From second webspace syndrome to second cross over toe: Clinical and radiological findings following Weil osteotomy with no soft tissue procedure.

BACKGROUND: The second webspace syndrome (SWS) refers to the progressive divergence between 2nd and 3rd toes associated with pain at the second intermetatarsal space that can be confused with Morton's neuroma and treated as such without considering the underlying deformity. There is yet no consensus regarding the best treatment, from isolated soft tissue or bony procedures or a combination of both. The objective of this study was to describe the clinical characteristics of the disease, as well as to evaluate the radiological outcomes of patients with SWS treated with open Weil's osteotomy or distal metatarsal minimal invasive osteotomy (DMMO) of the second metatarsal, with main emphasis on medialization of the head in the anteroposterior plane in either procedure. METHODS: A retrospective study of all patients with SWS treated with Weil's medializing osteotomy (open and percutaneous) associated or not with other forefoot procedures, treated between 2012 and 2019, was performed. Radiological variables such as metatarsal-phalangeal angle (MTPA), percentage of metatarsal uncoverage of M2 with respect to its phalanx, intermetatarsal angle (M1, M2 and M3), length of second metatarsal and intermetatarsal distance M2 - M3 were measured and compared before and after surgery. RESULTS: Twenty-six patients were included, with a mean follow-up of 26 months. All patients presented divergence between the 2nd and 3rd toes, 75 % associated pain at the level of the second intermetatarsal space and two patients presented neuropathic symptoms. After surgery (nineteen open and seven DMMO), all patients rated their results as good or excellent, and the two patients with neuropathic symptoms had improvement in their symptoms. Regarding the radiological results, the percentage of subluxation of the second MTP decreased in a large percentage of the operated patients (from 43.3 % to 3.9 %) with statistical significance as well as the length of M2, IM angle between M1 - M2, IM distance between M2-M3 and the percentage of uncoverage of the second MTP (p < 0.001). CONCLUSION: Medial translation associated with open Weil osteotomy or DMMO seems to correct the muscle-ligament imbalance of the second metatarsophalangeal joint and restore normal radiographic measurements, especially in the coronal and sagittal plane, without the need for soft tissue procedures, as well as the resolution of associated neuropathic symptoms in some patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Mediciones de imágenes fotográficas del pie como una metodología no invasiva y válida en la exploración clínica / Measurements of the Foot Photo Images as a Non-Invasive and Valid Methodology in Clinical Examination

Introducción: La evaluación anatómica músculo esquelética por imagen en la exploración clínica del pie diabético es la fotografía digital que evalúa la morfología superficial. Objetivos: Validar la obtención de las imágenes fotográficas del pie, calcular las mediciones longitudinales, angulares y el índice del arco plantar, de las imágenes fotográficas del pie por fotogrametría, y basados en estas, categorizar la normalidad de la forma en sujetos sanos. Métodos: Estudio exploratorio en 30 individuos sanos evaluados en la Unidad clínica de pie diabético en la ciudad de Trujillo, mediante un prototipo de cámaras alrededor de un podoscopio y un software de análisis de imágenes. La imagen fotográfica fue evaluada por mediciones longitudinales, angulares y el índice del arco plantar. Resultados: Los pacientes evaluados tenían una edad media de 25,06+/-11,95 años, y predominaron las mujeres. La longitud total del pie y anchura del metatarso en el lado derecho fue de 226,55 ± 36,49 mm y 98,99 ± 22,71 mm respectivamente; y en el lado izquierdo fue de 229,81 ± 42,25 mm y 104,49 ± 16,84 mm respectivamente. El ángulo intermetatarsal del 1-2 rayo, ángulo intermetatarsal del 4-5 rayo y ángulo del retropié para el lado derecho fueron 14 ± 4º, 11 ± 3º y 2 ± 2º respectivamente; para el lado izquierdo 14 ± 3º, 9 ± 3º y 2 ± 2º respectivamente, y el índice plantar del arco derecho e izquierdo fueron 0,23 ± 0,2 y 0,22 ± 0,1 respectivamente. La variabilidad solo se presentó en el antepie en el 20 percent de los casos. Conclusiones: La obtención de las imágenes fotográficas del pie fueron válidas, las mediciones fueron menores o similares a otros estudios. La variabilidad de la normalidad solo se presentó en el antepie(AU)

Introduction: The musculoskeletal anatomical evaluation by imaging in the clinical examination of the diabetic foot is digital photography that assesses the superficial morphology. Objectives: To validate the obtaining of photographic images of the foot, to calculate the longitudinal and angular measurements and the index of the plantar arch, from the photographic images of the foot by photogrammetry, and to categorize the normality of the shape in healthy subjects, based on these photographic images. Methods: This an exploratory study in 30 healthy individuals evaluated at the Diabetic Foot Clinical Unit in Trujillo city, using a prototype of cameras around a podoscope and image analysis software. The photographic image was evaluated by longitudinal and angular measurements and the plantar arch index. Results: The patients evaluated had a mean age of 25.06+/-11.95 years, and women predominated. Total foot length and metatarsal width on the right side were 226.55 ± 36.49 mm and 98.99 ± 22.71 mm, respectively; and on the left side it was 229.81 ± 42.25 mm and 104.49 ± 16.84 mm, respectively. The 1st-2nd ray intermetatarsal angle, 4th-5th ray intermetatarsal angle and hindfoot angle for the right side were 14 ± 4º, 11 ± 3º and 2 ± 2º respectively; for the left side 14 ± 3º, 9 ± 3º and 2 ± 2º respectively, and the plantar index of the right and left arch were 0.23 ± 0.2 and 0.22 ± 0.1 respectively. Variability only occurred in the forefoot in 20 percent of cases. Conclusions: Obtaining of the photographic images of the foot was valid, measurements were smaller or similar to other studies. The variability of normality only appeared in the forefoot(AU)

Pediatric Forefoot Deformities.

This article explores different pediatric forefoot deformities including syndactyly, polydactyly, macrodactyly, curly toe, and congenital hallux varus. The epidemiology and genetic background are reviewed for each condition. Preferred treatment options and recommended surgical techniques are discussed with review of the current literature.

Deformidades de los pies en niños / Foot deformities in children

Las alteraciones en los pies son una consulta frecuente en ortopedia pediátrica. La gran mayoría corresponde a condiciones que no constituyen patología y habitualmente no necesitan tratamiento, como el pie plano flexible. Por otro lado, existen deformidades patológicas que necesitarán un adecuado estudio y tratamiento. Según su morfología podemos clasificarlas en cavo-varo, plano-valgo y misceláneas. Su origen puede ser congénito o adquirido y de diversas etiologías, destacando el pie bot, metatarso varo, hallux valgus juvenil y aquellas secundarias a enfermedades neuromusculares, entre otras. Conocer la historia natural de cada deformidad nos permite decidir el momento más adecuado para cada tratamiento. Los antecedentes mórbidos y perinatales del paciente son muy importantes, así como el nivel de actividad física y/o deportiva. El examen físico debe incluir observar la marcha, extremidades inferiores, tobillo y pie. En el pie se debe analizar cada segmento por separado (antepié, mediopié y retropié) y las articulaciones respectivas. Es muy importante distinguir entre deformidades rígidas y flexibles. El tratamiento incluye la observación (condiciones benignas y autolimitadas), calzado adecuado, insertos plantares, órtesis, yesos correctores, cirugía de partes blandas y cirugía ósea; todo complementado por un adecuado programa de rehabilitación funcional y deportivo.

Foot disorders are a frequent cause of consultation in pediatric orthopaedics. The vast majority correspond to conditions that don't constitute pathology and usually don ́t need treatment, such as flexible flat foot. On the other hand, there are pathological deformities that will require a proper study and treatment. According to their morphology we can classify them in cavo-varus, plano-valgus and miscellaneous. Its origin can be congenital or acquired and due to various etiologies, highlighting clubfoot, metatarsus adductus, juvenile hallux valgus and those secondary to neuromuscular diseases, among others. Knowing the natural history of each deformity allows us to decide the most appropriate time for each treatment. Patient's morbility and perinatal history is very important, as well as their level of physical and/or sports activity. Physical exam should include gait obsevation, lower limbs, ankles and feet. In the foot, each segment should be analyzed separately (forefoot, midfoot and hindfoot) and their joints. It ́s very important to distinguish between rigid and flexible deformities. Treatments include observation (benign and self-limited conditions), adequate footwear, insoles, orthosis, corrective casting, soft tissue surgery and bone surgery; all complemented by an adequate functional and sports rehabilitation programs

Using the Biomechanical Examination to Guide Therapy.

In trying to explain the myriad of foot deformities and symptoms that have slow onset and/or are considered to be overuse syndromes, clinicians have been trying to develop quantitative examinations to describe the cause of the patient's problems and to better individualize treatment modalities. This type of examination is called a biomechanical examination. This article discusses some of the more common portions of a biomechanical examination of the foot and lower extremity. It will also point out some ways that the information from a biomechanical examination can be applied in clinically treating patients.

Talectomy as Part of Chronic Foot and Ankle Deformity Correction Procedure: A Retrospective Study.

Severe foot and ankle deformities can be associated with high complication rates and impaired quality of life in patients. Surgical correction using a talectomy procedure has previously been described in many lower extremity pathologies and is a powerful tool for the correction of severe foot and ankle deformity. This study aimed to describe the role of talectomy and the outcomes of this procedure in patients presenting with severe foot and ankle deformity. A review of 45 patients undergoing talectomy by a single surgeon was completed. Data extracted included the cause of deformity, history of infection, body mass index, and relevant comorbidities. Outcome measures of interest were minor or major complications and limb functionality at final follow-up. Statistical analysis was performed by using a Wilcoxon rank sum test and a Fisher exact test looking at variables affecting selected outcome measures. Limb salvage occurred in 38 of 45 patients (84.4%). Patients with an infection history had 89% lower odds of a functional limb at final follow-up (p = .0389). Six of 7 patients (85.7%) who ultimately underwent amputation had a history of prior infection. Women had 8.25 times higher odds of having a functional limb compared with men (p = .047). All 13 patients with major complications had neuropathy (p = .024). Patients with chronic lower extremity deformities can successfully be treated with a talectomy as a part of the reconstructive procedure. This is a challenging patient population that is associated with a high complication rate. Patients with a history of infection should be counseled on the possibility of requiring major amputation.

Structural, Dermal and Ungual Characteristics of the Foot in Patients with Type II Diabetes.

Background and Objectives: Diabetes is a chronic and metabolic disease, considered as an important public health problem. The objective of this study was to determine the prevalence of podiatric pathology in type II diabetic patients. Materials and Methods: An observational descriptive study of prevalence in the endocrinology service of Complexo Hospitalario Universitario A Coruña (CHUAC) (A Coruña-Spain) was carried out (n = 153). Type II diabetic patients included, of legal age who signed the informed consent. Sociodemographic variables were studied (age, sex, body mass index (BMI), smoking habit, alcohol consumption, family history), disease variables (time of evolution of diabetes, treatments, low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose), podiatric variables: measurement of the footprint, metatarsal and digital formula, nail, skin, hindfoot and forefoot alterations. The data collection was done in 2018 and the data analysis was carried out in 2019. Results: The patients with type II diabetes had greater age, obesity and arterial hypertension it compared to the general population. Diabetic patients had a higher prevalence of flat feet than the general population (71.2% vs. 20.7%, p < 0.001), with a predominance of normal foot according to the podoscope. The predominant podological pathology was the presence of claw toes (94.8%), followed by dermal (78.4%) and nail (71.9%) alterations, and the Hallux Valgus (66.0%). The Clarke angle and the Chippaux index showed a Kappa concordance index of 0.26 with the type of footprint measured with the podoscope. The Staheli index showed a Kappa index of 0.27 associated with an observed agreement of 54%. Conclusions: This study shows that foot problems continue to be prevalent in subjects with type II diabetes mellitus and for this reason, podiatry is essential in its treatment.

New Sagittal Plane Reference Parameters for Foot Deformity Correction Planning: The Vitruvian Foot.

Currently available methods for analysis and planning of post-traumatic or congenital deformity correction of the foot have some limitations. The aim of this retrospective study was to establish reference lines and angles (RLAs), and the resulting ratios, based on reproducible anatomic points on sagittal feet radiographs. The key starting point of our evaluation was the previously undescribed length and position of the talus joint line (TJL), from the border of the articular surface of the talus and the posterior process of talus. First, we calculated the relationships between the TJL and the axes of the foot, particularly the anatomic and mechanical lateral talometatarsal angle axes of the first metatarsal. Then, we assessed the relationships with the calcaneus, particularly the lateral heel angle. Finally, we calculated the parameters (angles and coefficients k) derived from the TJL and the foot-bearing points (foot quadrilateral). A total of 64 normal radiographs from 55 patients were analyzed. The values that resulted are as follows: anatomic lateral talometatarsal angle = 28.5° ± 4.5°, mechanical lateral talometatarsal angle = 23.6° ± 3.2°, lateral heel angle = 15.2° ± 3.4°, foot quadrilateral: abc = 144.6° ± 9.4°, bcd = 31.3° ± 2.6°, cda = 79.2° ± 9.8°, dab = 105.0° ± 8.3°, k1 = 3.09 ± 0.4, k2 = 3.77 ± 0.78, and k3 = 1.56 ± 0.24. Sagittal plane reference lines and angles are proposed, providing quantitative values for reference. These parameters have the potential to be easily implemented in foot deformity analysis and correction planning.

Surgical Treatment of Mild to Severe Hallux Valgus Deformities With a Percutaneous Subcapital Osteotomy Combined With a Lateral Soft Tissue Procedure.

Distal metatarsal (MT) osteotomies have been used in mild or moderate cases of hallux valgus (HV) and proximal MT osteotomy has been considered the treatment of choice for severe deformities. A distal osteotomy could achieve a greater degree of correction by the addition of a distal soft-tissue procedure and be used to treat also severe deformity. Limited evidence about the use of the percutaneous subcapital osteotomy (SCOT); a type of MT osteotomy, in combination of a soft tissue procedure, is available. We evaluated this procedure routinely used in our clinic. A total of 30 consecutive patients treated in our hospital from September 2012 to April 2015 with SCOT combined with lateral soft tissue release were included in this retrospective review. Outcomes assessed included radiological parameters: HV angle (HVA) and intermetatarsal angle (IMA), clinical evaluation using the American Orthopaedic Foot and Ankle Society (AOFAS) score, and complication rate. In 12 of the 30 patients included, the pathology was bilateral, comprising a total of 42 cases. The overall correction of the angles was statistically significant (P < .001), changing from a HVA of 28.2° and IMA of 13.5° preoperatively to 8.0° and 6.0° postoperatively, respectively. The cases were divided into mild-moderate (34/42) and severe (8/42). Both groups showed a statistically significant correction in the angles, 3 months after surgery (P < .001). The AOFAS score showed a median of 49 points (n = 24) preoperatively and of 95 points (n = 40) at the end of follow-up. The complication rate at end of follow-up was 19% (8/42). After a minimum follow-up of 1 year, our technique for HV correction results in a clinically relevant improvement of the radiological parameters and AOFAS score in mild to severe deformities. Combination with lateral release could be a meaningful surgical alternative for the treatment of severe cases to help decrease the risk of recurrence. Levels of Evidence: Level IV.

Treatment of complex foot deformities with hexapod external fixator in growing children and young adult patients.

BACKGROUND: Treatment of complex foot deformities in growing children and young adult patients is challenging. The traditional approach consists of extensive soft tissues releases, osteotomies and/or arthrodesis. More recently, distraction osteogenesis has been proposed as an alternative strategy. The aim of this study was to describe our treatment strategy and report clinical outcomes of the patients affected from complex foot deformities treated by distraction osteogenesis and hexapod external fixator. MATERIALS AND METHODS: We retrospectively reviewed 10 consecutive patients with complex foot and ankle deformities treated from 2014 to 2016 at our unit. A TrueLok external fixator system was used in all patients. Final outcome was classified as good, fair and poor according to the criteria indicated by Paley and Ferreira. The results were also evaluated by the pre-operative and post operative American Orthopedic Foot and Ankle Score (AOFAS) and The Manchester-Oxford Foot Questionnaire (MOXFQ). RESULTS: A plantigrade foot was obtained in eight patients at the end of treatment, while in two patients a recurrence of the deformity was noted. Result was classified as good in 6 patients, fair in 2 patients, and poor in 2 patients. The AOFAS score improved from 33.9±21.2 pre-operatively to 67.25±15.1 post-operatively (p=0.005). A statistically significant improvement was observed for the MOXFQ score as well (from 60.6±23.3 to 33.0±25.2, p=0.020). CONCLUSIONS: Our study shows that the TrueLok hexapod external fixator is a safe and effective tool in treatment of complex rigid foot deformities. Nevertheless, deformity recurrence can be observed in some cases and treatment remains challenging. Distraction osteogenesis should be reserved as a salvage solution for particularly complex cases and should be performed at dedicated specialized centers.

Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail-The Kings' Experience.

BACKGROUND: Corrective fusion for the unstable deformed hind foot and mid foot in Charcot Neuroarthropathy (CN) is quite challenging and is best done in tertiary centres under the supervision of multidisciplinary teams. METHODS: We present a follow up to our initial report with a series of 42 hind foot corrections in 40 patients from a tertiary level teaching hospital in the United Kingdom. The mean patient age was 59 (33-82). 17 patients had type1diabetes mellitus, 23 had type 2. 23 feet in 22 patients had chronic ulceration despite offloading. 17 patients were ASA 2 and 23 were ASA grade 3. All patients had hind foot nail fusion performed through a standard technique by the senior author and managed perioperatively by the multidisciplinary team. RESULTS: At a mean follow up of 42 months (12-99) we achieved 100% limb salvage initially and a 97% fusion rate. One patient with persisting non-union of ankle and subtalar joint with difficulty in bracing has been offered below-knee amputation. We achieved deformity correction in 100% and ulcer healing in 83%. 83% patients are able to mobilize and manage independent activities of daily living. There were 11 patients with one or more complications including metal work failure, infection and ulcer reactivation. There have been nine repeat procedures including one revision fixation and one vascular procedure. CONCLUSION: Single stage corrective fusion for hind foot deformity in CN is an effective procedure when delivered by a skilled multidisciplinary team.

[Treatment strategy for flail foot with sensory disorder of spina bifida sequela in adult].

Objective: To summarize the main methods and comprehensive effects of limited surgery combined with external fixation for the treatment of flail foot with sensory disorder of spina bifida sequela in adult. Method: The clinical data of 22 cases (30 feet) of the adult spina bifida sequela who suffered from flail foot with sensory disorder and treated by limited surgery combined with external fixation were retrospectively analysed between January 2005 and December 2015. There were 14 males and 8 females with an age of 8-38 years (mean, 21.5 years). All 30 feet were distal ankle sensory loss, including 2 cases (2 feet) on the left side, 2 cases (2 feet) on the right side, and 18 cases (26 feet) on both sides. There was 1 foot accompanied by ulcerative plantar ulcers, and 3 feet lost their toes due to foot osteomyelitis in the weight-bearing area. Combined with 3 cases of hip dislocation, 3 cases of scoliosis, 4 cases of knee deformity, and 3 cases of ptosis. There were 5 cases of normal control of urine and stool, 10 cases of partial control of urine and stool, 6 cases of overflow urinary incontinence, and 1 case of cystostomy. According to X-ray film, the lesion of spina bifida was evaluated, the laminar insufficiency was located at L 3-L 5 in 8 cases, L 5, S 1 in 9 cases, and L 3-S 3 in 5 cases. In the patients, 12 feet were performed ankle joint arthrodesis, 10 feet subtalar arthrodesis, and 8 feet tibia-talus-calcaneus arthrodesis. Ilizarov external fixator was used in 18 feet, Hybrid fixator in 8 feet, Hybrid fixator and cannulate screws in 3 feet, and Ilizarov fixator and cannulate screws in 1 foot. Results: All 22 patients were followed up 10-80 months (mean, 48.5 months). All ankle deformities were corrected effectively after operation, the middle and hind feet were stable, the plantar foot was restored, the whole foot was loaded, and the ulcer healed without recurrence. There were 2 cannulate screws ruptured in the subtalar arthrodesis, bone healed after screws break; no complication such as surgical infection, neurovascular injury, and so on happened. At last follow-up, based on the evaluation criteria of QIN Sihe lower limb deformity correction, the results were excellent in 15 feet, good in 9 feet, and fair in 6 feet, with an excellent and good rate of 80.0%. Conclusion: The treatment of flail foot with sensory disorder of spina bifida sequela is more demanding. The limited surgeries combined with external fixation play an important role for recovering the stability of foot and ankle, better clinical results, and less complications.

The Lisfranc Amputation: A More Reliable Level of Amputation With Proper Intraoperative Tendon Balancing.

Traditional transmetatarsal amputations are a reliable level of amputation. However, amputations at the Lisfranc level have met with limited success owing to improper biomechanics resulting from tendon imbalance, ultimately leading to foot deformity positions and an unstable soft tissue envelope with ensuing skin breakdown, infection, and below-the-knee amputation. We describe proper tendon rebalancing that results in improved biomechanics and a more reliable and stable amputation at the more proximal Lisfranc level.

Relationship Between Grading With Magnetic Resonance Imaging and Radiographic Parameters in Posterior Tibial Tendon Dysfunction.

The objective of the present study was to elucidate the relationship between the state of the posterior tibial tendon (PTT) on magnetic resonance images and foot deformity. The cases included 34 feet in 27 patients with PTT deformity and the controls included 18 feet in 12 patients who had undergone magnetic resonance imaging for other foot diseases. The PTT was closely examined on the magnetic resonance images and classified using the Conti classification. The control feet with no injury to the PTT were classified as grade 0. The talonavicular coverage angle, lateral talo-first metatarsal angle, medial cuneiform to fifth metatarsal height, calcaneal pitch angle, and varus-valgus angle were measured as radiographic parameters for flatfoot deformation, and the relation between the Conti classification and each parameter was examined statistically. A significant difference was observed in the talonavicular coverage angle between grade 0 and the other grades; the lateral talo-first metatarsal angle between grade 0 and the other grades and between grades 1 and 3; the medial cuneiform to fifth metatarsal height among grades 0, 2, and 3 and grades 1, 2, and 3; the calcaneal pitch angle between grades 1 and 3; and the varus-valgus angle among grades 0, 2, and 3 and between grades 1 and 3. Eversion of the forefoot was observed, along with an advanced collapse in the medial longitudinal arch, from an early stage of PTT injury.

Treatment of feet deformities in epidermolysis bullosa.

BACKGROUND: Inherited epidermolysis bullosa is a rare disease characterised by mechanical fragility of the skin when under insignificant stress. The main consequences of epidermolysis bullosa, mainly the dystrophic type, despite pseudosyndactyly, are joint contractures and deformities in hands and feet. In this study, we describe our experience treating patients suffering from epidermolysis bullosa, as far as feet deformities are concerned. METHODS: This is a retrospective analysis of a consecutive series of patients presenting feet deformities related to epidermolysis bullosa. Extension contractures of the toes, equinus and cavus deformities were treated with soft tissues surgery. RESULTS: Thirteen surgical procedures were done in six patients with feet deformities caused by epidermolysis bullosa. Of the feet operated 85.7 % extension contracture of the toes was asymptomatic at follow-up. However, 42.9 % developed hammertoe deformities. There were no recurrence or complications for other deformities. Subjectively, all patients declared themselves very satisfied with the results. CONCLUSION: Foot deformities must be treated as early as possible, due to progressive disability for walking and pain symptoms. We considered that, despite long term complications, treatment was adequate and we recommend it. Level of Evidence Level IV.

The influence of timing of knee recurvatum on surgical outcome in cerebral palsy.

Recent reports have shown that timing of genu recurvatum (GR) might be caused by different underlying factors and that equinus leads to GR especially during early stance. The purpose of this study was to investigate the reduction of GR after surgical correction of equinus in children with bilateral spastic cerebral palsy and whether the children with early and late type GR show differences in reduction of knee hyperextension after a surgery. In 24 limbs (mean age 10.3 years, GMFCS I-III) showing equinus and GR the kinematics of the knee and ankle as well as the kinetics of the knee were evaluated before and one year (mean follow up period: 12.8 months) after surgical correction of equinus. The study was approved by the local ethical committee. Limbs with early type GR showed a reduction by 11.1° (p<0.001) and those with late type GR by 6.0° (p<0.049) in GR after surgery. Before surgery limbs with early type GR showed increased external extending moments, which decreased significantly after surgery. In contrast limbs with late GR did not show a significant reduction of those moments. The findings of this study underline the influence of equinus on early GR as an underlying factor. As equinus is attributed to early knee hyperextension and proximal factors are more important as underlying factors in late type GR, a classification into early and late onset GR is useful to identify underlying factors and to choose adequate treatment.

Syndromic Feet: Arthrogryposis and Myelomeningocele.

Treatment of myelomeningocele and arthrogrypotic foot deformities has been controversial; many different procedures have been advocated for each type of deformity. In most cases, outcomes have had variable success rates, and many complications can occur. Treatment strategies should highlight care that avoids the development of a stiffened foot and allows for a variety of options to regain correction when a relapse occurs. This is particularly true in myelomeningocele, whereby a stiff foot runs a high risk for skin ulceration, leading to osteomyelitis. Discussion includes appropriate circumstances for the use of presented procedures and the author's preferred treatment for each deformity.

Neuromuscular Foot: Spastic Cerebral Palsy.

Foot and ankle deformities in cerebral palsy can be effectively treated with surgery. Surgery should be considered in patients with significant deformity and those who have pain or difficulty with orthotic and shoe wear. Equinus contracture of both gastrocnemius and soleus can be treated with open tendoachilles lengthening; ankle valgus with medial epiphysiodesis. Equinovarus is more commonly seen in hemiplegic patients and this deformity can usually be treated with tendon transfers. Triple arthrodesis is an option in children with severe degenerative changes. It is important to address all aspects of the child's pathology at the time of surgical correction.