonan, MD CASE #1, continued Since the last edi- CASE #1 tion of the POSNA An 11 year old girl presents with a navicular. This is the most common Resident Review, history of bilateral foot and ankle type of tarsal coalition and is best seen a horrific natural pain which she noted after a hiking on the oblique foot radiograph. Treat- calamity struck in trip with no definite injury. Exami- ment includes a course of nonoperative our neighboring nation reveals painful and limited bracing or immobilization followed by country of Hai- subtalar motion with peroneal spasm. operative intervention if symptoms ti. An estimated Radiographic image of her most persist. Resection of the coalition is 500,000 Haitians symptomatic foot is shown below in usually coupled with interposition of were either killed or injured in the Figure 1. Treatment course should extensor digitorum brevis or fat graft days following the earthquake of include: to prevent recurrence and has been January 12. The bulk of surviving A. Calcaneal sliding osteotomy reported to give satisfactory results patients had crushed limbs and B. Triple arthrodesis in 80% of cases (Level IV evidence). spines, at least a third of those in- C. Resection of bar and interpo- Interposition of the flexor hallicus jured were children. An amazing sition of extensor digitorum longus tendon may be considered after international outreach effort rapidly brevis resection of a subtalar coalition (the ensued and in the midst of this ef- D. Resection of coalition and second most common location). Calca- fort were many dozens of pediatric interposition of flexor hallicus neal osteotomy and triple arthrodesis orthopaedists from all over the longus tendon are salvage procedures in the case of world. As pediatric orthopaedists E. Physiotherapy and bracing and advanced arthritis or failed previous our specialty is uniquely suited to failing this…peroneus longus surgery. Peroneal spasm is thought apply non-operative and operative lengthening to be a mechanism to reduce pain by methods regardless of patient age. Your Response: ___ splinting subtalar motion. Historically, In this edition of the POSNA Resi- hindfoot coalitions were referred to dent Review we highlight a Resident peroneal spastic flatfoot and at- (A. Socci MD) and Consultant (M. tempts to relieve symptoms with Vitale, MD) who have contributed in peroneal lengthening failed. Haiti. We also take the opportunity to interview Dr. Kaye Wilkins; who The correct answer is C. has given decades of his life to edu- cation and service in underserved References countries. He epitomizes one of the Gonzalez P, Kumar SJ. Calcaneona- major missions of POSNA…service vicular coalition treated by resection to children everywhere. and interposition of the extensor digitorum brevis muscle. J Bone Joint Rounding out this edition are Surg Am 1990;72:71-77. OITE style questions on Pediatric Fig. 1 Lemley F, Berlet G, Hill K, Philbin Foot Conditions and articles on T, Isaac B, Lee T. Tarsal coalition. the Pediatric Orthopaedic Match Discussion Foot and Ankle Int 2006;27:1163-1169. and the upcoming IPOS Meeting in The oblique foot view shows a coali- Orlando in early December. tion (bar) between the calcaneus and Continued on page 9 Pediatric Orthopaedic Profile: Dr. Kaye Wilkins, DVM, MD By: Ken Noonan, MD

There are certainly those who don’t know Dr. Kaye Wilkins personally; yet every English reading orthopaedic resident in the last 2 decades has been influenced by his expertise in pediatric elbow trauma and he has written and taught on many other topics. He has also taken his expertise internationally and has taught pediatric orthopaedics in over 50 different countries. Kaye has held many leadership positions in academic medicine including the presidency of Pediatric Orthopedic Society of North America (POSNA) in 1987. Dr. Wilkins (far right) and his family Kaye was born in 1934 and eventually his family settled in Kirkwood, Mis- recently enjoying a family snowshoeing trip. souri. During his high school years he was fortunate to work in an animal that I have been teaching in countries ground floor of both a newly develop- hospital which stimulated his general with limited resources during my ing orthopedic subspecialty and the interest in biology and specifically in whole professional life, when in actual- Pediatric Orthopedic Study Group (the Veterinary Medicine. He completed ity it has only been within the last 15 precursor to POSNA). This association his undergraduate and graduate years. Up until then I focused on three provided many international contacts studies at Colorado A&M and he areas of my life: 1. Taking good care of which I subsequently used to develop received his DVM in 1958. Although patients in my practice. 2. Getting my my various international teaching he enjoyed large and small animal three sons educated and 3. Saving up conferences. medicine; he felt his future belonged for retirement so that I could eventu- farther up the evolutionary ladder. ally dedicate more time to educate in You have an international Thus he was accepted to Southwestern other countries. reputation in pediatric trauma. Medical School in Dallas, Texas where Why did you choose this field? he completed medical school and his The Editorial Staff of the POSNA Resi- This actually was the result of my de- orthopaedic residency training. Upon dent Review recently interviewed him cision to join Drs. Charles Rockwood completing his residency in 1966, he for this edition….. and David Green in the Department of served in the USAF for two years at Orthopedics at the University of Texas the height of the Vietnam War. What led you to Career in Health Science Center at San Antonio. Pediatric Orthopaedics? They recruited me to construct a chap- Kaye has been married to his wife In orthopaedics residency, I felt con- ter on elbow fractures in the edition Sidney for 53 years; he credits his suc- nected to children and became interest- dealing with adult fractures at the last cess to her unflagging support and ed in pediatric orthopedics during my minute when one of the original au- guidance. He firmly believes that the rotations at Scottish Rite Hospital. At thors failed to complete their chapter. most important decision in his life was that time there were very few individu- This led to production of in the second to marry her. Together they have raised als doing only pediatric orthopedics edition which included Volume III or 3 successful sons who have taken lead- and there were only four fellowship “Fractures in Children,” which I edited ership positions in academia, ministry programs in North America. I was with Dr. Richard King. and education. When asked the secret fortunate to do my fellowship at the to his success, he states…” Do what Hospital for Sick Children in Toronto I especially like trauma care because you love to do and do it with lots of which was, and still is one of the pre- children recover so rapidly and they energy. However remember that one’s mier pediatric orthopedic programs have only one goal…to return to their primary goal is to provide a caring in the world. relatively care free childhood. I enjoy secure and loving environment for the breadth that trauma brings; in ad- their family.” Put another way, Dr. My fellowship was a real turning point dition to the challenges of acute trau- Wilkins states, “Many people think in my career. I was able to be on the Continued on next page  Pediatric Orthopaedic Profile: Dr. Kay Wilkins, DVM, MD, continued ma; the reconstruction and salvage of learning the non-operative manage- to my sons and my local practice trauma complications is very fulfilling. ment of fractures in children. had been pretty well resolved and Regardless of the specialty one chooses thus I felt it was time to give back. in orthopaedics; in order to be a suc- Do you continue to take I had learned of Hopital St. Croix cessful one must have a genuine inter- trauma call? in Leogane, Haiti. I simply went on est in helping patients deal with their Yes, I take trauma call even if it is in the my own to see if I could provide any disabilities be they either temporary middle of the night. If I am going to be service to that hospital. My goal was of long term. The monetary rewards giving lectures on pediatric trauma, I to establish contacts and provide should be secondary. This means that feel it is important that I still be active teaching conferences. I wanted to find they should accept all patients that treating trauma patients. individuals who could come to the US need their services regardless of their to participate in short term observer financial status! This is especially true What are the top five rules that ships or even attend some conferences when it comes to the treatment of pa- residents should keep in mind in North America. The Haitians are tients with the public funding such as besieged with numerous visitors who when managing pediatric trauma? CHIPS and Medicaid. In most cases, have great plans for projects but never 1. First, try to assure the parents and our medical education was subsidized follow through. It took a number of children that the condition can by public funding. As a result, I feel trips to establish that I was sincere to usually be rectified. that we have an obligation to take care be there for the long run. 2. Keep the treatment as simple as of all children with trauma conditions One thing that became evident early possible respective of their funding. was that there were no post-graduate continuing education activities. Thus, My motto is to “leave skills not scars.” My efforts we organized a continuing education course on pediatric trauma. That have been directed towards providing continuing course was very successful as there was faculty from the US, Canada, education to our orthopedic colleagues in Cuba, France and of course Haiti. That these countries with limited resources. course was so successful that it was repeated two years later.

How has surgical management of 3. Be sensitive to the need for proper Do you have any current projects pediatric trauma evolved? pain relief. in countries with limited resources? When I was in training as a resident 4. Communicate frequently with the I have recently become very inter- and during my early career as a pedi- child and family during the treat- ested in developing a country wide atric orthopedist, we all followed the ment process. treatment program in Haiti. Dictum of Dr. Walter Blount who wrote 5. Provide good follow-up. This is a program in which we teach in 1955 that “Operating on a child with technicians the work in the various a fracture was the sign of an impetuous In addition to trauma, you are pediatric rehabilitation centers how surgeon.” Thus the rule was that all also well known for your forays to apply the casts using the Ponseti fractures in children should be treated into third world countries to method. The technicians take great non-operatively. provide service and education. pride in developing their skill of ap- plying the casts. With the advent of C-, internal This is a good place to mention the best fixation in children could be achieved way describe other countries. With the Is it better to do missions to with less invasive procedures. It has end of the cold war, here is no longer serve or to educate? taken a while for many of the older a Third World. Many countries resent My motto is to “leave skills not scars.” orthopedic surgeons to accept the fact being called a developing nation as My efforts have been directed towards that it is best to manage some fractures they may consider that they are de- providing continuing education to in children surgically. Unfortunately veloped. The politically correct term our orthopedic colleagues in these with improved operative skills, there to describe these nations is “Countries countries with limited resources. As is a lack of the development of non- with Limited Resources.” a result of the success of being able to operative skills. This trend to now provide continuing education using manage pediatric fractures operatively When did you first start to the protocol we established with our has created a lack of the teaching of provide orthopaedic care in courses in Haiti, POSNA members the non-operative skills in treating underserved regions? have been able to do the same in other fractures in the pediatric age group. I About 15 years ago I started to go to “countries with limited resources.” am distressed that our residents are not Haiti. At that time my commitment Continued on page 4  Pediatric Orthopaedic Profile: IPOS 2010 Dr. Kay Wilkins, DVM, MD, continued By: Jack Flynn, MD

Mark your cal- endars to join us for The Inter- a copy of the first national Pediat- page and put in ric Orthopedic other locations S y m p o s i u m , with your personal taking place at items. a new location: 2. Keep you money in The Swan Re- at least there secure sort in Orlando, places. Be sure to Florida Decem- bring a lot of small ber 1-4, 2010. Jack Flynn, MD bills such ones and This year we fives. You will need will have a special focus on complex Dr. Wilkins discusses the fine points them for tips. adolescent (International Guest of the Ponseti Method. Haiti, 2010. 3. Plan at least to al- Faculty, Reinhold Ganz), managing low two months to complications in pediatric orthope- To date the Committee on Pediatrics get your immunizations com- dics, limb deformity surgery (Inter- in Underserved Regions (COUR) has pleted. Take a water bottle that national Guest Faculty, Franz Grill), conducted 30 Outreach Continuing has a microphone filter. That way pediatric sports surgery (including hip Education Courses in 26 Countries. you can simply get the water from arthroscopy) and decision-making and This has become permanent activity the central water supply. Bring surgical techniques for ambulatory of that committee. an anti-diarrheal and a GI antibi- children with cerebral palsy (Interna- otic. tional Guest Faculty, Kerr Graham). What is the history of POSNA’s 4. Bring a cell phone that works COUR committee and how has it outside the US. Get the SIM card In addition to didactic sessions and changed over the years? for that country when you arrive panel case discussions, the IPOS Main The COUR Committee was established at the airport. The SIM card will Sessions will include some novel by Dr. Hugh Watts probably 20-25 provide one with a local phone educational approaches. In order to years ago. COUR has been the driv- number. These cell phones are explore solutions for some of the most ing force in organizing Continuing the cheapest way to call back to vexing pediatric surgical complica- Education Courses in countries with the US. tions, we have a morning set aside limited resources. It was instrumental 5. Always have the appropriate con- when 10 difficult complications are in developing a cooperative agreement vertor for electrical appliances presented to different expert panels, with European Pediatric Orthopaedic 6. Have available a portable light who will debate the optimal manage- Society to organize continuing educa- source such as a flashlight. It is ment. We will explore complications tion courses in many of the countries in best to have a supply of recharge- such as re-dislocation after DDH open and around Europe. These cooperative able batteries or I have found reduction, infection after spinal fusion, courses have been extended to work- the one that is rechargeable by stiffness after tibia eminence ing with the Pediatric Orthopedic So- turning a hand crank is especially fixation, and knee subluxation dur- ciety of India, and the pediatric section useful. ing limb lengthening. Also new this of the ASEAN (Association of South 7. Consider a spare generator unit year, we will have 2 different “Journal East Asian Nations). It is now respon- for recharging a laptop computer. Clubs”, in which we explore the evi- sible for bringing pediatric orthopedic I was at a conference where that dence regarding the role of Botox and surgeons on scholarships to both the unit shorted out for one of the hip surgery for CP hip subluxation POSNA and IPOS meetings. speakers. and the evidence for managing first 8. Bring a supply of power bars to time teen dislocation. Tips to remember when planning use when food is unavailable. a trip to an underserved area. Outside of the Main sessions, IPOS 1. Always keep your passport on emphasizes hands-on workshops your person at all times. Make Continued on next page  IPOS 2010, continued The Pediatric Orthopaedic Fellowship and breakouts. Registrants can choose Match: Recap of the 2010 Match and from five or six specialty breakout sessions on topics such as femoral Update on the 2011 Match acetabular impingement, principles of limb deformity correction, challenging By: Scott J. Luhmann, MD & Peter Waters, MD sports cases, advanced Ponseti casting, hands-on pelvic osteotomy workshop, Starting last September a new era for pediatric orthopaedic fellowships be- and selection fusion levels for idio- gan, the old system of multiple appli- pathic . Our industry spon- cations, interview inequity and “ex- sors have a number of hands-on work- ploding offers” came to an end, and shops which will allow participants a fair, equitable Match process began. to explore new technologies, in many POSNA enlisted the assistance of the cases using the surgical techniques and San Francisco Match Program (SFMP) implants on saw bone models. to organize and administer the match process, the first of which was com- To teach this broad array of main lec- pleted last April. tures, breakout sessions and hands-on This year’s pediatric orthopaedic fel- workshops, IPOS will have a faculty lowship Match was a resounding suc- of over 60 international experts in cess from the applicant and the fel- our field. There are special sessions lowship program’s perspective. This designed to mentor and generate en- year’s applicant class was the largest Scott Luhmann, MD is an thusiasm among orthopedic residents ever, and follows several years of and fellows (again under the direction gradually increasing numbers of resi- Associate Professor of Brian Smith), and a program to host dents going into pediatric orthopae- Orthopaedics at Washington visiting surgeons from the underde- dic fellowships. A total of 58 appli- University in St Louis. veloped world (under the direction of cants submitted rank lists to SFMP for David Spiegel). Generous donations 59 positions at the 36 registered North The 2011 Match for fellowship posi- by the Shriner’s Hospitals and POSNA American fellowship programs; 47 ap- tions starting 2012, starts September will allow IPOS to offer tuition scholar- plicants were matched. The remain- 1, 2010 with the uniform applica- ships to many registrants who may be ing 11 applicants (2 North American tion becoming available on the San future pediatric orthopedists. and 9 international) are in process to Francisco Match Program’s website secure a fellowship position. (www.sfmatch.org). The goal is to have all applications into the SFMP We encourage you to come to Orlando A survey of fellowship applicants by October 1st to optimize interview in December and experience the full reported the mean number of appli- scheduling. The SFMP will send out breadth of the dynamic field of pedi- cations submitted to fellowship pro- the application form (and supporting atric orthopaedics. Visit www.posna. grams was 11 with a mean 5 interviews documents) to all programs the appli- org and click on the link for the 2010 per applicant. 100% of the applicants cant lists on the website. Interviews IPOS meeting. reported there was no direct pressure will be conducted from November to make a commitment prior to the 15th through March 31st. Match lists Match Day. In response to the survey from the applicants and the fellow- information the fellowship directors ship programs are due on Thursday, Save the Date. voted to extend the interview process April 14th and then approximately 1 to begin at an earlier date (November week later (Thursday, April 21st) the 2010 IPOS 15th). This will permit interviews to match process will occur. Applicants December 1 - 4, 2010 be conducted at the IPOS and AAOS will be notified by the SFMP as to meetings and allow interviews to be Walt Disney World their assigned pediatric fellowship on spread out over a greater time period. Friday, April 22nd. Immediately af- Swan Resort Ideally this will create less scheduling ter the match notification applicants Orlando, Florida problems in residency programs with who do not match will be able to use a lower financial burden. Applicants the SFMP website to identify fellow- are encouraged to arrange formal vis- ships which did not fill and they can its to the fellowship program site and also contact the POSNA main office to view the IPOS and AAOS meetings (847-698-1692) as necessary to get as- as an “informal” opportunity to meet sistance. fellowship directors who attend the meeting.  Reflections from an Orthopaedic Resident in Haiti: Adrienne Socci, MD By: Brian Smith, MD

Across the devastated land, countless volunteers labored to help the victims of the January 12 earthquake that rocked southern Haiti. One such volunteer was Dr. Socci a third year resident from Yale; The POSNA Resident Review asked her to share in a portion of her experiences….

“…it has been seven weeks since the stunning the crowd with his effortless I found myself helping some first time earthquake, a Land Rover pulls up motion through the room. volunteers through some of the subtle with 7 or 8 people in back. Crutches challenges of this sort of mission. I hit the ground as the passengers dis- An overwhelming need for orthopae- have done this work before and found embark; empty sleeves and pant legs dic care in Haiti had been present the one of the most difficult is balancing drift in the wind. One man with an day before the earthquake, and was what you imagine you are going to impossibly high above knee amputa- taken to a horrifying degree when do with what actually needs to be tion makes his way up the stairs faster the ground opened up. The response done. Humility is something that or- than all the rest. Smiles and greetings of emergency medical professionals thopaedic residents are familiar with, abound as patients come out to meet was impressive, as the airport could and this is even more important in the them. Together they make their way not accept all the planes that wanted developing world. As volunteers, we into the church that is now a hospital to land. There is an urge to feel like became humbled guests in the hospital overflow ward. Victims are found savior, swooping in to save the day. which were manned by Haitian staff lying on mattresses with ex-fixes But in these settings where desperate who worked as hard as we did. They and casts, looking on with family need could often accurately be called toiled, perhaps after losing a family surrounding them. Inside, the arriv- acute-on-chronic, you meet amazing member and definitely after losing als join the queue awaiting a team people – doctors and nurses and com- friends in the earthquake. Their road of prosthetists. Some will be fitted munity health workers who had been has no end, ours lasted a week with a today; others are hoping to walk for saving the day long before you ever comfortable escape home. the first time since the latest of Haitian showed up. tragedies. 7 weeks after the earthquake, we spent our days rounding on 60-80 patients, I had heard about how devastating changing dressings, moving stiff joints. an amputation was in the Haitian The usual frequency of acute patients culture. This social stigma, whether continued to come to the hospital – a it was assumed, perceived, or real, hip fracture, ankle fracture, a distal was not apparent that day. Perhaps, radius, a septic knee, osteomyelitis in this overwhelming sea of suffer- – and we dealt with these as well as ing, prejudice has yielded in the face we could with equipment that was not of understanding and opportunity. always what we were used to. With As patients stood up on their new limited time to stay and sometimes leg(s), the boisterous crowd, made up limited ability to communicate with equally of patients, staff, and commu- the patients, it was a privilege to bear nity members, cheered them on. With witness to patients whose lives and trepidation they walked with smiles stories and wounds we knew well, and no one had seen for many weeks. Per- who would stand up and walk for the haps the storied cultural bias against first time on new legs….” amputees was more situational. There Dr. Socci spends time was no prosthetics in Haiti before; with one of her patients. thus an amputation was a societal burden and a personal end of story. For these young men and women, the future was coming back into focus. “Create Your Own” Self-Study Exams One of the prosthetists himself had an Create and take self study exams of previous OITE questions by picking artificial leg from his own AKA – he classifications and number of items. Go there now! wore shorts that day, intentionally Visit: http://www3.aaos.org/education/exams/exam.cfm  Surgical “Booties” on the Ground: Profile in Haiti – Dr. Michael Vitale, MD By: Craig Eberson, MD

After the disaster in Haiti, many phy- of Los Angeles. I have sicians answered the call to provide continued to experience medical care to the scores of injured the satisfaction of pro- citizens of that impoverished country. viding orthopedic care Of the estimated 300,000 injured Hai- to children. tians, it is estimated that up to 35% of those were children of which many What made you had shattered limbs. Inspired by the decide to go to Haiti? need for experienced orthopedists to I was down in Miami provide care to children, many pediat- participating in a spine ric orthopedists from around the world surgery course when I responded by providing their expertise was called by my part- in less than auspicious settings. Dr ner, Joshua Hyman. It Michael Vitale, Associate Chief of the was a few days after Military presence was critical in Division of Pediatric Orthopaedics the earthquake, and he facilitating care to injured in Haiti. and Chief of the Pediatric Spine and was arriving in Miami to Scoliosis Service at Morgan Stanley join a University of Miami Medishare cracy. It is a purity that we are losing Children’s Hospital of New York was group leaving for Port au Prince. Giv- in our health care system. I was very one such physician, and he shared his en the extreme need for physicians to fortunate to find the Love a Child experiences with us. care for the large numbered of injured Disaster Recovery Center where my children, I felt compelled to help. I ad hoc team spent the rest of our time. Tell me about your background. was able to arrange coverage for my It was an impressive place where the What led you to pediatric practice and I returned to New York, Humanitarian Health Initiative was orthopedics? gathered supplies, connected with quickly developing order. It is now the I did my residency at Columbia, another group and was on my way to largest sub acute hospital in Haiti, still where I initially became interested Santo Domingo 3 days later. doing lots of good work. in Pediatric Orthopaedics because of the diverse nature of the field and What was your first impression What are some lessons you the ability to make a difference in the of the situation in Haiti? learned from your experience? lives of children. I was offered and ac- I was unprepared for the amount of As pediatric orthopedists, we have cepted a position on staff at Columbia chaos, the enormity of the need and a unique ability to provide care for before I left for my Fellowship with the level of poverty. We did a lot of children in all settings. In addition to Vern Tolo at the Children’s Hospital surgery but we soon ran out of sup- high-tech complex treatments, we have plies. People were ap- experience with low tech, nonoperative pearing from all over, care of fractures, which is an invaluable but there was no real skill in these settings. Using basic tools order, and everyone (external fixator, Black and Decker was trying to figure Drill) we were able to rapidly stabilize out where to go, and patients and allow further definitive how to get supplies. care to occur later. We learned that the military is invaluable as a source What was the most to provide security, logistical support rewarding part of and organizational expertise. Getting your experience? involved with respected organizations The most rewarding with significant experience with hu- thing was the pure manitarian aid allows you to provide satisfaction of being care in an efficient manner. Most im- able to provide care to portantly, I learned how much good needy patients with- a small, dedicated group can do in a short time span if they work together Dr Vitale applies an external fixator with a Black out administrative for the benefit of their patients. and Decker Drill. (Dr Vitale has no Financial headaches of bureau- Continued on page 8 Relationship with Black and Decker).  Profile in Haiti, POSNA Job Site Announcement Dr. Michael Vitale, continued This secure, password protected site was designed to match practicing pediatric Do you plan to continue with orthopaedic surgeons and pediatric orthopaedic fellows with their ideal pediat- overseas work? ric orthopaedic surgery jobs. Importantly, it continues in keeping with our mis- I’ll definitely do more work abroad. In sion of “the highest quality education of pediatric orthopaedists thereby assuring fact, I have plans to go to Peru in No- the best possible care of musculoskeletal pediatric patients.” vember with Orthopaedics Overseas, and greatly look forward to getting Job searchers –can search efficiently and free of charge using their POS- more involved with International work NA identification number or AAOS ID number. Job seekers can search all jobs or in the future. There are lots of ways tailor the search by state, percentage of time focused in pediatric orthopaedics, or to contribute; as pediatric orthopaedic subspecialty areas of interest. Search for jobs now. http://www.posna.org/mem- surgeons, we are fortunate to have a ber/profile/login.cfm?appl_code=FINDJOBS skill set that we can leverage to make difference. Employers –can effectively reach their audience and advertise pediatric or- thopaedic surgery positions including information on percent time in pediatric orthopaedics, and subspecialty focus if desired. The cost to post a job is $200 for 6 months. Payment can be made securely online. Postings automatically expire in 6 months with friendly monthly contact from the POSNA office/ Post your job notice now. https://www4.aaos.org/spec/posna/timssnet/placement/tnt_ practice_login.cfm?appl_code=PRAC_SUB

If you need more information, you may want to contact Bryan Tompkins, Inter- net Committee Chair: [email protected] or Cristina Cabral at the POSNA office: (847) 698-1692 [email protected] . 2011 Editorial Board

Michelle Caird, MD Ann Arbor, MI 2011 AAOS-POSNA Pablo Castaneda, MD SPECIALTY DAY Mexico City, Mexico February 19, 2011 Craig Eberson, MD San Diego, California Providence, RI www.aaos.org Ron El-Hawary, MD Halifax, NS, Canada 2011 POSNA Chip Iwinski, MD ONE Day Course Lexington, KY Evidence Based Medicine in Pediatric Orthopaedics – What It Is, Why It Matters, and How to Understand It. Todd Milbrandt, MD Lexington, KY May 11, 2011 Montreal, Quebec, Canada Kristan Pierz, MD www.posna.org Hartford, CT

Susan Scherl, MD 2011 POSNA Omaha, NE Annual Meeting Brian Smith, MD May 12 - 14, 2011 New Haven, CT Montreal, Quebec, Canada EDITOR: Ken Noonan, MD www.posna.org Madison, WI

 Challenging Cases: What Would You Do? continued from page one

CASE #2 CASE #2, continued

A 13 old girl presents with a painful bunion deformity References (Figure 2) that has been refractory to nonoperative mea- Coughlin MJ. Roger A. Mann Award. Juvenile hallux valgus: sures. Surgical management should include: Etiology and Treatment. Foot Ankle Int. 1995 Nov;16(11):682-97. A. Distal soft tissue release/capsulorrhaphy Davids JR, McBrayer D, Blackhurst DW. Juvenile hallux valgus B. Distal first metatarsal osteotomy deformity: Surgical management by lateral hemiepiphysiodesis of the great toe metatarsal. J Pediatr Orthop. 2007 Oct-Nov; C. Distal soft tissue release/capsulorrhaphy 27(7):826-30. and proximal osteotomy McCluney JG, Tinley P. Radiographic measurements of patients D. Proximal hemiepiphysiodesis with juvenile hallux valgus compared with age-matched E. Metatarsal-phalangeal fusion controls: a cohort investigation. J Foot Ankle Surg. Your Response: ___ 2006 May-Jun;45(3):161-7.

CASE #3 A 12 year old soccer player complains about bilateral heel pain after games. He denies pain at rest. Squeezing the calcaneus reproduces his pain. His Achilles tendons are tight on physical exam. Optimal management should include: A. MRI to evaluate for calcaneal osteomyelitis B. Tendoachilles Lengthening C. Gastrocnemius Lengthening D. Achilles stretching, ice, heel cups E. Immediate cast immobilization Your Response: ___

Discussion Sever’s disuse, or calcaneal apophysitis, is a common afflic- tion in the adolescent population. Pain is often described after running activities. A common finding is a tight Achil- les tendon which may increase the stress on the apophysis. Fig. 2 Treatment is directed toward Achilles flexibility, anti-inflam- matories and ice, and perhaps gel heel cups. Casting may be indicated when initial treatment fails. While calcaneal Discussion osteomyelitis has been described, this patient has bilateral In juvenile hallux valgus, the problem usually arises from an involvement. Surgical lengthening of the Achilles or gas- increased intermetatarsal angle (IMA). When significantly trocnemius is rarely required. While rest is helpful, relief of increased, as in this patient, a proximal osteotomy, sparing minor symptoms can often be obtained without completely the physis, is indicated. Tightening the medial capsule with withdrawing from sports. or without medial release is helpful for realignment. A distal soft tissue procedure alone does not address the primary The correct answer is D. pathology. An isolated distal first metatarsal osteotomy also is insufficient. While some authors have described success References Kose O, Celiktas M, Yigit S, Kisin B. Can we make a diagnosis with proximal metatarsal hemiepiphysiodesis, this patient’s with radiographic examination alone in calcaneal apophysitis age precludes that. A fusion should be reserved for cases of (Sever’s disease)? J Pediatr Orthop B. 2010 Apr 29. multiple failed procedures or in neuromuscular patients. James AM, Williams CM, Haines TP. Heel raises versus prefabricated orthoses in the treatment of posterior heel pain The correct answer is C. associated with calcaneal apophysitis (Sever’s Disease): a randomized control trial. J Foot Ankle Res. 2010 Mar 2;3:3. Ogden JA, Ganey TM, Hill JD, Jaakkola JI. Sever’s injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop. 2004 Sep-Oct;24(5):488-92. Continued on page 10  Challenging Cases: What Would You Do? continued from previous page

CASE #4 CASE #5

A 15 year old boy with a leg length inequality since When treating a child with idiopathic clubfoot the first birth and a missing 5th ray on the left foot presented for method of choice is using Ponseti’s technique. Within consideration of a tibia lengthening procedure. His leg the clubfoot there are 4 different deformities treated, scanogram is shown below in Figure 4. The following which of the following is the last deformity that should foot or ankle abnormality would most likely be associated be corrected? with this radiograph: A. Hindfoot Varus A. Hallux varus B. Ankle Equinus B. Bony coalition of the calcaneonavicular and C. Midfoot Cavus subtalar joints. D. Forefoot Adductus C. Varus hind foot due to absence of peroneal muscles E. Forefoot Pronation D. Syndactylization of the remaining 4 toes Your Response: ___ E. Distal tibia and fibula Your Response: ___ Discussion The four basic deformities of a clubfoot are cavus, ad- ductus, varus, and equinus (CAVE). This pneumonic not only describes the clinical position of the clubfoot but also outlines the general order of deformity correction via the Ponseti method. Equinus is corrected last and should be attempted once the talonavicular joint is reduced and when the hindfoot is in neutral to slight valgus and the foot is abducted 70° relative to the leg. The correct answer is B.

References Ponseti IV (ed): Congenital Clubfoot: Fundamentals of Treatment. Oxford, England: Oxford University Press, 1996.

Fig. 4 CASE #6 When using the Ponseti technique to treat congenital Discussion clubfoot, what is the initial treatment for an early recur- The lower extremity scanograms demonstrate a shortened rence (<12 months of age) of deformity? tibia with a present but deficient fibula – fibular . A. Achilles tenotomy Careful examination of the radiographs also shows a ball B. Posteromedial release and socket ankle on the left. This is often accompanied C. Repeat manipulation and application of casts by a dense bony tarsal coalition. In general, the motion D. Abduction orthosis at the ball and socket ankle compensates well for the lack E. Tibialis anterior tendon transfer of subtalar motion and many patients are asymptomatic Your Response: ___ from the stiff hindfoot. Other associated abnormalities in include absence of the ACL (notice dys- Discussion plastic tibia spine) and shortened femur. Peroneal tendons Early recurrence is generally a result of either non-compli- may occasionally be deficient in fibular hemimelia but this ance with the foot abduction orthosis or from delayed ini- rarely leads to varus. Hallux varus, syndactylization, and tiation of treatment. It usually manifests as ankle equinus synostosis would not be expected. or forefoot adductus. Correction of residual deformity can The correct answer is B. be obtained and then subsequently maintained with the abduction orthosis. Surgical intervention is indicated when References recurrence of deformity does not respond to repeat casting. Lamb D. The ball-and-socket ankle joint. J Bone Joint Surg Br. However, extensive posteromedial is usually not needed in 1958;40:240. such cases. Vincent KA. Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281. The correct answer is C. 10 Challenging Cases: What Would You Do? continued from previous page

CASE #6, continued CASE #8

References A 12 year old female soccer player presents to clinic com- KJ Noonan and BS Richards, “Nonsurgical Management of plaining of pain and tenderness over a large prominence Idiopathic Clubfoot,” Am Acad Orthop Surg 2003; 11:392-402. on the medial side of the foot. On exam she has a planoval- gus foot and a tight gastrocnemius muscle. Radiographs are shown in Figure 8. The best surgical procedure for CASE #7 this patient is: A. Lateral column lengthening with Achilles tenotomy A two week old male presents with a left . B. Subtalar fusion Examination reveals excessive dorsiflexion of the ankle C. Excision of sub-talar coalition and plantarflexion to neutral, the calcaneus is normally D. Osteosynthesis of navicular stress fracture positioned in the heel. The child demonstrates normal E. Excision of the prominence motor function when the foot is stimulated. Clinical pho- Your Response: ___ tos demonstrate the position of the foot (Figure 7). The treatment predicted for complete resolution is: A. Prolonged bracing due to triceps surae weakness B. Manipulation and casting C. Isolated lengthening of foot dorsiflexors D. Posterolateral release with lengthening of the anterior tibialis E. Observation Your Response: ___

Discussion Fig. 8A Calcaneal-valgus foot de- formity occurs in approxi- Fig. 8B mately 1 in 1000 live births. The hindfoot is externally rotated and dorsiflexed at the ankle and the dorsum of the foot can come in contact with the anterior tibia. This condition can be seen in isolation or with posteromedial bowing of the tibia. In posterior medial bowing the apex Discussion Fig. 7 of the deformity is at the This child has an accessory navicular shown best on the distal tibia. Here the child’s tibia is straight. A similar foot oblique of the foot. Non-operative methods which include appearance can be seen in congenital vertical talus where orthotic management can decrease the pain and may avoid the calcaneus is elevated in the heel from tight posterior the need for future surgery. Surgery for this condition muscles, or in patients with paralysis of the triceps surae includes excision of the accessory navicular through the (). These disorders are ruled out in this patient synchondrosis and possibly removing a portion of the who has normal neurological exam and calcaneal pitch. prominent medial native navicular. Other surgical methods For this boy, stretching of the foot into plantarflexion and above are useful for recalcitrant coalitions, flexible flatfeet inversion can be suggested but the majority resolve spon- or arthrosis. Attempts to fuse the synchondrosis are not taneously by 3-6 months of age. indicated. The correct answer is E. The correct answer is E.

References References Sankar WN, Weiss J, Skaggs DL, Orthopaedic conditions in the Noonan, KJ. The foot and lower extremity. Orthopaedic Knowledge newborn: J Am Acad Orthop Surg., 2009 Feb 17(2): 112-22 Update 9, AAOS Publication. 2008 Continued on page 12 11 Challenging Cases: What Would You Do? continued from previous page

CASE #9 CASE #10, continued

A 14 year old boy with a long history of painless flatfeet and 3 lesions are treated initially presents to your clinic. His mother has flatfeet which are non-surgically with a weight occasionally painful. Which of the following statements bearing cast or cam-walker as well is true? as activity restriction. Although A. His foot should have been treated with an arch patients will be asymptomatic support as a child after this treatment, there are a B. he should be tested for hereditary Charcot Marie significant number of patients Tooth who will continue to present with C. He should be scheduled for subtalar CT scan. persistent lesions on radiographs. D. Treatment should be based on symptoms. These patients are generally E. Orthotic treatment will definitely avoid future observed on a yearly basis. problems Patients with persistent pain or Fig. 10 Your Response: ___ stage 4 lesions are candidates for arthroscopic evaluation and either surgical drilling, Discussion debridement or fixation followed by non-weight bearing Flatfeet are commonly seen and are not usually related for at least 3 weeks. It has been shown that in skeletally to heritable neurological conditions such as CMT, these immature patients, OCDT lesions usually respond to non- patients usually present with cavus feet. Evaluation of his operative treatment, which include activity modification foot with a CT scan might be indicated if treatment for a and suspension of sports. painful flatfoot is considered, such a test can evaluate for tarsal coalition. Orthotic use in asymptomatic feet will not The correct answer is D. prevent future problems regardless of age. References The correct answer is D. Perumal V, Wall E, Babekir N; Juvenile osteochondritis dissecans of the talus; J Pediatr Orthop. 2007 Oct-Nov;27(7):821-5 References Noonan, KJ. The foot and lower extremity. Orthopaedic Knowledge Update 9, AAOS Publication. 2008 CASE #11

CASE #10 A 5 week old baby boy is seen with a rigid planovalgus deformity of both feet; the clinical and radiographic A 12 year old girl has a 6 month history of anterolateral appearance is shown in Figures 11. The pathology ankle pain, effusion, tenderness and on includes: dorsiflexion; she plays soccer regularly. Radiographs are A. Congenital fusion of the subtalar joint shown in Figure 10. The next step at this point could B. Fixed dorsal dislocation of the navicular on the include all of the following except: talar head and neck A. Obtain an MRI C. Congenital absence of one or more of the midfoot B. Non-weight bearing in a short-leg cast or bones cam-walker D. Posterior tibia tendon dysfunction C. Activity modification E. Posteromedial tibia bowing D. Ankle arthroscopy and drilling Your Response: ___ E. Non-steroidal anti-inflammatory medication Your Response: ___ Discussion The condition known as Congenital Vertical Talus (CVT) is Discussion an uncommon foot deformity characterized by fixed dorsal Osteochondritis Dissecans of the Talus (OCDT) considers 4 dislocation of the navicular on the talar head and neck; in stages: Stage 1 is a small area of compression of subchondral addition a significant posterior contracture is present. Its bone, Stage 2 is a partially detached osteochondral incidence is estimated to be 1/10000 and is associated with fragment, Stage 3 is a completely detached fragment neuromuscular or genetic disorders in about half of the which is still in the crater bed and Stage 4 is a completely cases. Diagnosis is confirmed on a forced plantar flexion detached and displaced fragment. Symptomatic Stage 1, 2 lateral radiograph in which the talus remains vertical and 12 Challenging Cases: What Would You Do? continued from previous page

CASE #11, continued CASE #12

A 10-year-old girl has a two-month history of foot pain, Fig. 11A especially when running. Examination reveals localized pain and minimal swelling localized to the distal second metatarsal. Metatarsal-phalangeal joint range of motion is limited. Her X-rays and MRI are shown in Figure 12. Initial management should include: A. Obtain laboratory studies to rule out infection B. Excision of the second metatarsal-phalangeal joint with interposition arthroplasty C. Arrange for urgent biopsy D. Dorsal closing wedge osteotomy of the distal second metatarsal E. limited weight bearing with crutches, orthotics, and shoe modifications Fig. 11B Your Response: ___

Fig. 12A

does not align with the 1st metatarsal. Although a calcaneal valgus foot can appear similar to this patient with CVT, the later disorder has posterior equinus contracture that is diagnosed via an elevated calcaneus present on these radiographs. Tibia bowing is not seen with CVT. Tarsal coalition is a condition seen more frequently in adolescents Fig. 12B presenting as a painful and rigid flatfoot deformity with limited subtalar motion. Posterior tibia tendon dysfunction is a cause of acquired flatfoot deformity seen mostly in adults. Accessory navicular can present as pes planus and is caused by an ossicle on the medial side of the foot in continuity with the tibialis posterior tendon. The correct answer is B.

References Discussion Dobbs MB, Purcell DB, Nunley R, Morcuende JA; Early results The patient’s history, physical exam, and imaging studies of a new method of treatment for idiopathic congenital vertical are consistent with Freiberg’s infraction or disease. This talus. J Bone Joint Surg Am. 2006 Jun;88(6):1192-200 osteochondrosis of the metatarsal head typically presents in adolescence and has a 5:1 female preponderance. The sec- ond (usually longest) metatarsal is most frequently affected. The etiology is not fully understood; however, trauma and vascular compromise are the most popular theories. Various classification schemes exist which correlate physical and ra- diographic findings with treatment options. Initial stages Continued on page 14 13 Challenging Cases: What Would You Do? continued from page eleven

CASE #12, continued CASE #13, continued include early fracture of the subchondral epiphysis followed altered blood flow to the by collapse of the dorsal central portion of the metatarsal navicular prior to changes head with flattening of the articular surface. Later stages seen on plain radiographs, include increased collapse of the central metatarsal head these additional studies are resulting in medial and lateral projections which can fracture unlikely to alter diagnosis. off and result in loose bodies. End-stage arthrosis can occur Invasive procedures are un- with marked collapse and flattening of the metatarsal head necessary. Kohler’s disease and joint space narrowing. A trial of conservative treatment is usually self-limited with including protective weight-bearing, casting, orthotics, and no long term problems. In shoe modifications is recommended, especially in young the early painful phase, patients in early stages (as in the case example). For those activity modifications may who fail non-operative treatment, a variety of surgeries have be useful. Casting has been been described including: joint debridement, metatarsal shown to decrease the du- head excision (which may result in unsightly shortening of ration of symptoms from the toe), metatarsal dorsiflexion osteotomies (which rotate an average of 10 months healthier plantar cartilage into the joint), and even joint down to 3 months. replacement for severe cases. The correct answer is C. The correct answer is E.

References Fig. 13 Carmont MR, Rees RJ, Blundell CM: Current concepts review: Freiberg’s Disease. Foot Ankle Intern 2009;30(2):167-176. Katcherian DA: Treatment of Freiberg’s Disease. Orthop Clin References North Amer 1994;25(1):69-81. Ippolito E, Ricciardi Pollini PT, Falez F: Kohler’s disease of the tarsal navicular: Long-term follow-up of 12 cases. J Pediatr Orthop 1984;4:416-417. Borges JL, Guille BA, Bowen JR: Kohler’s bone disease of the CASE #13 tarsal navicular. J Pediatr Orthop 1995;15:596-598.

A 5-year-old boy from India presents with the complaint of foot pain and limp that increases with activity and decreas- es with rest. Exam reveals a well-appearing child with CASE #14 minimal swelling and faint erythema and warmth along the dorsal-medial midfoot. Palpation reveals tenderness The recommended treatment for a painful toe deformity in the region of the tarsal navicular. X-rays are shown in in a three year old seen in Figure 14 is: Figure 13. The next most appropriate step is to: A. Splinting. A. Obtain a bone scan B. Flexor tenotomy. B. Arrange for biopsy C. Flexor-to-extensor transfer. C. Place him in a short-leg walking cast for 8 weeks D. Syndactylization to the adjacent toe. D. Place a PPD test E. Proximal interphalangeal joint arthrodesis. E. Obtain labs to rule out infection Your Response: ___ Your Response: ___ Discussion Discussion Congenital curly toe is secondary to congenitally short or The patient’s history, physical exam, and radiographs are tight flexor digitorum longus or brevis muscles. Initially, consistent with the diagnosis of Kohler’s Disease, or osteo- there is no capsular contraction. The condition is often famil- chondrosis of the tarsal navicular. This condition typically ial, bilateral, and symmetrical. It is usually asymptomatic at presents between the ages of 2 to 9 years and is characterized first, but corns and calluses can develop if the toes become by sclerosis, fragmentation, and flattening of the navicular. stiff. Splinting has not been found to be effective. Proximal Bone restoration occurs in 6 to 16 months. Although imaging interphalangeal joint arthrodesis is reserved for cases in such as MRI or bone scan can reveal changes consistent with older children and adolescents in whom a fixed deformity 14 Challenging Cases: What Would You Do? continued from previous page

CASE #14, continued CASE #15, continued

Discussion Metatarsus adductus can be quantified based on where a heel bisector hits the toes. If it hits the third toe the meta- tarsus is considered mild, the fourth toe is moderate, and the fifth toe severe. Qualitatively, metatarsus adductus is actively correctable if tickling the lateral border of the child’s foot causes him/her to straighten the foot in response, it is passively correctable if gentle stretching will straighten the foot, and rigid if the foot does not correct with manipulation. Metatarsus adductus is a component of clubfoot but this child does not have cavus or equinus deformity. Fig. 14 The correct answer is B. has developed. Syndactylization has been described, but there are simpler, effective treatment options. Both flexor to References Bleck, EE: Metatarsus adductus: classification and relationship extensor transfer (Girdlestone procedure) and simple flexor to outcomes of treatment. J Pediatr Orthop, 3:2-9, 1983. tenotomy are effective, but in a prospective, randomized clinical trial, Hamer et al. found no difference in outcome between the two procedures. The correct answer is B. CASE #16

References Figure 16 below demonstrates a foot deformity in a young Hamer, AJ, et al. Surgery for curly toe deformity: a double-blind, child. All of the following are false except: randomized, prospective trial. J. Bone and Joint Surg., A. This is an example of pre-axial which 75-B(4):662-663, 1993. is more common. B. This is an example of post-axial polydactyly which is more common. C. Typically the patient is treated with ray resection CASE #15 D. Most polydactyly can be inherited as an autosomal recessive trait. Based on Figure 15, the foot shown on the right (the infants E. Polydactyly may present as poly- left) would be classified as: Your Response: ___ A. Calcaneal valgus foot B. Moderate metatarsus adductus. C. Severe metatarsus adductus. Fig. 16 D. Mild clubfoot E. Postural (positional) clubfoot Your Response: ___

Fig. 15

Continued on next page 15 Challenging Cases: What Would You Do? continued from page thirteen

CASE #16, continued CASE #17, continued

Discussion disease also now known as Hereditary Sensory Motor Neu- Polydactyly is the most common congenital toe deformity, ropathy. The characteristic deformity in Congenital Vertical occurs in about 1 in 1000 births and most frequently involves Talus is the so-called Rocker Bottom Foot in which the plan- the lateral side of the foot (Post-Axial). This is a Pre-Axial tar flexed talus produces fullness in the arch. All of the other polydactyly and is much less common. Typically inherited disorders mentioned above can cause unilateral or bilateral as an autosomal dominant trait, it may be simple in the cavus feet. In general, the presence of a cavus or varus foot form of a rudimentary toe or more complex with fusion of demands consideration for a neurological work-up. the bony elements or polysyndactyly. Usually the border digit is resected as it is the most rudimentary in function The correct answer is D. and the procedure is fairly simple. Ray resection or resec- tion of the more medial digit is performed if it is clearly the References J. R. Kasser, “The Foot,” in Lovell and Winter’s Pediatric less developed digit. Orthopaedics, R.T. Morrissy and Stuart Weinstein, Ed., The correct answer is E. Lippincott Williams and Wilkins, 2006, page 1311-2. M. D. Sussman, “Progressive Neuromuscular Diseases,” in Orthopaedic Knowledge Update: Pediatrics 3, M. F. Abel, Ed, References 2006, page 129. J. R. Kasser, “The Foot,” in Lovell and Winter’s Pediatric Orthopaedics, R.T. Morrissy and Stuart Weinstein, Ed., Lippincott Williams and Wilkins, 2006, page 1306-7. B. W. Olney, “Conditions of the Foot,” in Orthopaedic Knowledge Update: Pediatrics 3, M. F. Abel, Ed, 2006, page 241. CASE #18

The toe deformity shown in Figure 18 is symptomatic with shoe wear and shoe modifications. Surgical correction CASE #17 would consist of: A. Flexor digitorum longus tenotomy Figure 17 represents a foot deformity that could be seen B. Extensor digitorum tenotomy th in all of the following disorders except: C. 5 MTP joint fusion th th A. Muscular dystrophy D. Syndactylization of the 4 and 5 toes B. Chiari malformation E. Capsular release, extensor lengthening and C. Charcot Marie Tooth disease pinning D. Congenital vertical talus Your Response: ___ E. Freidreich ataxia Your Response: ___ Discussion This child has a congenitally overriding 5th toe and can be Discussion seen as an isolated condition. Pathologically the proximal phalanx is displaced on the fifth metatarsal head. Surgery Whether unilateral or bi- Fig. 17 lateral, the elevation of the consists of capsular release medial longitudinal arch and reduction of the MTP Fig. 18 or Cavus foot is often a joint and pinning. The ex- manifestation of another tensor tendon and the dorsal disorder or condition. Typi- capsule usually requires a cally intrinsic muscles are Z-lengthening. atrophied and the muscle The correct answer is E. imbalance produces the foot deformity. Many patients References will have concurrent hind J. R. Kasser, “The Foot,” in foot varus. Clawing of the Lovell and Winter’s Pediatric toes as seen here is often Orthopaedics, R.T. Morrissy seen concurrently. The clas- and Stuart Weinstein, Ed., sic cause of a cavo-varus Lippincott Williams and foot is Charcot-Marie-Tooth Wilkins, 2006, page 1311-2. 16 Challenging Cases: What Would You Do? continued from previous page

CASE #19 CASE #19, continued

A 15 year old boy with bilateral and symmetric foot de- Discussion formities is sent to you by his pediatrician who wants This boy has a foot deformity commonly called Skewfoot, to know if he can play high school football.. He is cur- Zed-Foot, Z-foot or Serpentine foot. Anatomically he has rently asymptomatic but his foot is examined and his forefoot adduction (Meta tarsus Adductus) on the midfoot gastrocnemius is tight. Clinical photos and radiographs and valgus midfoot displacement on the hindfoot. Addition- are shown. (Figure 19). The diagnosis and treatment of ally he does have a bunion deformity. Surgical correction this condition is: could consist of calcaneal lengthening, midfoot osteotomy, A. Serpentine foot that requires a calcaneal forefoot osteotomy and/or gastrocnemius lengthening. lengthening However he is asymptomatic and he should not undergo B. Zed-foot that is best managed with first cuneiform any surgical treatment. osteotomy C. Metatarsus adductus treated with Tendoachilles The correct answer is D. lengthening References D. Skew foot treated with observation J. R. Kasser, “The Foot,” in Lovell and Winter’s Pediatric E. Adolescent bunion treated with proximal Orthopaedics, R.T. Morrissy and Stuart Weinstein, Ed., osteotomy and soft tissue balancing Lippincott Williams and Wilkins, 2006, page 1311-2. Your Response: ___

Fig. 19

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